Hyperemesis Gravidarum Flashcards
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Definition
Persistent nausea and vomiting in early pregnancy severe enough to cause dehydration, weight loss and electrolyte disturbance/ketosis
How common is it?
0.1-1% women
Risk factors?
Multiparous
Multiple pregnancies
Molar pregnancies
Previous HG
When does it present (or when does it stop)?
Rarely persists after 14w
Not to be confused with…
…morning sickness (NVP) is mild to moderate nausea and vomiting in pregnancy (mild affects 50% and typically self-limiting, and moderate affects 5%, which can lead to hospital admission, but not as severe as HG)
Presentation
Inability to keep food/fluids down Weight loss +/- nutritional defecit Dehydration Hypovolaemia Tachycardia Postural hypotension Electrolyte disturbance (hypokalaemia, hyponatraemic shock) Polyneuritis (from vitamin deficiency) Behavioural disorders Mallory-Weiss tears (haematemesis) Liver and renal failure May be ptyalism (failure to swallow saliva) and spitting
Ix
Urine dip (ketones and UTI - send MSU)
FBC (raised hct)
U and E (exclusion of hypokalaemia/hyponatraemia)
LFT (transaminases deranged, albumin low)
USS to rule out mole and diagnose multiple pregnancy
Management
Admission
Fluid resuscitation (be aware glucose may cause Wernickes so prescribe folic acid and thiamine)
Regular monitoring (U&Es etc)
Antiemetics (metoclopromide, cyclizine or ondansetron)for hyperemesis, use corticosteroids if antiemetics ineffective (prednisolone 40-50mg OD or hydrocortisone 100mg/12hr IV)
Thromboprophylaxis (enoxaparin 40mg/24hr SC + antithromboembolic stockings)
Psychological support
What is nausea and vomiting of pregnancy (NVP)?
Onset of N&V in first trimester with other causes excluded
What is the management of mild NVP?
Oral antiemetics
Oral hydration
Dietary advice (i.e. cold food over hot)
Support, reassurance
What first line oral anti-emetic would be indicated in NVP?
Anti-histimine (cyclizine, promethazine)
Phenothiazine (prochloperazine)
What is the pathophysiology of HG?
Adverse reaction to rising hCG levels in blood (hence HG risk higher in multiple pregnancies, molar pregnancy)
hCG structurally similar to TSH (abnormal TFTs in 2/3 HG pts - but euthyroid clinically so treatment with anti-thyroid drugs inappropriate)
Increase in levels of oestrogen and progesterone (decreased gastric emptying/gastric motility and inc laxity of lower oesophageal sphincter)
FHx suggests a genetic link
What scoring system is used to assess the severity of HG?
PUQE score
Mild NVP = 6; moderate NVP 7-12; severe NVP >12
Used to track progress with treatment
On admission for HG, what should be considered when prescribing?
Anti-emetics IV fluids Analgesia Abx? (if UTI etc) Ranitidine Folic acid Thiamine Thromboprophylaxis
What anti-emetics can be used when first line fail for HG?
Metoclopramide (D antagonist)
Risk of extrapyramidal side effects
Avoid in <18y
Ranitidine can be used to alleviate reflux symptoms
