Module 13 - Nausea and Vomiting in Pregnancy

Question 1

What proportion of pregnancies are affected by N&V vs HG?

Answer 1

80% N&V
0.3 - 3.6% HG

Question 2

What is the risk of recurrence of HG?

Answer 2

15 - 80% (depends if self reporting).
But only 10% if a different dad.

Question 3

When can N&V in pregnancy be diagnosed?

Answer 3

Only in 1st trimester

Question 4

When is the typical onset of N&V in Pregnancy?
When does this generally peak and resolve?

Answer 4

Onset week 4-7 weeks.
Peak 9 weeks.
90% resolves by 20 weeks.

Question 5

What stratification can be used for N&V or HG?

Answer 5

PUQE Score
Rhodes Score

Question 6

What proportion of women with HG will have abnormal TFT’s? (Why?)

Answer 6

66%
bHCG similarity to TSH

Question 7

What proportion of women with HG will have abnormal LFTs?

Answer 7

40%

Question 8

Where should women with N&V in pregnancy vs HG be cared for?

Answer 8

N&V in pregnancy - in the community.

HG - Ambulatory care.

Question 9

Is metoclopromide safe in pregnancy?

Answer 9

Yes,
but there is a risk of extra-pyramidal SEs (including tardative dyskinesia).
This makes it second line.

Question 10

What proportion of women with N&V will have symptom relief with SC Metoclopromide?

Answer 10

90%

Question 11

Which anti-emetics have good safety data in pregnancy?

Answer 11

H1 receptor antagonists (cyclizine, promethazine).
Phenothiazines (Prochlorperazine).

Question 12

Why is ondanstron 2nd line anti-emetic in N&V and HG?

Answer 12

Limited data.
Danish study shows no association, some studies show risk of cleft palate.

Question 13

What is pyroxidine?

Answer 13

Vit B6

Question 14

When are cortocosteroids given? What dose is used?

Answer 14

Refractor HG.
100mg IV BD then convert to PO Pred 40-50mg OD and reduce until find maintenance dose.

Question 15

Why should diazepam not be used?

Answer 15

Although decreases nausea, does not decrease vomiting.

Question 16

What IVI should be used for rehydration in N&V or HG?

Which should be avoided and why?

Answer 16

NaCL+KcL (guided by daily bloods).

Avoid Dextrose as this can precipitate Weneke’s encephalopathy.

Question 17

What vitamin supplement should be given to HG women?

Answer 17

Thiamine (B1)

Question 18

What is the evidence for ginger to be used?

Answer 18

No RCTs for HG.

For N&V:
But better than placebo in N&V.
Equal to B6 and dimenhydrinate.
Less effective than metoclopromide.

Question 19

What is the evidence for accupuncture and accupressure?

Answer 19

Accupuncture - no evidence.

Accupressure - may improve NVP and some evidence improves HG.

Question 20

Is gastrodyodenoscpy safe in pregnancy if women develop haemoptysis or severe GI bleeding?

Answer 20

YES

Question 21

What vitamin should be avoided in NVP/HG patients?

Answer 21

Iron containing preparations as these worsen symptoms.

Question 22

What is the OR of increased VTE risk for women with HG?

Answer 22

OR 2.5

Question 23

Define HG

Answer 23

Intractable N&V
>5% weight loss

Question 24

What are the risks in later pregnancy for women with HG?

Answer 24

IUGR (therefore need growth scans).
<7kg gained in pregnancy, increases risk of PTL (RR3) and decreased birth rate (RR3).

Ketonuria can be monitored to catch symptoms before they start.

Question 25

What medications are first line for treatment of NVP/HG?

Answer 25

Cyclizine
Prochlorperazine
Promethazine
Chlorpromazine

Question 26

What medications are 2nd line for NVP/HG?

Answer 26

Metoclopromide
Domperidone
Ondansatron

Question 27

What PUQE score should prompt EPAU review and ambulatory care?

Answer 27

13+

Question 28

What is Doxylamine/Pyridoxine (Xonvea)

Answer 28

Delayed release tablet of Doxylamine (100mg antihystamine) and Pyroxidine (10mg vitB6).

Question 29

When can Doxylamine/Pyridoxine (Xonvea) be used?

Answer 29

Can be used 1st line in pregnancy in women >18 years.
(but released after NICE guideline and GTG published).

Question 30

What is the evidence for Doxylamine/Pyridoxine (Xonvea)?

Answer 30

Good RCT evidence but only compared to placebo.
Not compared directly to other treatments.