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Nausea and Vomiting > Nausea and Vomiting > Flashcards

Nausea and Vomiting Flashcards

1
Q

Recurrence

A

Wide range: 15-80%

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2
Q

Hyperemesis Diagnostic Criteria

A

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

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3
Q

When in pregnancy does N/V occur in most women?

A

BEFORE 9 weeks.

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4
Q

DDx of N/V in pregnancy

A

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

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5
Q

When should you treat hyperthyroidism when present with hyperemesis?

A

Proof of primary thyroid disorder: Goiter present or presence of thyroid autoantibodies

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6
Q

hCG stimulates what organ?

A

THYROID (so increase levels of Thyroid Hormone which neg feedback TSH, so TSH gets low)

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7
Q

What produces hCG?

A

Placenta

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8
Q

Another hormone responsible for N/V in pregnancy?

A

Estrogen

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9
Q

Smokers have less risk for hyperemesis, why?

A

Lower levels of hcg and estrogen

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10
Q

Risk factors for hyperemesis

A

Mother/sisters had it
Large placental mass (molar preg/multiple gestations)
Previous hyperemesis

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11
Q

Significant morbidity from hyperemesis?

A

Wernicke’s Encephalopathy (Vitamin B1 deficiency/Thiamine)–> death/neurologic disability

Esophageal rupture

PTX

Splenic avulsion

Acute tubular necrosis

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12
Q

Hyperemesis–most common fetal effect? other effects?

A

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

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13
Q

Why important to treat first stages of N/V in pregnancy?

A

Reduce hospital admissions

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14
Q

Nonmedical options for tx N/V

A

Ginger (reduces nausea, but not vomiting)
Protein (reduces sx more than fat/carbs)
Avoid inciting stimuli
Small frequent meals

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15
Q

Prenatal vitamins can prevent or lessen N/V in pregnancy. How long to take prior to conception?

A

3 months

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16
Q

Acupuncture pressure point? Does it work?

A

P6 (Neiguan, inside wrist) with acupuncuture, acupressure, accustimulation, wrist bands
Conflicting studies, 2 of the largest studies showed no different than placebo

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17
Q

First line therapy to treat N/V pregnancy? Dosing?

A

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!)

18
Q

Odansetron common side effects

A

drowsiness, headache, fatigue, constipation

19
Q

Dangerous side effect odansetron, how do you prevent it? Dose iv?

A

Prolonged QT interval –> Torsades

Avoid use in arrhythmias, hypokalemia, hypomagnesiemia

No greater than 16mg iv dose

20
Q

What other antiemetic can cause this dangerous side effect that zofran does?

A

droperidol

21
Q

Do Zofran or Reglan pumps work?

A

Limited data on efficacy; up to 30% have complications

22
Q

Safety of Zofran questionable in which trimester, causing what malformation in the fetus?

A

First Trimester
Cleft palate
Cardiac defects, esp. septum (studies are conflicting)–overall risk is LOW

23
Q

Is Zofran better than other drugs?

A

IV zofran vs. metoclopramide (Reglan) less xerostomia/drowsiness/persistent ketonuria in 24 hrs…similar efficacy

Zofran comp to diclegis more effective

24
Q

Meds CI in pts taking Zofran

A 
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
25
Q

Methylprednisolone fetal effects? How common is it? Dose? Does it work?

A

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

26
Q

Should we use methylprednisolone routinely? What gest age is safer for use?

A

It is not a first line agent; only use in REFRACTORY cases!

Avoid before 10 wks

27
Q

How long should we use methylprednisolone to observe response?

A

No response in 3 days, d/c use…then taper over 2 wks oral prednisone

28
Q

How do we avoid maternal adverse effects from prolonged steroid use?

A

Do not cont effective dose/tx hyperemesis for longer than 6 wks

29
Q

Presence of ketonuria indicate severity of hyperemesis?

A

No

30
Q

Labs that may be abnormal in hyperemisis

A 
elevated amylase
elevated ast/alt (300s highest)
tsh low, elevated free thyroxine (T4)
electrolytes
elevated bili (less than 4mg/dL)
31
Q

What dx should we consider if hyperemesis persistent and resistant to standard therapies and how do we test for it? Tx?

A

Gastric Ulcer
H. pylori
H2-receptor antagonist + abx

32
Q

What kind of acidosis/alkalosis present with hyperemesis?

A

hypchloremic metabolic alkalosis

33
Q

What percentage of hyperemesis pts have abnormal thyroid labs?

A

70%

34
Q

When should hyperthyroidism resolve in hyperemesis without treatment?

A

20wks

35
Q

Do you need to routinely order thyroid studies on hyperemesis pts?

A

Not unless there is goiter present. Hyperthyroid rarely presents with N/V.

36
Q

What do we need to replenish in hyperemesis pts?

A

Thiamine first
Dextrose
Correct vitamin deficiencies
Correct ketosis

37
Q

First line therapy in hyperemesis who cannot maintain weight/not responsive to medical therapy to maintain nutrition?

A

Enteral feedings (NGT or nasoduodenal tube)

38
Q

What about TPN?

A

Potentially life threatening: thromboembolism/sepsis

Adverse neonatal outcomes

39
Q

Why use a PICC line?

A

Peripherally inserted central catheters–to avoid central access, but still significant morbidity…only use when enteral feeding is not possible! LAST RESORT!

40
Q

Complications with PICC lines?

A 
superficial thrombophlebitis
cellulitis
Line infections
Mechanical line failure
pain necessitating d/c line
sepsis
thromboembolism
bacteremia most frequent major comp
41
Q

Hypnosis?

A

Some studies have shown effective

Nausea and Vomiting (1 decks)

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