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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > Hyperemesis > Flashcards

Hyperemesis Flashcards

1
Q

What is hyperemesis gravidarum?

A

Defined as persistent vomiting in pregnancy which causes weight loss (>5% pre-pregnancy weight) and ketosis

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2
Q

When is the onset of hyperemesis gravidarum?

A

Always within the first trimester

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3
Q

What are risk factors for the development of hyperemesis gravidarum?

A
  • Multiple pregnancies (high bHCG levels)
  • Molar pregnancies
  • Previous hyperemesis gravidarum
  • Youths
  • Non smokers
  • Primips
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4
Q

Which hormone is thought to be the causative agent for hyperemesis gravidarum?

A

BHCG

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5
Q

How is BHCG correlated with symptoms in hyperemesis gravidarum?

A

Directly correlated to severity of vomiting - more BHCG there is, more vomiting

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6
Q

Why does hyperemesis present in the first trimester?

A

Peak levels of HCG in pregnancy are around 6-12 weeks

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7
Q

Why can those with hyperemesis have elevated free thyroxine levels?

A

HCG shares a common alpha-subunit with TSH and acts as a thyroid stimulator in patients with hyperemesis

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8
Q

Why might hyperemesis be more common in those with multiple pregnancies and molar pregnancies?

A

HCG levels are higher than normal singleton pregnancy.

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9
Q

What are clinical features of hyperemesis gravidarum?

A
  • KEY TRIAD OF
    _WEIGHT LOSS,
    DEHYDRATION,
    ELECTROLYTE IMBALANCE    _
  • Inability to keep down food or fluid
  • Decreased weight (>15%) +/- nutritional deficiency
  • Dehydration
  • Ketosis
  • Electrolyte disturbacnce (hypokalaemia, hyponatraemia)
  • Tachycardia
  • Postural hypotension
  • Polyneuritis
  • Mallowry-Weiss tears
  • Liver and renal failure
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10
Q

What would you consider as a differential diagnosis for someone with features of hyperemesis gravidarum?

A
  • UTI
  • Multiple pregnancy
  • Hydatiform mole
  • GORD/Peptic ulceration
  • Thyrotoxicosis
  • Addison’s disease
  • Pancreatitis
  • Enteric infection
  • Hepatitis
  • Hypercalcaemia
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11
Q

What investigations would you consider doing in somoene with features of hyperemesis gravidarum?

A
  • Bedside - Diptick, MSSU, weight
  • Bloods - U+E’s, FBC, TFTs, BHCG, LFTs
  • Imaging - USS

Must take HR, BP and weight - repeat weight every 3 days, >5% weight loss assocaited with LBW)

Note diagnosis of exclusion eg UTI, SBO, acidosis, pancreatitis

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12
Q

What might you find on investigation of urine dipstick in someone with hyperemesis gravidarum?

A
  • Proteinuria - UTI
  • Ketones - diabetes, catabolic state
  • SG - dehydration
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13
Q

What might you find on investigation of MSSU?

A

UTI (which could be the cause of the N+V!)

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14
Q

What might you find on investigation of U+E’s in someone with hyperemesis gravidarum?

A
  • Hyponatraemia
  • Hypokalaemia
  • Low urea
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15
Q

What might you find on investigation of FBC in someone with hyperemesis gravidarum?

A

Raised haematocrit (occurs in dehydration)

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16
Q

When should TFTs be performed in someone with hyperemesis gravidarum?

A

Only if other signs of hyperthyroidism

17
Q

Why might you perform a abdominal USS in someone with features of hyperemesis gravidarum?

A

Look for signs of multiple pregnancy, mole and assess current pregnancy

18
Q

How would you initially manage someone with hyperemesis gravidarum?

A
  • GORD management - Elevate head of bed, small meals, alginates
  • Anti-emetic trials - find ones that work
    • If intractable on anti-emetics - Steroids
  • Vitamin injection
  • If severely dehydrated- admit and rehydrate with electrolyte replacement
  • Consider VTE thromboprophylaxis
19
Q

How would you manage someone with hyperemsis if N+V continued for >3 days

A
  • Change antiemetic therpay
  • Ranitidine for reflux
  • Steroids
  • Nasogastric/jejunal feeding if weight loss >10% - get dietician!
  • Consider TPN (thrombosis risk)
20
Q

What antiemetics are used in managing hyperemesis gravidarum?

A
  • Cyclizine (antihistamine)
  • Prochlorperazine (antihistmaine)
  • Metoclopramide (dopamine agnosist)
  • Chlopromazine
  • Domperidone (dopamine agonist)
  • Ondansetron 5HT3 blocker
21
Q

What vitamin supplementation should you give someone with hyperemesis gravidarum?

A
  • Folic acid
  • Pabrinex - Thiamine multivitamin
22
Q

Why should you give thiamine and folic acid replacement in someone with hyperemesis gravidarum?

A

Risk of wernicke’s encephalopathy

If retrograde amnesia, impaired ability to learn and confabulation - korsakoff’s

23
Q

What fluids would you use to correct dehydration in someone with hyperemesis gravidarum?

A
  • Normal 0.9% saline - fluid of choice.
  • Hartmann’s solution
  • To correct hypokalemia - infusion of 40mmol/L of KCL can be used.
24
Q

Why would you not give someone dextrose solution if they had hyperemesis gravidarum?

A

Precipitates Wernicke’s encephalopathy

25
Q

Why is VTE prophylaxis advised in someone with hyperemesis gravidarum?

A

Due to dehydration combined with the fact they are pregnant, they are a thombosis risk

26
Q

When are corticosteroids used in hyperemesis gravidarum?

A

After anti-emetics and fluid replacement have not worked

(40mg intially then reduce as tolerated)

27
Q

What other health professionals should be involved in the management of someone with hyperemesis gravidarum?

A
  • Dietician
  • Clinical psychologist
28
Q

What may be needed in terms of nutritional management of someone with severe hyperemesis gravidarum?

A

Total parental nutrition

29
Q

What complications are associated with TPN?

A
  • Thrombosis
  • Phlebitis
30
Q

If a woman with hyperemesis gravidarum presented with feeling unsteady on her feet, having blurred visionhas increased confusion, her short term memory is not what it used to be, what might you suspect purely from the symptoms is the cause of her problems?

A

Wernicke’s encephalopathy

31
Q

What might you see on examination in a woman with wernicke’s encephalopathy?

A
  • Thought process appears slow
  • Can obey commands
  • Hoizontal and vertical nystagmus
  • Normal limb movement and sensation
  • Ataxic gait
  • Opthalmoplegia
32
Q

What is wernicke’s encephalopthy caused by?

A

Vitamin B1 deficiency

33
Q

What is the classic triad for wernicke’s encephalopathy?

A

The classic triad is of confusion, opthalmophlegia and ataxia.

34
Q

How would you treat wernicke’s encephalopathy in a woman with hyperemesis gravidarum?

A

IM thiamine injections - prognosis depends on severity

35
Q

Complications of hyperemesis

A
  • Liver and renal failure
  • Wernicke’s encephalopathy
  • Mallory-weiss tear
  • ATN
  • Fetal - small gestational age and preterm birth

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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