Hyperemesis Gravidarum Flashcards
Define hyperemesis gravidarum
Intense nausea ± vomiting during pregnancy
> 5% weight loss
Dehydration
Electrolyte imbalance
What are the causes of nausea in pregnancy
Hyperemesis gravidarum
Hydatidiform/molar pregnancy
Ectopic pregnancy
Acute fatty liver of pregnancy
Pre-eclampsia
Genitourinary: UTI, renal disease, pyelonephritis, ovarian torsion, renal stone
Endocrine/metabolic: hypercalcaemia, hyperPTH, thyrotoxicosis, DKA, Addison’s
GI: gastritis, peptic ulcer, gastroenteritis, pancreatitis, cholecystitis, bowel obstruction
Neuro: migraine, CNS tumour
Iron or opioid use
What are the risk and protective factors for hyperemesis gravidarum
PMHx hyperemesis gravidarum, ectopic, hydatidiform
Young maternal age
Hyperthyroid disorders
Pre-existing diabetes
Multiple pregnancy
Psychiatric illness
FMHx hyperemesis gravidarum, ectopic, hydatidiform
Protective: smoking, maternal age >30
What % of pregnancies are affected by nausea and vomiting and hyperemesis gravidarum
N&V - 90%
hyperemesis gravidarum - 1%
What questions should be asked for a pregnant women with increased Nausea and vomiting
Onset, duration, frequency, severity
Oral intake
Weight loss OR weight prior to pregnancy
Impact on mood and emotional wellbeing (coping, support, routine, QOL)
Presence of fever, urinary symptoms, headache, neurological symptoms, abdominal pain
PMHx diabetes mellitus or CKD (symptoms increase risk of complications)
What signs should be looked for on examination for nausea and vomiting in pregnancy
Obs - ?Severe dehydration: tachycardia, hypotension and delirium
Height and weight - HG - >5% weight loss
General
Signs of dehydration:
Prolonged capillary refill
Dry mucous membranes
Reduced skin turgor
Sunken eyes
Abdominal
Assess pregnancy
What investigations should be done for nausea and vomiting in pregnancy
Pregnancy-Unique Quantification of Emesis (PUQE) score.
Urine dipstick: ketones + elevated SG + exclude pre-eclampsia
Bloods done for moderate-severe symptoms
FBC
U&Es (hyponatraemia, hypochloraemia)
LFTs
TFTs: may show suppressed TSH due to elevated HCG
Amylase (exclude pancreatitis)
Pelvic USS: Exclude multiple gestation, GTD, hydrops fetalis, increased nuchal translucency
What is the management for hyperemesis gravidarum
Re-assure: common in pregnancy and usually resolves by 16-20 weeks
Self-care:
- Rest, avoid triggers (odours, heat, noise)
- Eat plain biscuits or crackers in the morning
- Eat small, bland, frequent meals
- Cold meals may be more easily tolerated
- Drink little and often rather than in large amounts
- Ginger, acupressure
First line: Cyclizine oral or prochlorperazine (stemetil IM)
Second line: oral metoclopramide or ondansteron
Third line: Corticosteroids
What features suggest a need for admission if they have nausea and vomiting in pregnancy
Systemically unwell
Clinically dehydrated
Unable to keep down fluids
Persistent symptoms despite medication
Suspected complication
What is the acute management for hyperemesis gravidarum on pesentation to secondary care
- Fluids and electrolyte replacement
a. Administration of normal saline with potassium chloride to correct dehydration and cyclizine to reduce nausea and vomiting - Thiamine replacement: Pabrinex (Vit B and C)
a. For Wernicke’s encephalopathy (look out for diplopia and ataxia) - DVT prophylaxis
- Anti-emetics IM
What are the side effects of oral metoclopramide, domperidone and ondansetron
Metoclopramide: extrapyramidal effects
Domperidone: cardiac adverse effects
Ondansetron: small increased risk of cleft lip/palate in first trimester
What are the complications of hyperemesis gravidarum
Hypokalaemia → muscle weakness, cardiac arrhythmias
Thiamine deficiency → Wernicke’s encephalopathy → ophthalmoplegia and confusion
Mallory-Weiss tears
Retinal haemorrhages
Central pontine myelinolysis
Acute tubular necrosis
HG: SGA
What is the prognosis for nausea and vomiting in pregnancy and hyperemesis gravidarum
Uncomplicated NVP has excellent prognosis, resolving by the 20th week of gestation + shown to have improved pregnancy outcomes e.g. miscarriage, pre-term delivery, stillbirth
Hyperemesis may persist throughout the pregnancy and often requires ongoing pharmacological intervention, intravenous hydration, and hospital admission.
Associated with an increase in maternal morbidity, and also increased fetal morbidity and mortality.