Hyperemesis Flashcards
Definition of hyperemesis gravidarum
Nausea and/or vomiting caused by pregnancy leading to significant reduction of oral intake
and weight loss of at least 5% compared with pre-pregnancy, with or without dehydration and/or
electrolyte abnormalities.
SOMANZ definition
Evaluate 2 scoring systems for assessing the severity of HG
Rhodes score
PUQE- Pregnancy-Unique
Quantification of Emesis and Nausea
PUQE more simple than Rhodes score
Incidence of HG?
Natural history of HG?
1%
50% of women start to have resolution of sx by week 14, majority by week 22
Risk factors for HG
- High HCG e.g. due to trophoblastic disease, twins Mixed evidence for: - Pre-existing H Pylori - deficiency of trace elements, - excess thyroid hormones, -Gravidity, - fetal female sex, - psychiatric - dietary factors - Family history - black or asian ethnicity
Hx and examination of women with HG
History and physical examination should be directed towards identification of alternate diagnoses.
Physical examination should include assessment of temperature, weight, palpation of the abdomen for
abdominal tenderness and signs of peritonism, and an assessment for neck stiffness and signs of
raised intracranial pressure if the history is suggestive of a central nervous system cause for the
symptoms.
Signs to support a diagnosis of dehydration include decreased skin turgor, dry mucous
membranes, decreased urine output, concentrated urine, and postural drop in blood pressure
Investigations for HG
- Sodium, potassium, chloride, bicarbonate, magnesium, urea and creatinine
- Bilirubin, Alanine Transaminase (ALT), Aspartate Aminotransferase (AST), Albumin
- Obstetric ultrasound to exclude multi-fetal or gestational trophoblastic disease
- Tests to exclude alternate diagnoses where indicated
- Thyroid stimulating hormone (TSH) where indicated, TFTs frequently abnormal but usually normalise and rarely require treatment
Management
- Try to provide ambulatory care where possible
- Rehydration
- If severe HG and admitted for IVF then repeat U+Es
- Metaclopramide and Ondansetron should be second line antiemetics due to metaclopramides risk of extrapyramidal side effects and Ondansetrons minimal safety data
- Replace thiamine either PO or IV
- Consider clexane for women admitted to hospital
- Steroids when standard therapies have failed
- If severe- consider MDT, with dieticians, therapists, psych if needed etc
Complementary therapies for HG
Ginger- several systematic reviews have found evidence that ginger improves the symptoms of N+V when compared to placebo
Acustimulations – acupressure and acupuncture. Some improvement in systematic review to support the use of accupressure. No evidence of harm in pregnancy.
Hypnosis- no evidence
When should inpatient management of HG be considered?
- continued N&V with inability to keep down antiemetics
- continued N&V with >5% weight loss and/or ketonuria
- confirmed/suspected comorbidity (eg UTI and unable to keep down PO ABx)
Why is dextrose fluid not recommended for fluid replacement in HG?
- Risk of precipitating Wernickes encephalopathy in thiamine deficiency
- Risk of central pontine myeolinolysis in hyponatraemia
Proposed theories of HG?
- Caused by rise in HCG
- Relaxation of oesophageal sphincter and decreased gastric motility
- May be linked to thyroid hormones as many women found to have raised thyroid hormones in HG
- Possibly due to nutrient deficiency
Investigations for HG?
Urine dipstick:
– quantify ketonuria as 1+ ketones or more
G MSU
G Urea and electrolytes:
– hypokalaemia/hyperkalaemia
– hyponatraemia
– dehydration
– renal disease
G Full blood count:
– infection
– anaemia
– haematocrit
G Blood glucose monitoring:
– exclude diabetic ketoacidosis if diabetic G Ultrasound scan:
– confirm viable intrauterine pregnancy
– exclude multiple pregnancy and trophoblastic disease
G In refractory cases or history of previous admissions, check:
– TFTs: hypothyroid/hyperthyroid
– LFTs: exclude other liver disease such as hepatitis or gallstones, monitor malnutrition
– calcium and phosphate
– amylase: exclude pancreatitis
– ABG: exclude metabolic disturbances to monitor severity
Differential diagnosis of HG
peptic ulcers, cholecystitis, gastroenteritis, hepatitis, pancreatitis, genitourinary conditions such as urinary tract infection or pyelonephritis, metabolic conditions, neurological conditions drug-induced nausea and vomiting.
When should inpatient management be considered?
Continued nausea and vomiting and inability to keep down oral antiemetics
ketonuria and/or weight loss (greater than 5% of body weight), despite oral antiemetics
Confirmed or suspected comorbidity (such as urinary tract infection and inability to tolerate
oral antibiotics).
Advice for future pregnancies?
HG likely to recur
Some evidence to support pre-emptive antiemetics, found to reduce severity of HG in subsequent pregnancy
