N+V in pregnancy Flashcards
common in which trimester
1st
common in first trimester. usually resolves spontaneously within ….
16-20 weeks
the onset of symptoms after …. weeks gestation usually suggests an alternative cause of symptoms that are unrelated to pregnancy
11 weeks
a patient presents with nausea and vomiting after 11 weeks gestation. is this normal pregnancy sickness, or does it suggest an alternative cause of symptoms unrelated to pregnancy?
Onset of symptoms after 11 weeks of gestation usually suggests an alternative cause of symptoms unrelated to pregnancy
You can recommend ginger for mild to moderate nausea or acupressure - true or false
true
2 non pharmacological options
acupressure
ginger for mild to moderate nausea
when to consider antiemetics
persistent symptoms where self care measures e.g. ginger, acupressure, rest, oral hydration ,dietary changes are ineffective
self care advice to give (3)
rest
oral hydration
dietary changes
if you have given an antiemetic, how often should you assess response to treatment
after 24h
if inadequate response, switch to antiemetic from different class
reassess after 24h and if symptoms not settled, specialist
for moderate to severe n+v, consider these adjunct to antiemetic
IV fluids
acupressure
true or false - oral iron or opioids can cause n+v
true
Ask pt about comorbids e.g. DM or CKD as symptoms may increase the risk of complications e.g.
DM - DKA
CKD - AKI
sign of dehydration
reduced or concentration urine output
what is hyperemesis gravidarium
more serious condition
characterised by prolonged, persistent and severe n+v unrelated to other causes, weight loss (usually at least 5% of pre pregnant body weight) and dehydration & electrolyte imbalance
HG is characterised by weight loss - usually this much
at least 5% of pre pregnant body weight
management of HG
regular antiemetic therapy, IV fluid and electrolyte replacement
sometimes also nutritional support
for women with severe or persistent HG, may be more appropriate to give non-PO antiemetics e.g. via
rectal or parenteral routes
True or False - consider thiamine supplementation in pt with HG to reduce risk of Wernicke’s encephalopathy
true
RF for n+v in pregnancy (5)
- obesity
- family history of n+v in pregnancy of HG
- Hx HG
- first pregnancy
- increased placental mass - molar gestation, multiple pregnancy
true or false - having twins puts you at increased risk of n+v in pregnancy
true - increased placental mass e.g. molar gestation and multiple pregnancies is a RF for n+v in pregnancy
which of the following is NOT a risk factor of N+V in pregnancy
- obese
- having triplets
- not the first pregnancy
not the first pregnancy.
first pregnancy = risk factor
true or false - possible maternal complication of severe symptoms of n+v can cause GORD and VTE
true
3 possible foetal complications if there is HG
Preterm delivery
Low birthweight
Small-for-gestational age
what is some specific self care advise you can give for mild to moderate symptoms
- rest as needed
- avoid triggering sensory stimuli e.g. odours, heat, noise
- eat plain biscuits or crackers in morning
- eat bland, small, frequent, protein rich meals that are low in carbs and fat
- cold meals may be more easily tolerated in nausea is smell related
- drink little and often, not large amounts
- ginger - fresh, tea, caps or syrup form
- acupressure e.g. over P6 point on ventral aspect of wrist using wrist band or finger pressure
true or false - if n+v is related to smell, it may be best to take cold meals
true
where would you recommend acupressure
over P6 point on ventral aspect of wrist using a wrist band or finger pressure
advice on avoiding meals that may contribute to symptoms
iron containing preps depending on clinical judgement
if a pt has had n+v in pregnancy, what would you say about future pregnancies
early use of lifestyle measures and antiemetics before or immediately at start of symptoms may be helpful
1st line antiemetics for n+v (3 options) + reviews
oral cyclizine or promethazine (antihistamines)
prochlorperazine or chlorpromazine (phenothiazines)
Xonvea: doxylamine/pyridoxine
reassess after 24h.
if responsive, continue and review pt once a week thereafter depending on clinical judgement
if 1st line option is ineffective, give these 2nd line
+ review and what to do if ineffective
switch to 2nd line antiemetic from a different drug class and reassess after 24h e.g.
- dopamine receptor antagonists e.g. metoclopramide, domperidone
- 5HT3 antagonist e.g. ondansetron
is responsive, continue and review pt once a week thereafter, depending on clinical judgement
if ineffective, specialist advice
max duration of use metoclopramide and domperidone
m: max 5 days, risk of neurological extrapyrimadol SE
d: max 7 days, risk of cardiac adverse effects
max duration of use ondansetron and in pregnancy
max 5 days
1st trimester: small increased risk of cleft lip/palate
which antiemetic holds a small increased risk of cleft lip/palate if used in first trimester
ondansetron
Review the need for ongoing treatment and advice on gradually reducing and stopping meds when symptoms improve, depending on clinical judgement
- may be possible to stop at around 12-16 weeks when symptoms have usually improved
- gradually tapering dose may reduce risk of symptoms recurring
when to arrange admission or referral
- persistent moderate to severe n+v and
- suspected HF despite oral antiemetics
- suspected severe or serious complication
- symptoms not controlled with management in primary care
- unable to tolerate all antiemetics or oral fluids
- unable to tolerate other necessary oral drug treatments e.g. abx for UTI or usual meds for comorbid conditions
true or false - have a lower threshold for admitting pt to hospital to seeking specialist advice if the woman has comorbids e.g. DM which may be adversely affected by symptoms
true
