Hyperemesis Gravidarum Flashcards
What is Wernicke’s encephalopathy
potentially reversible yet serious neurological manifestation caused by vitamin B1(thiamine) deficiency
Wernicke’s encephalopathy causes
- commonly associated with alcohol consumption
- hyperemesis gravidarum
- starvation
- prolonged intravenous feeding
What percentage of pregnant women with hyperemesis gravidarum in early pregnancy experience transient hyperthyroidism?
60%
incidence of nausea and vomiting in pregnancy
80%
What is HEG
Presistent NVP with triad of
Dehydration
>5% pre-pregnancy weight loss
Electrolyte imbalance & Ketonuria
Incidence of HEG
0.3-3.6%
Causes of HEG
Genetic
Immunological
Due to rising bhcg - exclude multiple pregnancy and v mole
NVP when it starts, peaks and ends?
starts by 4-7w, peeks at 9 weeks, ends by 20 weeks in 90%
Which scoring index can be used to assess severity ?
PUQE
Rhodes was initially used for ?
Nausea & vomiting in chemotherapy patients
Investigations to be done for NVP & HEG ?
- CBC: raised HCT
- Urea and electrolytes: low Na & K
- Urine analysis and dipstick: Ketones
- LFTs: raised ALT,AST
- Thyroid function test (if refractory)
- ABG: metabolic alkalosis
Which metabolic disturbance is seen in HEG
Hypochloraemic metabolic alkalosis
Severe cases - metabolic acidosis
Which thyorid abnormality may be associated with HEG
Biochemical thyrotoxicosis - raised free thyroxine levels with or without low TSH
in 2/3 of cases or 66%
doesn’t require treatment
LFTs is abnormal in how many HEG cases
40%
elevated transaminases
DD of elvated transaminases other than HEG
Peptic ulcer
Hepatitis
Cholecystitis
Pancreatic
Gastroenteritis
UTI
Pyelonephritis
Metabolic
Neurological
Drug induced
Management of mild to moderate NVP or with PUQE score of 3-12 ?
Managed as outpatient
Lifestyle - dietary change
oral hydration
Oral antiemetics
Which antiemetics can be used in treating mild HEG
1st line
Antihistamines H1 receptor antagonists
Phenothiazines
2nd line
Metoclopramide
Domperidone
Ondansetron
Side effects of Metoclopramide and its max dose
S/e - extrapyramidal symptoms, oculogyric crisis
Max dose 30 mg / 24 hrs or 0.5 mg/kg / 24 hrs whichever is lower. Not for more than 5 days.
Congenital abnormalities seen with Ondansetron?
cleft palate
CVS defects
Cardiac septal defects
What if mild HEG don’t respond to a single antiemetic?
Combination of antiemetics from different classes
if not: change routes of adminstration
Which complementary therapies are useful in mild-moderate HEG
Ginger
Acupressure at PC6 point
No role of acupuncture and hypnosis
Fetal and Maternal side effects of ginger ?
No fetal adverse effects
Maternal
Stomach irritation
Bleeding
Interaction with beta blockers and benzodiazepene
What type of anti-emetics not to be used in outpatient management of HEG
Pyridoxine
no evidnece of safety
If HEG isn’t responding to outpatient management
admission for rehydration and monitoring
inpatient mangament regimen of HEG
- Hydration: Normal sline or Harttman solution + KCl
(adapted daily according to her elctrolyte results) - Routine Thiamine supplement (oral/IV) to prevent Wernicks encephalopathy.
- Monitor weight, pulse & BP
- Stop drugs that cause nausea & vomiting temporarily (iron)
- Thromboprophylaxis (Enoxaparin 40mg) + stocking
What not to do in inpatient hydration regimen of HEG
Don’t:
* Use double strenght saline as rapid correction of hyponatremia may cause Central Pontine myelnolysis.
* Don’t use solutions contain dextrose as it has no enough NA+ and may cause Werniche enchephalopathy
When can we give dextrose in HEG
after correction of sodium and thiamine
Indications of inpatient management of HEG
- PUQE 13 and above with complications
- NV with complications - ketonuria and / or weight loss despite oral antiemetics
- Inability to tolerate oral with continued NV
- Confirmed or suspected co-morbidities
What if 1st and 2nd line antiemetics fail ?
Corticosteroids
Iv hydrocortisone 100 mg BD till clinical improvement
Then oral prednisone 40-50 mg with tapering till lowest maintenance dose is achieved
what is complications of giving corticosteroids in 1st trimester
studies show risk of oral clefting, so it should be restricted to refractory cases where maternal benifits overweigh fetal risks
what if all medical management fail?
Enteral or parenteral nutrition
if fails: termination of pregnancy
How many females affected with HEG end up with unwanted termination?
10%
How do you follow up further in the pregnancy?
Follow up in ambulatory care
Continue with hydration and antiemetics
Serial growth scans
Recurrence rate of HEG
15-80%
Are antithyroid drugs beneficial in HEG
No aa there is no increase in thyroid activity
What is the antidote for metoclopramide extrapyramidal symptoms?
Procyclidine IV
How many women w HEG will be readmitted within same pregnancy
1/3 of women
How many patient with HEG mat terminate
10%
Common reason for termination in HEG
- inability to care for onself or family
- Fear of maternal or fetal death
- Concerns about fetal malformations
Rate pf recurrence of HEG in subsequent pregancnies
89%
