Early Pregnancy (hyperemesis + complications) Flashcards
Define hyperemesis gravidarum
NICE:
This describes the most severe spectrum of symptoms, and is a clinical diagnosis of exclusion characterized by:
Prolonged, persistent and severe nausea and vomiting unrelated to other causes.
Weight loss (usually at least 5% of pre-pregnancy body weight).
Dehydration and electrolyte imbalance
( < 20 weeks usually )
Oxford Specialities book:
Persistent nausea and vomiting in pregnancy causing weight loss (>5%), dehydration and electrolyte imbalance
When is risk of hyperemesis gravidarum increased?
Oxford:
* multiple pregancies
* molar pregnancies (ones where fertilised egg is not viable)
* had previous HG with other pregnancies
NICE:
* increased placental mass
* first pregnancy
* Hx of HG in other pregnancies
* Hx of motion sickness
* Hx of migraines
* Hx of nausea with oestrogen containing contraception
* FHx (1st degree relative)
* Obesity
* Chronic H.pylori infection
High levels of ____ is thought to be related to hyperemesis gravidarum
hCG
Clinical presentation of hyperemesis gravidarum?
Nausea
Vomiting
Hypersalivation
Spitting
Weight loss
Inability to tolerate food and fluids
Effect on quality of life
How can you quantify the severity of hyperemesis gravidarum?
Using PUQE score (based on frequency of nausea, vomiting and retching)
Pregnancy-Unique Quantification of Emesis (PUQE) Index
An objective and validated score of nausea and vomiting that can be used to classify/monitor the severity of symptoms. Total score is sum of replies to each of the three questions.
PUQE-24 score: Mild ≤ 6; Moderate = 7–12; Severe = 13–15.
Ddx for hyperemesis gravidarum if patient has also presented with urinary symptoms?
UTI
Pyelonephritis
Ovarian torsion
Other: End stage renal disease and uraemia, renal stones (not as common in pregnancy)
Ddx for hyperemesis gravidarum if pt also has palpatations?
Thyrotoxocosis
Metabolic/endocrine ddx for hyperemesis gravidarum?
Hypercalcaemia
Hyperparathyroidism
Thyrotoxicosis
DKA
Addison’s disease
DDx for hyperemesis gravidarum if pt also mentions they have abdominal pain?
Gastritis
Peptic ulcer
Gastroenteritis
Pancreatitis
Cholecystitis
Cholelithiasis
Bowel obstruction
Heapatitis
Appendicitis
Neurological ddx for hyperemesis gravidarum?
Vestibular disease
Migraine
CNS tumours
Psychological ddx for hyperemesis gravidarum?
Eating disorders
Withdrawal - alcohol, opiod, anxiolytic
When taking a Hx for suspected hyperemesis gravidarum, you need to exclude other causes of N+V.
What would you ask about to do this?
Abdo pain
Urinary symptoms
Infection - fever
Drug Hx
Chronic H.pylori infection
What is important to carry out in examination of a pt w/ suspected hyperemesis gravidarum?
Full set of obs
Abdo exam
Weigh in
Look for signs of dehydration and muscle wasting
What investigations would you conduct for a woman who is presenting with persistent nausea and vomiting?
**Bedside: **
Urine dip for ketones and uti (send off MSU). Weight, BP.
**Bloods: **
FBC (may show raised haematocrit),
U&Es (exclude hypokalaemia, hyponatraemia).
Albumin - will be low
TFTs - thyroid disorders
LFTs - exclude hepatitis and gallstones
Bone - Calcium and phosphate
Amylase -rule out pancreatitis
ABGs - exclude metabolic disturbance/monitor severity
Imaging:
Pelvic USS - e.g. multiple or molar pregnancy/trophoblastic disease
How is hyperemesis gravidarum managed?
think: conservative, pharamcological
Conservative:
- ginger
- acupressure
- bland, small frequent protien rich meals
- rest
- reassure as can take toll on mental health status of woman
Pharmacological:
Antiemetic - oral cyclizine or promethazine, or prochlorperazine, or combination drug doxylamine/pyridoxine are 1st line options
Then reassess woman after 24hrs
If 1st line is ineffective, switch to 2nd line = metoclopramide or domperidone, or ondansetron and reassess after 24hrs.
