Hyperemesis Gravidarum Flashcards
How does this patient present?
Signs of dehydration Tachycardia Low urine output (with ketonuria) Unable to retain liquids or solids Persistent Vomiting refractory to meds
Tests show Electrolyte disturbances and nutritional deficiencies
What are rhe risk factors for HG?
Primigeavidae Teenagers Non smokers Obesity Multiple pregnancy
What is the incidence of hyperemesis gravidarium
Less than 1%
What causes HG? (Aetiology)
Endocrine factors
- hypothyroidism
- high estrogen at CTZ (check receptor trigger zone
- High HCG due to Trophoblastic disease or multiple pregnancy
Psychogenic factors
*Emotional stress and fear
*
What are your differentials for HG?
MEDICAL
Pre eclampsia (after 20 weeks)
HELLP Syndrome
SURGICAL Appendicitis Acute intestinal obstruction Cholecystitis torsion of ovarian cyst
INFECTIOUS
Uti /pyelonephritis
Rare: diabetic ketoacidosis, cerebral tumors, cerebral thrombosis
What are the complications of HG?
Weight loss
Dehydration
Thromboembolism
Electrolyte disturbance (hyponatremia, hypokalemia, hypochloremia)
Mendelsons syndrome - aspiration pnemonitis
Mallory Weiss syndrome - esophageal mucosa tears secondary to retching
Vitamin deficiencies
- b1– wernickes encephalopathy
- b12, b6– megaloblastic anemia and peripheral neuropathy
Fetal growth restrictions
What investigations would you do on this patient with HG and WHY??
Urinalysis - 2+ ketonuria significant (if protein blood leucocytes or nitrites present then MSU indicated)
Mid stream urine MSU - for microscopy, C+S
Complete blood count - raised hematocrit in dehydrated patient ans thrombocytopenia in HELLP syndrome.
Urea and electrolytes - reveal if there is hypo- natremia, chloremia, or kalemia
LFTs - elevated transaminases
Thyroid function tests - may be abnormal due to HCGs stimulating effect on the Thyroid.
Ultra sound scan - rule out multiple pregnancy and gestational trophoblastic disease ( molar pregnancy)
How would you manage a mild case of HG?
Mild cases
General management
Reassurance
Dietary advice (no oil, dry bland foods, sip water or electrolytes)
Ginger and pyroxidine
Why ketonuria in Hyperemesis gravidarum?
Not sure yet????
What is the usual time-frame for vomiting in pregnancy
Starts at 4- 7 weeks
How do you manage a severe case of HG?
Specific/advanced management
- Admission to hospital
- Strict input output charting
- Iv fluids ( isotonic-ns)
- Daily electrolytes/ chemistry
- AVOID DEXTROSE (may cause wernickes encephalopathy)
- Antiemetic drugs
- Antacids (omeprazole, ranitidine)
- Vitamins b1 (thiamine, very important) , b6, b12
- Nutritional support eg. Parental nut. If severe
- Thromboprophylaxis (obesity, immobilization)
- Termination of pregnancy
List the antiemetics that are safe for use in pregnancy and HG treatment.
- Dopamine antagonists- chlorpromazine(largactil), domperidone
- Antihistamines- dimenhydrinate (gravol), promethazine
- Piperazine derivatives - Cyclizine
- serotonin antagonists - refractory cases
- corticosteroids- intractable cases
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