Nausea and Vomiting Flashcards
Recurrence
Wide range: 15-80%
Hyperemesis Diagnostic Criteria
No definitive diagnostic criteria, diagnosis of exclusion
Most commonly cited: persistent vomiting not related to other causes…measure of acute starvation (large ketonuria)…at least 5% prepregnancy weight loss
When in pregnancy does N/V occur in most women?
BEFORE 9 weeks.
DDx of N/V in pregnancy
GI causes (gastroenteritis, gastroparesis, hepatitis, biliary tract disease, peptic ulcer disease, intestinal obstruction)
GU causes (degenerating fibroid/uremia/stones/ovarian torsion)
Metabolic (Addison’s Disease, porphyria, DKA, Hyperthyroid/hyperparathyroidism)
Neurologic (lymphocytic hypophysitis, tumors, vestibular tumor, migraines, pseudotumor cerebri)
Pregnancy Related (PreE, Acute Fatty Liver)
Drugs toxicity/intolerance
Psych
When should you treat hyperthyroidism when present with hyperemesis?
Proof of primary thyroid disorder: Goiter present or presence of thyroid autoantibodies
hCG stimulates what organ?
THYROID (so increase levels of Thyroid Hormone which neg feedback TSH, so TSH gets low)
What produces hCG?
Placenta
Another hormone responsible for N/V in pregnancy?
Estrogen
Smokers have less risk for hyperemesis, why?
Lower levels of hcg and estrogen
Risk factors for hyperemesis
Mother/sisters had it
Large placental mass (molar preg/multiple gestations)
Previous hyperemesis
Significant morbidity from hyperemesis?
Wernicke’s Encephalopathy (Vitamin B1 deficiency/Thiamine)–> death/neurologic disability
Esophageal rupture
PTX
Splenic avulsion
Acute tubular necrosis
Hyperemesis–most common fetal effect? other effects?
Low birthweight (LBW)/SGA
Death rare
Less miscarriage (placenta is healthy, producing hcg!)
Long term effects unknown
Generally good outcome with N/V in pregnancy
Why important to treat first stages of N/V in pregnancy?
Reduce hospital admissions
Nonmedical options for tx N/V
Ginger (reduces nausea, but not vomiting)
Protein (reduces sx more than fat/carbs)
Avoid inciting stimuli
Small frequent meals
Prenatal vitamins can prevent or lessen N/V in pregnancy. How long to take prior to conception?
3 months
Acupuncture pressure point? Does it work?
P6 (Neiguan, inside wrist) with acupuncuture, acupressure, accustimulation, wrist bands
Conflicting studies, 2 of the largest studies showed no different than placebo
First line therapy to treat N/V pregnancy? Dosing?
Vitamin B6 (Pyridoxine) + Doxylamine (antihistamine/H1 blocker) = Diclegis (10mg/10mg) –> FDA approved for those who don’t respond to diet/lifestyle changes: 2 tabs at bedtime, if persistent take 2 tabs at bedtime and 1 tab morning of day 3. Max dose four tabs daily (can move to eventual 1 tab morn, afternoon, 2 at bedtime.
Vit B6 10-25mg/8hrs (some studies show good effect with severe, but not mild N/V!)
Odansetron common side effects
drowsiness, headache, fatigue, constipation
Dangerous side effect odansetron, how do you prevent it? Dose iv?
Prolonged QT interval –> Torsades
Avoid use in arrhythmias, hypokalemia, hypomagnesiemia
No greater than 16mg iv dose
What other antiemetic can cause this dangerous side effect that zofran does?
droperidol
Do Zofran or Reglan pumps work?
Limited data on efficacy; up to 30% have complications
Safety of Zofran questionable in which trimester, causing what malformation in the fetus?
First Trimester
Cleft palate
Cardiac defects, esp. septum (studies are conflicting)–overall risk is LOW
Is Zofran better than other drugs?
IV zofran vs. metoclopramide (Reglan) less xerostomia/drowsiness/persistent ketonuria in 24 hrs…similar efficacy
Zofran comp to diclegis more effective
Meds CI in pts taking Zofran
Flagyl (BV) Macrolides (Azithromycin/Erythromycin) (Chlamydia/PPROM) Analgesics/Sedatives (Methadone)--heroin recovery Fluoxetine (SSRI) HIV protease inhibitors TCA Diuretics Antihistamines (hydroxyzine) Trazadone Antipsychotics Antimalarials Antiarrhythmics
Methylprednisolone fetal effects? How common is it? Dose? Does it work?
Cleft palate in first trimester use
1-2/1000 – rare
48mg daily x3 days then 2 wk taper
Some studies show reduced readmission, others not really
Should we use methylprednisolone routinely? What gest age is safer for use?
It is not a first line agent; only use in REFRACTORY cases!
Avoid before 10 wks
How long should we use methylprednisolone to observe response?
No response in 3 days, d/c use…then taper over 2 wks oral prednisone
How do we avoid maternal adverse effects from prolonged steroid use?
Do not cont effective dose/tx hyperemesis for longer than 6 wks
Presence of ketonuria indicate severity of hyperemesis?
No
Labs that may be abnormal in hyperemisis
elevated amylase elevated ast/alt (300s highest) tsh low, elevated free thyroxine (T4) electrolytes elevated bili (less than 4mg/dL)
What dx should we consider if hyperemesis persistent and resistant to standard therapies and how do we test for it? Tx?
Gastric Ulcer
H. pylori
H2-receptor antagonist + abx
What kind of acidosis/alkalosis present with hyperemesis?
hypchloremic metabolic alkalosis
What percentage of hyperemesis pts have abnormal thyroid labs?
70%
When should hyperthyroidism resolve in hyperemesis without treatment?
20wks
Do you need to routinely order thyroid studies on hyperemesis pts?
Not unless there is goiter present. Hyperthyroid rarely presents with N/V.
What do we need to replenish in hyperemesis pts?
Thiamine first
Dextrose
Correct vitamin deficiencies
Correct ketosis
First line therapy in hyperemesis who cannot maintain weight/not responsive to medical therapy to maintain nutrition?
Enteral feedings (NGT or nasoduodenal tube)
What about TPN?
Potentially life threatening: thromboembolism/sepsis
Adverse neonatal outcomes
Why use a PICC line?
Peripherally inserted central catheters–to avoid central access, but still significant morbidity…only use when enteral feeding is not possible! LAST RESORT!
Complications with PICC lines?
superficial thrombophlebitis cellulitis Line infections Mechanical line failure pain necessitating d/c line sepsis thromboembolism bacteremia most frequent major comp
Hypnosis?
Some studies have shown effective
