Wernicke’s encephalopathy (WE) is a serious neurological syndrome caused by severe thiamine (vitamin B1) deficiency. In pregnancy thiamine requirements are increased. If the pregnancy is complicated by hyperemesis gravidarum (HG), thiamine rapidly depletes. WE is a rare but known complication of severe HG and in non-alcoholic patients the prevalence ranges from 0.04% to 0.13%.1 Its acute recognition and treatment are crucial to prevent long-term neurological sequelae or death.
We report the case of a 36-year-old G3P at 16+1 weeks of gestation, who presented to emergency with intractable nausea and vomiting, decreased oral intake for 11 weeks and progressive inability to mobilise. Her presentation was complicated by a concealed miscarriage concordant with 14 weeks gestation. Investigations showed severe micro and macro nutritional deficiencies from HG associated with 24kg weight loss, microcytic anaemia (Hb 102 g/L, MCV 59fL), hypokalaemia (2.2 mmol/L), hypercalcaemia (2.75 mmol/L corrected), hypo-albuminaemia (22 g/L), TSH < 0.02 and Free T4 of 22. On assessment she was confused and slow to respond. Examination revealed mouth ulcers, oculomotor abnormalities including nystagmus and ataxia. She was in urinary retention and suffering from severe constipation.
The patient was treated symptomatically with antiemetics, intravenous fluids, thiamine, electrolyte and multi-vitamin replacement. Induction of labour for miscarriage was completed post stabilisation on day 4 of admission with mifepristone and misoprostol. An MRI brain showed T2 hyperintensity involving posteromedial aspects of the thalami bilaterally without significant associated mass effect. She was monitored closely for refeeding syndrome and did not require total parenteral nutrition (TPN).
She was managed via a multi-disciplinary team approach and remained in hospital for over three weeks and subsequently discharged to a private hospital for ongoing rehabilitation and strengthening.
This case highlights the importance of early diagnosis and treatment of WE in pregnancy and demonstrates the importance of a multi-disciplinary approach in managing such complex patients.