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12- NVP / HG Guidelines > Green Top Guideline > Flashcards

Green Top Guideline Flashcards

1
Q

When is NVP diagnosed ?

A

Nausea and vomiting prior to 16w

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2
Q

When is HG diagnosed?

A
  • symptoms early in pregnancy
  • severe: limit daily activities
  • signs of dehydration.
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3
Q

What is the percentage of pregnant women affected by NVP?

A

90 %

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4
Q

What is the most common indication for hospital admission among pregnant women?

A

NVP
Typical stays of 3-4 days

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5
Q

When are symptoms of NVP start?

A

Start 4-7w
Peak 9w
Resolvie 20 w

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6
Q

What is the incidence of HG in pregnancy?

A

0.3- 3.6 %

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7
Q

What is the pathophysiology of NVP & HG ?

A

GDF15 : growth differentiation factor 15 / from the placenta
- genetic expression of GDF15
( families / recurrence in future pregnancies)

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8
Q

According to PUQE-24 scoring system how to classify NVP?

A

Mild <6
Moderate 7-12
Severe 13-15
<12👉management in the community
>13 with no red flag 👉ambulatory daycare management
>13 with any red flag 👉 inpatient management

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9
Q

What are the laboratory tests changes associated with NVP & HG?

A

Hyponatremia ⬇️Na
Hypokalemia ⬇️K
Low urea ⬇️urea
Raised Ht ⬆️
Ketourea ( with metabolic alkalosis)
Severe 👉metabolic acidosis

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10
Q

What is the correlation between HG & thyroid functions?

A

📌2/ 3 (60%) of women with HG have abnormal TFs tests
[ due to similarity between TSH & HCG ] :
Raised FT4 +
with or without low TSH
Rarely have thyroid antibodies
( by absence of antibodies we can differentiate transient hyperthyroidism of HG from hypothyroidism)
🚩treatment is unnecessary

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11
Q

What is the correlation between HG & liver function tests ?

A

LFs tests are abnormal in 40 % of women with HG :
1- rise in trabsaminas ⬆️⬆️
2- bilirubin + amylase : ⬆️ mild

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12
Q

What is the correlation between HG and ketonuria ?

A

IS NOT an indicator of dehydration
NOT associated with severity of NVP or HG
& may be misleading

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13
Q

What are the neurological signs that should be detected in women with HG?

A

Confusion
Ataxia
Nystagmus
Could indicate Wernicke’s encephalopathy

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14
Q

What are the routine investigations should be done in a woman with NVP or HG ?

A

1- urine analysis ( culture &sensitivity if indicated)
2- urea & electrolytes
3- CBC
4- glucose level
5- ultrasound scan

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15
Q

What are the investigations should be done in refractory cases of NVP or HG ?

A

1- TFTs
2- LFTs ( to exclude Hepatitis/ gallstones )
3- Ca +phosphate amylase ( to exclude pancreatitis)
4- venus blood gases VBG ( to exclude metabolic disturbances)

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16
Q

What are the indications of inpatient care in cases of NVP?

A

1- inability to keep down oral antiemetics
2- clinical dehydration
3- weight loss > 5% of body weight
4- comorbidity: UTI and inability to tolerate oral antibiotics
5- comorbidity: epilepsy/ diabetes/ HIV / hypoadrnalism / psychiatric diseases
6- Recurrent or ongoing NVP despite ambulatory day care treatment

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17
Q

What is the first line therapeutic options for women with NVP?

A

📌combinations of different drugs should be used in women who don’t respond to a single drug
1- Doxylamine/pyridoxine (vitB6)
20 /20 po/ at night increase to additional 10/10 in the morning and 10/10 at lunch time.
2- Cyclizine 50mg (po/IM)/ 8h(anti-H)
3- promethazine ( anti-H)
4- prochlorperazine 5-10mg / 6-8h
( block dopamine receptors)
5- chlorpromazine
( block dopamine receptors)
[ 2 3 4 5 are phenothiazines]

18
Q

What is the famous antiemetic drug in pregnancy ?

