Hyperemesis Gravidarum

Question 1

What is Wernicke’s encephalopathy

Answer 1

potentially reversible yet serious neurological manifestation caused by vitamin B1(thiamine) deficiency

Question 2

Wernicke’s encephalopathy causes

Answer 2

• commonly associated with alcohol consumption
• hyperemesis gravidarum
• starvation
• prolonged intravenous feeding

Question 3

What percentage of pregnant women with hyperemesis gravidarum in early pregnancy experience transient hyperthyroidism?

Answer 3

60%

Question 4

incidence of nausea and vomiting in pregnancy

Answer 4

80%

Question 5

What is HEG

Answer 5

Presistent NVP with triad of
Dehydration
>5% pre-pregnancy weight loss
Electrolyte imbalance & Ketonuria

Question 6

Incidence of HEG

Answer 6

0.3-3.6%

Question 7

Causes of HEG

Answer 7

Genetic
Immunological
Due to rising bhcg - exclude multiple pregnancy and v mole

Question 8

NVP when it starts, peaks and ends?

Answer 8

starts by 4-7w, peeks at 9 weeks, ends by 20 weeks in 90%

Question 9

Which scoring index can be used to assess severity ?

Answer 9

PUQE

Question 10

Rhodes was initially used for ?

Answer 10

Nausea & vomiting in chemotherapy patients

Question 11

Investigations to be done for NVP & HEG ?

Answer 11

• 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

Question 12

Which metabolic disturbance is seen in HEG

Answer 12

Hypochloraemic metabolic alkalosis

Severe cases - metabolic acidosis

Question 13

Which thyorid abnormality may be associated with HEG

Answer 13

Biochemical thyrotoxicosis - raised free thyroxine levels with or without low TSH

in 2/3 of cases or 66%

doesn’t require treatment

Question 14

LFTs is abnormal in how many HEG cases

Answer 14

40%
elevated transaminases

Question 15

DD of elvated transaminases other than HEG

Answer 15

Peptic ulcer
Hepatitis
Cholecystitis
Pancreatic
Gastroenteritis
UTI
Pyelonephritis
Metabolic
Neurological
Drug induced

Question 16

Management of mild to moderate NVP or with PUQE score of 3-12 ?

Answer 16

Managed as outpatient

Lifestyle - dietary change
oral hydration
Oral antiemetics

Question 17

Which antiemetics can be used in treating mild HEG

Answer 17

1st line
Antihistamines H1 receptor antagonists
Phenothiazines

2nd line
Metoclopramide
Domperidone
Ondansetron

Question 18

Side effects of Metoclopramide and its max dose

Answer 18

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.

Question 19

Congenital abnormalities seen with Ondansetron?

Answer 19

cleft palate
CVS defects
Cardiac septal defects

Question 20

What if mild HEG don’t respond to a single antiemetic?

Answer 20

Combination of antiemetics from different classes
if not: change routes of adminstration

Question 21

Which complementary therapies are useful in mild-moderate HEG

Answer 21

Ginger
Acupressure at PC6 point

No role of acupuncture and hypnosis

Question 22

Fetal and Maternal side effects of ginger ?

Answer 22

No fetal adverse effects

Maternal
Stomach irritation
Bleeding
Interaction with beta blockers and benzodiazepene

Question 23

What type of anti-emetics not to be used in outpatient management of HEG

Answer 23

Pyridoxine

no evidnece of safety

Question 24

If HEG isn’t responding to outpatient management

Answer 24

admission for rehydration and monitoring

Question 25

inpatient mangament regimen of HEG

Answer 25

• 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

Question 26

What not to do in inpatient hydration regimen of HEG

Answer 26

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

Question 27

When can we give dextrose in HEG

Answer 27

after correction of sodium and thiamine

Question 28

Indications of inpatient management of HEG

Answer 28

• 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

Question 29

What if 1st and 2nd line antiemetics fail ?

Answer 29

Corticosteroids

Iv hydrocortisone 100 mg BD till clinical improvement
Then oral prednisone 40-50 mg with tapering till lowest maintenance dose is achieved

Question 30

what is complications of giving corticosteroids in 1st trimester

Answer 30

studies show risk of oral clefting, so it should be restricted to refractory cases where maternal benifits overweigh fetal risks

Question 31

what if all medical management fail?

Answer 31

Enteral or parenteral nutrition
if fails: termination of pregnancy

Question 32

How many females affected with HEG end up with unwanted termination?

Answer 32

10%

Question 33

How do you follow up further in the pregnancy?

Answer 33

Follow up in ambulatory care
Continue with hydration and antiemetics
Serial growth scans