Hyperemesis Gravidarum Flashcards
What is the triad of hyperemesis gravidarum?
5% Pre pregnancy weight loss
Electrolyte imbalance
Dehydration
Risk factors for hyperemesis gravidarum
Multiple pregnancies Trophoblastic disease Hyperthyroidism Nulliparity Obesity
What is associated with a decreased incidence of hyperemesis gravidarum?
Smoking
Definition of hyperemesis gravidarum
Excessive nausea and vomiting in pregnancy
Treatment of hyperemesis gravidarum
Anti emetic therapy
- Antihistamines 1st line (promethazine)
- Ondansetron and metoclopramide 2nd line
IV hydrationcs
TSH and T4 if no improvement over 48 hours
Refer to dietician for dietary advice if not improving after 48 hours
Treat GORD
Complications of hyperemesis gravidarum
Wernickes encephalopathy Mallory weis tear Central pontine myelinolysis Acute tubular necrosis Small for gestational age of foetus Pre term birth
Differential diagnosis of hyperemesis gravidarum
UTIs Multiple pregnancy Hydatiform mole Reflux oesophagitis Thyrotoxicosis Addisons disease Pancreatitis Enteric infections Infections Hypercalcaemia Peptic ulceration Hepatitis Appendicitis
Investigations of hyperemesis gravidarum
MSSU (UTI exacerbating or predisposing N + V) Urine dipstick - proteinuria - ketones (Diabetes, catabolic) Urine specific gravity (dehydration) U and Es FBC Patient weight USS
U and Es findings of hyperemesis gravidarum
Hyponatraemia
Hypokalaemia
Low urea
FBC findings in hyperemesis gravidarum
Haemtocrit increase in dehydration
Why is an USS an investigation of hyperemesis gravidarum?
To rule out multiple pregnancy and mole
If nausea and vomiting > 3 days, what may be done?
Change anti emetic therapy Prescribe ranitidine if reflux is a problem Vitamin injections Steriods - 40mg initially then reduce as tolerated NG or NJ feeding if weight loss > 10% body weight Refer to clinical psychologist Alternative therapies - aromatherapy - hypnotherapy - acupunture - "C bands" - relaxation TPN
Examples of vitamin injections
Pabrinex IVHP
Solvito N
When does hyperemesis gravidarum occur in pregnancy?
Early pregnancy
- first trimester - 6 - 8 weeks of pregnancy
What is HG a diagnosis of?
Exclusion
Which hormone may cause HG?
Human chorionic gonadotrophin
What is the level of HCG correlated to in HG?
The severity of vomiting
Relation of HCG levels and thyroid levels
HCG shares a common alpha-sub unit with TSH and acts as a thyroid stimulator in patients with hyperemesis , hence elevated free thyroxine concentrations
What is the fluid replacement of choice in HG?
Normal saline
What makes up normal saline?
Sodium chloride 0.9%, 150mmol/L Na+
What makes up Hartmanns?
Sodium chloride 0.6%, 131 mmol/L Na+
Which fluid choice is contraindicated in HG and why?
Dextrose
It precipitates Wernickes encephalopathy and can worsen hyponatraemia
How can hypokalaemia be treated in HG?
Infusion bags containing 40mmol/L of potassium chloride
What should fluid replacement in HG have done to it?
Titrated against U and Es
Examples of anti emetics that can be used in HG which do not respond to IV fluids and anti emetics alone
Cyclizine
Prochloperamide
Stemetil
Metoclopramide
Complications of TPN
Phlebtitis
Thrombosis
How quickly can the effects of TPN work?
Quickly
How is TPN given?
Via a central line
Cause of wernickes encephalopathy
Vitamin B1 (Thiamine) deficiency
What can wernickes encephalopathy be precipitated by?
IV fluids containing dextrose
Triad of wernickes encephalopathy
Confusion
Ataxia
Opthalmoplegia
Incidence of foetal death in WE
40%
Treatment of WE
IV/IM Thiamine replacement
Recovery rate if WE also has retrograde amnesia, impaired ability to learn and confabulation (korasskoff psychosis)
50%
