Hyperemesis Gravidarum (Complete) Flashcards
Define hyperemesis gravidarum
Severe nausea and vomitting occuring before 16th week of gestation
What is the aetilogy of hyperemesis gravidarum?
Increase in beta-hCG and oestrogen activates chemoreceptors of brainstem triggering nausea and vomitting
Hyperemesis gravidarum most commonly occurs between which weeks of gestation?
4-8th week
What are the main risk factors for hyperemesis gravidarum?
Genetic predisposition:
Previous history of hyperemesis gravidarum
Family history of hyperemesis gravidarum
Pre-existing migraines or motion sickness
Pregnancy-related:
First pregnancy
Multiple pregnancy (Higher beta-hCG levels)
Molar pregnancy (very high beta-hCG levels)
Female foetus
Pre-existing GI conditions:
GORD
H. pylori
Coeliac disease
Other:
Young maternal age
BMI >25
N.B. Smoking is associated with decreased risk of hyperemesis gravidarum
What is the diagnostic criteria for hyperemesis gravidarum?
ALL THREE of the following:
1) >5% pre-pregnancy weight loss
2) Clinical dehydration
- Reduced skin turgour
- Dry mucous membranes
- Tacchycardia
- Hypotension
- Reduced urine output
3) Electrolyte imbalance (any of following)
- Hypokalaemia
- Hyponatraemia
- Metabolic alkalosis (elevated bicarbonate)
- Metabolic acidosis (in severe cases)
Which patients should be considered for hospital admission?
Unable to keep down liquids or oral antiemetics
Ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics
Confirmed or suspected comorbidity (e.g. unable to tolerate oral antibiotics for a UTI)
What differentials should be considered alongside hyperemesis gravidarum?
Molar pregnancy
- Very elevated beta-hCG levels + uterine enlargement, vaginal bleeding, absent foetal heartbeat
Infection (e.g gastroenteritis, UTI, meningitis)
Gastrointenstinal conditions
* Cholecystitis
* Appendicitis
* Bowel obstruction
DKA
Drug toxicity
What investigations should be conducted in patients with suspected hyperemesis gravidarum?
Bedside:
Basic obs: Check for haemodynamic instability
Body weight: Check for weight los > 5%
Urine dipstic: Check for ketones seen in dehydration
PUQE score: Check need for hospital admission (> 13 points)
Bloods:
VBG/ABG: Check for alkalosis/acidosis and blood glucose levels
U&Es: Check for electrolyte disturbance and AKI
beta-HCG: Check for signs of molar pregnancy
What questionaire tool can be used to assess whether patients with hyperemesis gravidarum require hospital admission?
PUQE score
The Pregnancy-Unique Quantification of Emesis and Nausea
What points on PUQE scoring system are suggestive of severe presentation, requiring hospital admission?
>13 points
For moderate cases consider ambulatory day centres for management
What are PUQE scores for the following?
Mild
Moderate
Severe
Mild: < 6 points
Moderate: 7-12
Severe: > 13 points
How are patients with hyperemesis gravidarum managed?
Conservative:
Oral rehydration (mild cases)
Medicine:
IV fluids with electrolyte correction (e.g. pottasium chloride if hypokalaemia)
First-line anti-emetics:
- Cyclizine
- Prochlorperazine
- Promethazine
Second-line anti-emetics:
- Ondansetron
- Metoclopramide
- Domperidone
Thiamine (e.g. IV pabrinex) and folic acid supplementation
- Prevent wernicke’s encephalopathy
Antacid therapy: For reflux symptoms
Thromboprophylaxis
- LMWH
- Compression stockings
What are first-line anti-emetics for patients with hyperemesis gravidarum?
Cyclizine
Prochlorperazine
Promethazine
What first-line anti-emetic has sedative effects and may be useful in patients with night-time presentation?
Promethiazine
List examples of second-line anti-emetics in management of hyperemesis gravidarum
Ondansetron
Metoclopramide
Domperidone
Why is ondansetron only considered in severe cases?
Small increased risk of the baby having a cleft lip/palate
Patients MUST be informed of the risks before giving
Why is domperidone and metoclopramide only considered in severe cases?
May cause extrapyramidal effects
Should be used for no more than 5 days to minimise risk
What is given to avoid risk of Wernicke’s encephalopathy in patients with hyperemesis gravidarum?
Thiamine (IV pabrinex) and folic acid
What is given as prophylaxis for thromboembolism due to dehydration in patients with hyperemesis gravidarum?
Compression stockings
Low-molecular weight heparin
What are some maternal complications of hyperemesis gravidarum?
Wernicke’s encephalopathy
Thromboembolism
Hypoglycaemia
Mallor-weiss tear
Malnoutrition
Anorexia
Psychological sequelae (deppresion, resentment towards pregnancy)
What are some foetal complications of hyperemesis gravidarum?
Low birth weight
IUGR
Premature labour
