Hyperemesis Gravidarum Flashcards
Symptoms illustrative of Hyperemesis gravidarum include:
- Severe, persistent vomiting
- Starvation with > 5% loss of PRE-pregnancy weight
- Dehydration
- Orthostatic hypotension
Symptoms persistent after the _______ trimester is illustrative of Hyperemesis gravidarum.
SECOND
Symptoms persistent after the SECOND trimester is illustrative of Hyperemesis gravidarum, however in general this is a disorder of persistent vomiting during the early portion of the pregnancy.
Outside of the physical examination, what labs can be used to aid in the diagnosis of Hyperemesis gravidarum?
- Urine ketones are elevated
(due to prolonged hypoglycemia from inadequate oral intake) - Hypochloremic hypokalemic metabolic alkalosis
(from vomiting) - Hemoconcentration
What can rule Hydatidiform mole either out or in for the cause of Hyperemesis gravidarum?
An U/S and hCG levels can be used to rule hyperemesis gravidarum caused by an hydatidiform mole either out or in as a diagnosis.
What is the difference between morning sickness commonly seen during early pregnancy and Hyperemesis gravidarum?
Morning sickness is marked by MILD nausea and vomiting and is common in early pregnancy. This is a situation with severe vomiting and leads to weight loss, dehydration, orthostasis, and lab irregularities (elevated urinary ketones, hypochloremic hypokalemic metabolic alkalosis.
What are the risk factors for Hyperemesis gravidarum?
- Hydatidiform mole due to increased hCG
- Multifetal gestation due to increased hCG
- History of migraine headaches
- History of GERD
- History of hyperemesis gravidarum
- History of first pregnancy (nulliparity)
- History of nausea with exposure to estrogen
What is the appropriate steps in managing a pregnant patient with Hyperemesis gravidarum?
- Admission to hospital
- Antiemetics & IVFs
IVFs to include electrolytes to correct Hypochloremic hypokalemic metabolic alkalosis
When treating Hyperemesis gravidarum, what B vitamin may be important and why?
Pyridoxine (B6) to serve as the initial antiemetic
Thiamine (B1) to prevent Wernicke’s encephalopathy and should be administered before solutions containing dextrose to prevent precipitating Wernicke encephalopathy.
What medications are used for the initial antiemetics for hyperemesis gravidarum?
Pyridoxine (B6) and/or Doxylamine
What is the appropriate dosage of Pyridoxine (B6) and/or Doxylamine for Hyperemesis gravidarum?
Pyridoxine/doxylamine 10 mg/10 mg PO
2 tablets at bedtime
or
1 tablet every 8 hours
Is TPN used in the treatment of Hyperemesis gravidarum?
Enteral feeding or TPN is recommended in patients with persistent symptoms and weight loss despite antiemetic therapy.
What medications are added for Hyperemesis gravidarum if Pyridoxine (B6) and/or Doxylamine is not sufficient enough to control symptoms?
Step-up medications for Hyperemesis gravidarum:
Diphenhydramine
25–50 mg PO every 4–8 hours
Dimenhydrinate
25–50 mg PO/PR every 4–8 hours as needed.
Max. 200 mg per day if the patient is also on doxylamine)
Promethazine
12.5–25 mg PO/PR every 4–6 hours
Prochlorperazine
25 mg PR every 12 hours
What medications are indicated for Hyperemesis gravidarum if Pyridoxine (B6) and/or Doxylamine with the appropriate step-up medications are not sufficient enough to control symptoms (refractory symptoms)?
Metoclopramide
5–10 mg PO/IM/IV every 6–8 hours
Ondansetron
4–8 mg PO/PR every 8–12 hours
Promethazine
12.5–25 mg PO/PR every 4–6 hours
What are the last resort medications for Hyperemesis gravidarum?
Chlorpromazine and methylprednisolone are last-resort options that may be considered in patients with nausea and vomiting refractory to antiemetics and if the benefits outweigh the risk associated with these drugs. Their use is contraindicated in the first trimester of pregnancy.
What are the fetal complications from hyperemesis gravidarum?
Preterm delivery, intrauterine growth restriction, low birth weight
