Green Top Guideline Flashcards by Siba Kherbek

When is NVP diagnosed ?

Nausea and vomiting prior to 16w

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When is HG diagnosed?

symptoms early in pregnancy
severe: limit daily activities
signs of dehydration.

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What is the percentage of pregnant women affected by NVP?

90 %

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

NVP
Typical stays of 3-4 days

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When are symptoms of NVP start?

Start 4-7w
Peak 9w
Resolvie 20 w

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What is the incidence of HG in pregnancy?

0.3- 3.6 %

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What is the pathophysiology of NVP & HG ?

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

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

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

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

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What is the correlation between HG & thyroid functions?

📌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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What is the correlation between HG & liver function tests ?

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

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What is the correlation between HG and ketonuria ?

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

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

Confusion
Ataxia
Nystagmus
Could indicate Wernicke’s encephalopathy

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

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

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

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

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

📌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]

What is the famous antiemetic drug in pregnancy ?

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

What are the second line therapeutic options for NVP?

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

What are the considerations about ondasteron as antiemetic in pregnancy?

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

What are the third line therapeutic options for NVP ?

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

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

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

When to consider thromboprophylaxis in women with NVP?

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

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

Odds ratio 2.5

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

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

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

Vit K + bit B1

When is gastroscopy indicated in women with NVP?

Haematemesis Epigastric pain

What are the consequences of Wernicke encephalopathy?

Chronic cognitive disorders in 65% Pregnancy loss 50%

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

If the symptoms continued into late second or third trimester

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

1/ 3

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

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]

HG is a risk factor for What mental disorder ?

PTSD

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

3 to 6 times

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

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

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

10 %

What is the reported rates of recurrence in HG ?

15- 81 %

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

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

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

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

What is the old criteria for diagnosing HG?

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

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

Metabolic hypochloraemic alkalosis