Nausea and Vomiting

Question 1

In which week does HG usually start?

Answer 1

Week 5

Question 2

In which week is HG at its worst?

Answer 2

Week 9

Question 3

When does HG usually disappear?

Answer 3

week 16 to 18

Question 4

What is Nausea?

Answer 4

unpleasant painless subjective feeling that one will imminently vomit.

Question 5

What is Vomiting

Answer 5

forceful expulsion of gastric contents

Question 6

What is Retching?

Answer 6

Strong involuntary reverse movements of the stomach and esophagus without vomiting

Question 7

Define Hyperemesis Gravidarum?

Answer 7

It is a severe, persistent form of pregnancy related vomiting characterized by loss of weight, dehydration and electrolyte imbalances

Question 8

Describe the pathogenesis of HG

Answer 8

-Pregnancy induces elevated levels of Human Chorionic Gondatotropin, estrogen, progesterone, and Growth Differentiation Factor 15, largely from the placenta.
-Hormonal changes (HCG, estrogen and progesterone) cause delayed gastric emptying and gastroesophageal reflux by relaxing the smooth muscles of the gut.
-Hormonal and gastric changes, along with elevated GDF15 levels, activate the Chemoreceptor Trigger Zone and vomiting centre in the brain.
-These factors results in the typical symptoms of nausea and vomiting during pregnancy

Question 9

What are the risk factors associated with HG?(10)

Answer 9

Previous history of nausea and vomiting
Family history
BMI >30 before pregnancy
History of migraines
History of motion sickness
Multiple gestations
Trophoblastic disease
Nulliparity
Maternal age less than 20
History of other GI problems like GERD

Question 10

Differential Diagnosis of HG?

Answer 10

GUT: Urinary tract infections
GIT: Esophagitis, GERD, Irritable Bowel Syndrome (IBS) Paralytic Ileus/Bowel Obstruction
.systemic: Malaria
Endocrine: Diabetic Ketoacidosis (DKA), Hyperthyroidism and Thyrotoxicosis,
In later pregnancy, considerations also include polyhydramnios, pre-eclampsia, and onset of labour.

Question 11

What is the difference between morning sickness and HG?

Answer 11

Morning sickness -N &V only happens in the morning
In HG the nausea and vomiting occurs anytime of the day and is severe enough to cause an inability to eat and drink normally and strongly limits daily activities of living

Question 12

What tools are used to asses the severity of HG?

Answer 12

Pregnancy-Unique Quantification of Emesis
HELP

Question 13

How is the PUQE severity score graded

Answer 13

Mild ≤ 6
Moderate= 7-12
Severe = 13-15

Question 14

Describe the PUQE score.

Answer 14

REFER TO HANDOUT.

Question 15

What factors exacerbate HG(4)

Answer 15

Genetic predisposition, psychological stress, nutritional deficiencies, and H. pylori infection

Question 16

What pertinent history points would you ask in someone you suspect HG?

Answer 16

-Previous history of NVP/HG
-Quantify severity using assessment tools
-Nausea, vomiting, ptyalism (hypersalivation) and spitting
-Inability to tolerate food and fluids
-Effect on quality of life and ability to perform daily activities
-Ask about self-reported nutritional status or rapid weight loss
-Ask about co-morbidities: epilepsy, diabetes, HIV, psychiatric conditions
- Abdominal pain
Urinary symptoms
Infection
Drug history (prescription and/or recreational)
Chronic Helicobacter pylori infection

Question 17

What are the signs and symptoms of HG?

Answer 17

Loss of weight
Signs of dehydration(reduced skin turgor, dry mucus membranes,sucken eyes, reduced urine output)
-Weakness,fatigue, presyncope,dizziness
-Inability to eat and drink
-N&V that affects their daily living activities.

Question 18

What investigations would you do in a patient you are suspecting HG?

Answer 18

Bloods
FBC
U+E+Cr- to rule out AKI, electrolyte imbalances(Hypokalemia)
Blood glucose level-Incase of DKA
Liver function tests
Arterial blood gasses

Imaging
-Ultrasound Scan- to rule out multiple gestation/Polyhdraminos/GTD
-Endoscopy- if hx of hematemesis

Others
Urine Dipstick -To rule out UTI, ketouria

Question 19

What are the goals of treatment in HG?(4)

Answer 19

Reduce severity of symptoms and improve quality of life.

Correct hypovolemia, ketonuria and electrolyte abnormalities, if present.

Prevent serious complications including, but not limited to, vitamin deficiencies, electrolyte abnormalities, or weight loss.

