PROM,ectopic,hyperemesis Gracidarum, PMB Flashcards
What is hyperemesis gravidarum
What is emesis
What is excessive vomiting
HG refers to a clinical syndrome which includes dehydration weight loss of more than 5% electrolyte imbalance Hypokalemia hyponatremia hypochloremia and acid base balance metabolic alkalosis
All due to excessive vomiting
Emesis in pregnancy is vomiting that doesn’t worry the woman or cause a problem to her
Excessive vomiting causes a problem to her or worries her or makes her unable to eat and whatever
Hyperemesis gravidarum is a diagnosis by exclusion meaning you have to exclude Al other possible causes of vomiting. I’m the history you have to rule out all the other causes
State ten other causes of vomiting and five other causes in pregnancy
Note that these are also the ddx of hyperemesis gravidarum
Gastroenteritis ( vomiting and diarrhea)
Malaria fever chills malaise bitter taste
Typhoid fever
GERD
Gastritis
Peptic ulcer disease
Worm infestations
UTI
Raised ICP dizziness headache vomiting
Intestinal obstruction
Wernicke encephalopathy
Acute appendicitis
Acute cholecystitis
Acute pancreatitis
Endocrine- Hyperthyroidism, Addison’s Disease, Diabetes Ketoacidosis
CNS- Intracranial Tumors, Vestibular Disease Others- Eating disorders, Drug Intoxication.
Pregnancy:
Multiple gestation( this causes double of HCG causing increased vomiting)
Gestational trophoblastic disease
, Acute Fatty Liver of Pregnancy, HELLP Syndrome, Pre-Eclampsia
Molar pregnancy
State the pathophysiology of hyperemesis gravidarum and the causes of it
HormonalStimulation:-
HCG – High HCG levels (Twins, GTT)
High Estrogen Level- Increased E2 causes a decrease in GI motility and gastric emptying altering GI pH and encourages sub-clinical H. Pylori infection.
Progesterone Excess- Relaxation of Gastric Sphincter and Impaired Gastric Motility.
Thyroid hormone- Physiological gestational transient thyrotoxicosis. Raised FT3 and low TSH found in 66% of Hyperemesis Gravidarum.
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Cont’d
Dietary deficiency
Low carbohydrateIntake,Vit B6 and B1deficiency
Gastrointestinal dysfunction. Liver Dysfunction
Infection
Vestibular system dysfunction Allergic or Immunological basis Psychological issues
Genetic( if mum had hyperemesis you’re likely to get it too or sister had it you’re likely to get it too
State six signs and six symptoms of hyperemesis gravidarum
Symptoms
Nausea
Excessive Vomiting
Inability to eat or drink Weight loss
Abdominal pain
Oliguria
Lethargy
Dizziness
Extreme tiredness
Headaches
• Signs
signs of Dehydration
Anaemia
Dry skin
Tachycardia
Abdominal Tenderness (epigastric)
Ketonuria
signs of Weight loss
Low Blood pressure
Deep and fast breathing in extreme cases and breath with ketotic odour
What will you ask during the history
When obtaining history from the patient, discuss present symptoms (vomiting) Obtain information pertaining to the timing, onset, severity, pattern, and alleviating and exacerbating factors (eg, relationship to meals, prenatal vitamins, stress, other triggers).
Quantify severity using PUQE score.
A thorough review of systems for any symptoms that might suggest other gastrointestinal, renal, endocrine, and central nervous system disorders is vital. (eg Nausea, Inability to tolerate food and fluids History Abdominal pain, urinary symptoms
Review past medical placing emphasis on past medical conditions (egChronic H. Pylori Infection),
History
surgeries, medications, allergies, adverse drug reactions, family history, social history.
Obtaining a thorough gynecologic history of symptoms, such as vaginal bleeding or spotting, past pregnancies, past use of oral contraceptives, and response to oral contraceptives used, is important.