A

XONVEA
Phenothiazine( antipsychotic)+ pyridoxine- Doxylamine
Should be prescribed initially when required for NVP

19
Q

What are the second line therapeutic options for NVP?

A

1- metoclopramide 5- 10 mg /8h
( short duration 5 days)
2- Domperidone 10mg/8h
3- ondasteron 4mg/8h OR 8mg/12h

20
Q

What are the considerations about ondasteron as antiemetic in pregnancy?

A

📌 women may require laxatives if constipation develops
📌 safe: very small increase risk of OROFACIAL CLEFTING 14/ 10 000
Compared to 10/ 10 000 control

21
Q

What are the third line therapeutic options for NVP ?

A

Hydrocortisone 100mg/ 12h IV
Once clinical improvement occurs
Convert to prednisolone 40-50mg/d PO &gradually tapered 5-10mg/w until lowest maintenance dose that controls the symptoms
📌 should control BP +Glucose
📌 is NOT associated with malformations

22
Q

What supplements should be considered in pregnant women admitted with vomiting ?

A

THIAMINE 100mg po TDS
Or IV B complex
Especially: before administration of dextrose or parenteral nutrition
[ NVP can lead to Wernicke encephalopathy due to vit B1 deficiency

23
Q

When to consider thromboprophylaxis in women with NVP?

A

IF admitted to the hospital
LMWH
* in the community: assess VTE risks

24
Q

How much the risk of VTE is increased in women with HG?

A

Odds ratio 2.5

25
Q

What is the role of PPI in treating women with NVP?

A

Along with antiemetic drugs
Reduce PUQE-24 scores
Improve quality of life

26
Q

If patient having HG with a history of gastric band or gastric bypass which deficiency is common?

A

Vit K + bit B1

27
Q

When is gastroscopy indicated in women with NVP?

A

Haematemesis
Epigastric pain

28
Q

What are the consequences of Wernicke encephalopathy?

A

Chronic cognitive disorders in 65%
Pregnancy loss 50%

29
Q

When to offer serial scans to monitor fetal growth in women with NVP?

A

If the symptoms continued into late second or third trimester

30
Q

How many women will be readmitted after discharge after HG treatment?

A

1/ 3

31
Q

What is the optimal rehydration regimen for ambulatory and inpatient ( with NVP)?

A

NORMAL SALINE with additional KCL in each bag
Daily monitoring of electrolytes
📌Dextrose is NOT RECOMMENDED
( can precipitate Wernicke encephalopathy)
[ dextrose is appropriate for nausea and vomiting in the 3rd trimester to prevent starvation keratosis]

32
Q

HG is a risk factor for
What mental disorder ?

A

PTSD

33
Q

How many times women with HG have low quality of life compared with women with NVP?

A

3 to 6 times

34
Q

In women with severe NVP or HG what is the multidisciplinary approach needed?

A

1- mental health team
2- psychiatric care
3- dietician

35
Q

What percentage of women would want termination of pregnancy as treatment option in HG ?

A

10 %

36
Q

What is the reported rates of recurrence in HG ?

A

15- 81 %

37
Q

What are the red flags to refer a woman with NVP to inpatient management?

A

1- any PUQE score + complications
2- inability to tolerate oral intake
3- unresponsive to outpatient management
4- clinical dehydration
5- weight loss >5% of the body weight
6- confirmed comorbidity:UTI
7- comorbidity: epilepsy - HIV
8- concerns regarding mental health

38
Q

What is the management in the case of HG inpatient care ?

A

1- antiemetics IV / IM
2- IV fluids ( 0.9 % normal saline +KCL + daily monitoring of electrolytes
3-THIAMINE supplements 50mg TDS
4- venous thromboprophylaxis
5- PPI
6- mental health assessment
7- ultrasound gestational scan

39
Q

What is the old criteria for diagnosing HG?

A

1- electrolytes imbalance
2- 5% weight loss from pre pregnancy
3- dehydration

40
Q

Which abnormality of acid- balance is most commonly seen in women with NVP?

A

Metabolic hypochloraemic alkalosis

12- NVP / HG Guidelines (1 decks)

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