Minimize the potential foetal effects of maternal pharmacotherapy

Question 20

What is approach to treatment to for HG?

Answer 20

-Non pharmacological and Pharmacological treatment.

Question 21

What is the non-pharmacological treatment for HG?(10)

Answer 21

Eat smaller amounts of food more often
Preference bland foods that are low in fat
Avoid spicy foods
Eat foods high in protein
Don’t skip meals
Avoid cooking or being in the kitchen when food is being prepared if this triggers nausea
Eat a few dry crackers or biscuits prior to getting out of bed
Ginger (in any form) is widely suggested to aid NVP symptoms
Aim to drink eight glasses of water per day
Carbonated drinks or ginger/peppermint tea may relieve symptoms.

Question 22

What is the pharmacological treatment for HG?(Outpatient)

Answer 22

Vitamin B6 (Pyridoxine): 25-50 mg three times daily.
Thiamine (Vitamin B1): To prevent Wernicke’s encephalopathy in prolonged vomiting cases.
Antihistamines:
Doxylamine: Often combined with vitamin B6
Antiemetics:
Metoclopramide: Enhances gastric emptying (10 mg up to three times daily).
Ondansetron: Effective for nausea, used with caution (4-8 mg every 8 hours).
Promethazine: For more severe symptoms (12.5-25 mg every 4-6 hours).

Question 23

What are the side effects of Ondasentron?

Answer 23

-Constipation
-increased chance of birth defects for instance cardiac defects and neutral tube defects and cleft palate

Question 24

When do we consider a patient for Inpatient Care?

Answer 24

-Continued nausea and vomiting and inability to keep down oral antiemetics
-Continued nausea and vomiting associated with clinical dehydration or weight loss >5% despite oral antiemetics

Question 25

What is the approach for inpatient care?

Answer 25

Assess and address ABCs
Begin with 2 L of RL over 3 hours to maintain a urine output of > 100 mL/hour.
Subsequent fluids up to 1 L every 4 hours for up to 3 days(ongoing assessment)
Electrolyte Replacement:
Add Potassium Chloride: 20-40 mEq per liter of NS, adjusted as needed.
Magnesium Sulphate: 1-2 grams IV over 1-2 hours for hypomagnesemia.
Thiamine (Vitamin B1): 100 mg IV daily
Correct other electrolytes based on based on lab results.
Providing psychological support to manage stress and anxiety.
- Antihistamines and Corticosteroids

Question 26

What are the 1st line drugs given to inpatients?

Answer 26

First line
Pyridoxine (vitamin b6) monotherapy
Doxylamine and Pyridoxine (vitamin B6)
Promethazine
Chlorpromazine
Cyclizine
Prochlorperazine

Question 27

What are the 2nd line drugs given to inpatients?

Answer 27

Metoclopramide
Ondansetron
Domperidone

Question 28

What are the 3rd line drugs given to inpatients? And why are tapered?

Answer 28

-Corticosteroids
-They cause adrenal insufficiency

Question 29

What 3 things are monitor amongst the inpatients?

Answer 29

Vital Signs and Hydration Status
Regular monitoring of blood pressure, heart rate, and urine output.
Laboratory Tests:
Monitoring of serum electrolytes, liver enzymes, and renal function.
Nutritional Support:
Enteral Feeding: NGT
Parenteral Nutrition in severe cases where enteral feeding is not possible.

Question 30

What are the maternal complications of HG?(10)

Answer 30

Vitamin deficiencies (B1, B6, B12)
Electrolyte imbalances
Dehydration and Metabolic acidosis
Mallory-Weiss tears
Gastroesophageal reflux disease (GERD)
Acute kidney injury
Liver Dysfunction
Thromboembolic Events
Wernicke’s Encephalopathy
Depression and anxiety

Question 31

What are the fetal complications of HG?(3)

Answer 31

Intrauterine growth restriction
Low birth weight
Preterm birth

Question 32

What are the side effects of using metoclopramide?

Answer 32

Extrapyramidal effect: movement disorders e.g. slurred speech, tremors,
Tardive dyskinesia: disorder resulting in involuntary repetitive movements e.g. sticking out the tongue, smacking the lips

Question 33

Adverse effects of Promethazine?

Answer 33

-Extrapydramidal Symptoms
-Sedation

Question 34

Side effect of cyclizine?

Answer 34

-sedation

Question 35

Side effect of prochlorperazine?

Answer 35

-Extrapyramidal Symptoms
-Sedation