Rule out the other causes of hyperemesis
What will you look for on examination of a patient with hyperemesis gravidarum
What is the Difference between Morning Sickness and Hyperemesis Gravidarum
Assessment of General Condition
Check Vitals
Signs of Dehydration Signs of weight loss
Abdominal and Other Examinations as per History of Individual Patient
Difference between Morning Sickness and Hyperemesis Gravidarum
Morning sickness is extremely common during pregnancy — up to 80% of people report experiencing it. It’s not as severe as hyperemesis gravidarum and doesn’t cause dehydration or weight loss. Morning sickness may cause occasional vomiting and nausea, but you should still be able to keep food and liquids down most of the day. It tends to subside or disappear completely after 12 weeks of pregnancy (the first trimester).
Hyperemesis gravidarum causes you to vomit several times per day. This can eventually lead to weight loss, electrolyte imbalance and dehydration. Symptoms of HG often last longer than morning sickness. You might need treatment in a hospital with IV fluids (fluids given intravenously, or through your vein) if you become dehydrated
State ten risk factors for hyperemesis gravidarum
Nullipara
Risk Factors
• HistoryofHyperemesis
•Under or Overweight women
Gravidarum
• family history of HG
• HistoryofMotion sickness
• MultiplePregnancy
GI disorder
H. pylori infection
Socio- Economic factors; Anxious and highly stressed women
Migraine
Diabetic
Genetics
State six investigations for Hyper emesis
State six complications
FBC
Urine R/E
Bf for MP
Stool R/E if there is diarrhea to also check for worm infestations and other things
Typhoid IgG IgM
( first five are done on OPD basis usually)
Urine analysis for ketones and specific gravity, protiens and colour
FBC
BUE and Creatinine (usually done for in patients )
FBS
Liver Funtion Test(if you suspect liver problem)
Thyroid Function test
Obstetric ultrasonography: Usually warranted to evaluate for multiple gestations or molar pregnancy.
Upper abdominal ultrasonography: If clinically indicated, to evaluate the pancreas and/or biliary tree
Maternal Complications
ExtremeElectrolyte Imbalance
Malnourishment
Wernicke’s Encephalopathy
AKI
Hepatic failure in extreme cases
Malory- Weiss tears
Fetal Complications
IUFD
IUGR
Low Birth Weight Baby Premature Infants
WhT is the non pharmacological management of hyperemesis or emesis in pregnancy
Mild cases can have treatment at home with frequent small meals
Avoid fatty and spicy foods.
Avoid eating cold foods
They should determine which food is good for them or that doesn’t make them vomit
Increase intake of dry foods eg biscuits
Eliminate pills with iron.
Drink fluids in sips or small volumes. Or take in foods in smal amount at higher frequencies or time intervals. Don’t attempt to finish a full Meal at a go(counsel for dietitian consult too cuz they’re eating in small amounts so they’ll need to know the kind of food to eat and the portions to take to help them eat a balanced diet and still eat small
Change of environment if current environment is nauseating
What is the Pharma management of hyper emesis at OPD and in the ward
OPD:
(Treat infections if any )
Promethazine 25mg 3times daily
Metoclopramide 10mg tid
Domperidone suppository 30mg tid
Multivite with B6 (pyrodoxine)
Drink more water and they should come back if things aren’t improving
In patient:
Admit Patient
Perform Primary Resuscitation
Insert 2 large bore cannula for fluid management. Normalsaline,IV,(alternate with 5% Dextrose to meet requirements) Or Ringers lactate, IV, (alternate with 5% Dextrose to meet requirements)
And Metoclopramide, IM or IV, 5-10 mg 8 hourly, If body weight < 60 kg, give 5 mg 8 hourly. Do not exceed 500 micro- gram/kg in a day OR
Ondansetron IM or IV, 4-8 mg 8 hourly as needed OR
Promethazine hydrochloride, IM or IV, 25 mg 8-12 hourly (max. daily dose, 100 mg)
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Othersupportivetreatment
