Nausea and vomiting in pregnancy and hyperemesis gravidarum

Question 1

When does nausea and vomiting normally start in pregnancy

Answer 1

Symptoms usually start from 4 – 7 weeks, are worst around 10 – 12 weeks and resolve by 16 – 20 weeks

Question 2

What causes physiological N+V in pregnancy?

Answer 2

HCG produced by the placenta (Thought to protect against infection in pregnancy)

Question 3

What are some conditions that increase severity of N+V in pregnancy

Answer 3

Molar pregnancy
Multiple pregnancy
First pregnancy
Obesity

Question 4

What percentage of women get N+V in pregnancy

Answer 4

90%

Question 5

What is hyperemesis gravidarum

Answer 5

the severe form of nausea and vomiting in pregnancy

Question 6

What are the criteria for diagnosing hyperemesis gravidarum

Answer 6

• More than 5 % weight loss compared with before pregnancy
• Dehydration
• Electrolyte imbalance
• Ketosis
• Altered liver function
• Signs of malnutrition
• Emotional instability
• Wernicke’s encephalitis

Question 7

What scoring system is used for N+V in pregnancy

Answer 7

PUQE score - Pregnancy-Unique Quantification of Emesis

Question 8

PUQE score <7 =

Answer 8

Mild

Question 9

PUQE score 7-12 =

Answer 9

Moderate

Question 10

PUQE score 12-15

Answer 10

Severe

Question 11

What is a possible genetic cause of severe N+V in pregnancy

Answer 11

Hypersensitivity to vomiting hormone growth differentiation factor 15 (GDF-15)

Question 12

What are some symptoms of hypersensitivity to GDF-15

Answer 12

Loss of appetite
Taste aversion
Nausea + Vomiting
Weight loss
Peak at 20 weeks

Question 13

Management of mild N+V in pregnancy

Answer 13

Oral anti-emetics at gome

Question 14

Anti-emetic options for N+V in pregnancy

Answer 14

1. Prochlorperazine (stemetil)
2. Cyclizine
3. Ondansetron
4. Metoclopramide

Question 15

When should admission be considered in mild N+V in pregnancy

Answer 15

• Unable to tolerate oral antiemetics or keep down any fluids
• More than 5 % weight loss compared with pre-pregnancy
• Ketonesare present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
• Other medical conditions need treating that required admission

Question 16

Management of moderate-severe N+V in pregnancy

Answer 16

Ambulatory cate (Early pregnancy assessment unit)
Admission for:
- IV or IM antiemetics
- IV fluids (normal saline with added potassium chloride)
- Daily monitoring of U&Es while having IV therapy
- Thiamine supplementationto prevent deficiency (preventsWernicke-Korsakoff syndrome)
- Thromboprophylaxis(TED stockingandlow molecular weight heparin) during admission