Need daily U+Es done to guide sodium and potassium replacement
Potassium chloride - in case of hypokalaemia
Thiamine and folic acid to prevent development of Wernicke’s encephalopathy
Thromboembolic (TED) stockings and low molecular weight heparin as there is increased risk of venous thromboembolism. This is due to the combination of pregnancy, immobility and dehydration
Why should oral metoclopramide not be prescribed for longer than 5 days?
Risk of neurological extrapyramidal adverse effects
Why should oral domperidone not be prescribed for longer than 7 days?
Risk of cardiac adverse effects
Why should ondansetron not be prescribed for longer than 5 days, especially in the first trimester?
Small increased risk of baby having cleft lip and/or palate
You see a woman with hyperemesis gravidarum in primary care. When should you admit to hospital?
Unable to keep anything down depsite oral antiemetics
Requires rehydration
Requires correction of metabolic disturbances
Has coexisiting morbidity e.g. UTI
What are fluid replacement options for woman w/ HG?
0.9% Sodium chloride or Hartmann’s
Causes of hyperemesis gravidarum?
hCG levels (being too high)
Oestrogen - levels are high
Evolutionary adaptation - a mechanism to prevent woman eating harmful foods
Gastric dysfunction - during pregnancy, oesophageal, gastric and small bowel motility are impaired because of smooth muscle relaxation due to increased levels of progesterone.
Why is there more smooth muscle relaxation in pregnancy?
Increased levels of progesterone
What are metabolic complications associated to HG?
- weight loss
- dehydration
- electrolyte imbalance
- AKI
- abnormal LFTs - secondary to hypovalameia, malnutrition, lactic acidosis
- nutritional and vitamin deficiencies
Complications of HG requiring input from GI team?
GORD, oesophagitis, gastritis.
Mallory-Weiss tear or oesophageal rupture
Complication of HG needing ophthalmology?
Retinal haemorrhage
Complication of HG needing assessment by Respiratory team?
Pneumothorax
Pneumomediastium
Other than metabolic and mechanical (Gastro, Resp) complications, women experience other complications during HG.
Name three complications - (Hint: these can present in non-pregnant peole too!)
- VTE - immobile and dehydration during HG are risks for this
- Fatigue
- Psychosocial - depression, anxiety, emotional distress, PTSD, reduced QofL, suicidal ideation (due to severity of symptoms)
Prescribing drugs in pregnancy:
When is the period of greatest risk for teratogenesis from drugs?
3rd - 11th week of pregnancy
Safe prescribing in pregnancy:
How can some drugs affect pregnancy in the 1st trimester?
Produce congenital malformations/teratogenesis
Safe prescribing in pregnancy:
How can drugs affect preganancy in the second and third trimester?
Can affect the growth or functional development of the fetus, or have toxic effects on fetal tissues
When should drugs be prescribed in pregnancy?
- ONLY if expected benefit to the mother is thought to be greater than the risk to the fetus.
- All drugs should be avoided if possible during 1st trimester
- Drugs which have been extensively used in pregnancy and appear to be usually safe should be prescribed in preference to new or untried drugs; and the smallest effective dose should be used
Generally (any system), what are differentials for hyperemesis?
- Infections such as gastroenteritis, urinary tract infection, hepatitis and meningitis
- Gastrointestinal problems: Appendicitis, cholecystitis, bowel obstruction
- Metabolic conditions: Diabetic ketoacidosis, thyrotoxicosis
- Drug toxicity
- Molar pregnancy (abnormally high levels of beta-hCG due to gestational trophoblastic disease can cause severe nausea and vomiting)