Vitamin supplementation specially Thiamine (50mg oral once daily), Anti-Reflux Measures H2 blockers such as Ranitidine and proton pump inhibitors (Omeprazole)
Diet and Lifestyle (Small Frequent dry meal, learn to avoid certain scents which make the patient intolerable)
Reassure patient
Avoid Mental Stress and try to keep mind occupied
Still do the non pharma treatment here
Fluids - ringers and DNS
IV promethazine
IV meto
IV Domperidone
vitamin B complex IV
All the above can be done at the health center
You can add dexamethasone or prednisone
Add odansetron if still nothing is working(Ondansetron, sold under the brand name Zofran among others, is a medication used to prevent nausea and vomiting caused by cancer chemotherapy, radiation therapy, or surgery. It is also effective for treating gastroenteritis)
And if still everything isn’t working recheck your diagnosis cuz maybe the vomiting could be from another cause
And if after everything it’s from nowhere else, terminate the pregnancy
What is menopause and which age averagely is when menopause starts
What is pre menopausal state or peri menopausal state
What is post menopausal bleeding
What are you most worried about in such patients
Absence of menstruation for 12 consecutive months is menopause
Average age is 47 years
Absence of menses for 5 consecutive months is perimenopausal or pre menopausal
Post menopausal bleeding PMB
Is any bleeding from the genital tract regardless of the quantity in a menopausal woman
Cancer. So you have to rule them out. You can reassure this patient us it’s not normal. Explain to patient Whatsup and why they have to do bunch tests so you can rule out any cancers
State five causes of post menopausal bleeding
Most common- atrophic vaginitis
And atrophic endometrium
This causes it because atrophy leads to smaller vessels leading to easy bleeding
2. Trauma. a. Usually from sex (small erosions in Vaginal walls on speculum examination)
b. From a fall
3. Infections (not really common
4. Tumors
a. Benign ( cervical polyps endometrial polyps endometrial hyperplasia( precursor to cancer)
b. Malignant ( make sure any sore on the genitals in a post menopausal woman should be biopsied to see If it’s a cancer or just a sore )
Vulva cancer ( most common)
Cervical cancer
Vaginal cancer
Endometrial cancer
Ovarian cancer
Fallopian tube cancer
5. Withdrawal bleeding from hormone replacement therapy
State four investigations and examinations to be done in PMB
Do pelvic exam
Do DRE to rule out bleeding from the rectum
You can pass a catheter to rule out bleeding from bladder or hematuria from bleeding from the vagina
USS
Pap smear
Hysteroscopy(to view inside uterus)
Do biopsy if you see a mass
Sometimes bleeding could be from adjacent areas to the uterus as said earlier
So look for the source of the bleeding
Ask if she has a general bleeding problem example if she bleeds after brushing her teeth. Maybe she has developed a bleeding disorder
State six risk factors for PMB
Exogenous hormones. Careful history taking must exclude the use of hormone replacement therapy by the woman.
•Vulvar lesions such as dystrophies and tumours must be excluded.
•Atrophic vaginitis is the commonest cause of PMB in our environment and may be precipitated by trauma (coital or non-coital).
•Tumours of the genital tract include cancers of the vulva/vagina, cervix, endometrium and ovary.
•Ovarian estrogen secreting tumour
•Endometrial hyperplasia
•Uterine polyps
State the things to ask from the history and examinations
History
-LMP
-Bleeding
•Like a period?
•Associated with intercourse?
•Previous episodes
-Vaginal discharge
•Any features suggestive of infection?
-Last cervical smear to rule out cancer
Drug history
•On HRT that is not designed to have cyclical bleeding?
•Previous use of oral contraceptive pill
-Obstetric history
Nulliparity associated with endometrial carcinoma
-Functional enquiry
Any recent unexplained weight loss, loss of appetite
Examination
-Abdominal examination
-Speculum examination – take smears if indicated from history or examination
-Bimanual Vaginal examination- assessment of uterus size and consistency
