*Hyperemesis Gravidarum

Question 1

Define hyperemesis gravidarum

Answer 1

PERSISTENT pregnancy related VOMITING associated withWEIGHT LOSS (>5%) not related to other causes
PLUS an objective measure of acute starvation such as carbohydrate depletion, electrolyte abnormalities and/or acid base disturbance (?ketosis).

Question 2

*Causes of HG

Answer 2

• Multifactorial causes: endocrine, gastrointestinal and psychological factors
• More common with increased levels of hormone GDF15: genetic link
• More common in multiple pregnancy and hydatidiform mole, suggesting an association with the level of hCG .
• Infection with Helicobacter pylori, the organism implicated in gastric ulcers, may also contribute
• History of HG - more likely to experience it again (15% 83%: limited research)

Question 3

Diagnosis of HG

Answer 3

History

Physical exam should include fetal heart rate (depending on gestational age) and an examination of fluid status, including an examination of blood pressure, heart rate, mucous membrane dryness, capillary refill, and skin turgor. A patient weight should be obtained for comparison to previous and future weights. If indicated, abdominal examination and pelvic examination should occur to determine the presence or absence of tenderness to palpation.

Clinical features - severity of symptoms
* sunken eyes
* loss of skin elasticity
* parched mouth and ips
* ketonuria
* oliguria (urinary output less than 20mls/hr, 400 mls/day)
* tachycardia,
* hypotension

Investigations
Full blood count
Electrolytes (sodium, potassium, chloride, bicarbonate, magnesium, urea and creatinine)
Liver and thyroid function tests (bilirubin, ALT, AST, albumin)
Urine; dipstick (high specific gravity = ?volume depletion, ketones = starvation) and MC&S
Ultrasound to look for multiple pregnancyor gestational trophoblastic disease.

Results:
Elevated haematocrit (percentage by volume of red cells in your blood), alterations in electrolyte levels and ketonuria are associated with dehydration.

Question 4

*Treatment of HG

Answer 4

Consider - what is the impact for her?
Consider - assessment of severity of HG using N&V ass. tool
Non-pharmacological then pharmacological

Non-pharm
* Switching prenatal vitamins to folic acid supplementation only
* Supplements - ginger + B6, thiamine
* Applying acupressure wristbands.
* Complimentary treatment: acupuncture./acupressure, hypnosis
* Diet - smaller and more frequent eating. ? protein meals decrease N&P. Eat desired foods.
* Smoothies. Avoid spicy food if triggering. Crackers before getting out of bed. Snack before bed or not - what are her triggers?
* Lifestyle: rest and avoid stress (referral to psychological medicine if necessary)

Medication:
Antiemetic therapy - Maxalon, Ondansetron
Antihistamine
Acid suppression
Laxatives
Steroids
Other supplements
Treatment for H.pylori
Treatment for ptyalism (excessive salivation)
* Need to consider teratogenic impact (if any)

Hospital admission for assessment and management of symptoms.
IV fluids to correct hypovolaemia and electrolyte imbalance
Thromboprophylaxis with compression stockings and low molecular weight heparin should be considered.
Slow re introduction of oral fluids and solids.

Rarely parenteral nutrition (TPN) - IV admin of nutrition

Consideration of interrupting pregnancy

Question 5

Nenonatal impact of HG

Answer 5

• Low birth weight
• Preterm birth
• PE (HG in 2nd trimester)
• Placenta abruption (HG in 2nd trimester)
• Vitamin K deficiency in newborn