Jan 2016
nd
Halim 2
-
Dr.Raghad Abdul
1
BY : TAHER ALI
in Pregnancy
Vomiting
Nausea and vomiting affect up to 50% of pregnant women. The onset of symptoms
is usually early in the first trimester at around 5-6 weeks gestation, this is called
morning sickness. Most of maintain women are able to maintain fluid and nutrient
intake by dietary modification and the symptoms will resolve by the end of the 1
st
trimester.
HYPEREMESIS GRAVIDARUM:
Definition: H.G. is nausea and vomiting of pregnancy when the woman is unable to
maintain adequate hydration and nutrition, either because of severity or duration of
symptoms. The severe and protracted vomiting is associated with marked weight loss,
muscle wasting, ketonuria, dehydration, and electrolyte disturbance including
hypokalemia and metabolic hypochloremic alkalosis.
Incidence: affects 0.5-2% of all pregnancies.
A common associated symptom is ptyalism- excess salivation and the inability to
swallow saliva, an increased olfactory and gustatory aversion. Some discrete
measures of severity, the most commonly accepted criterion being loss of 5% of pre-
pregnancy weight.
Etiology: H.G. is clearly related to a product of placental metabolism since it does
not require the presence of the fetus.
Strong temporal association between hCG level and the time course of nausea
and vomiting of pregnancy.
There is association of biochemical hyperthyroidism with the severity of
nausea and vomiting of pregnancy. The thyroid stimulator of pregnancy is hCG
(hCG can stimulate TSH receptors in the thyroid gland).
Higher level of maternal estradiol.
Certain cytokines is seen to be increased in patients with H.G. such as TNF-α.
Genetic predisposition of mother (family history seen in monozygotic twin, or
in mother).
Jan 2016
nd
Halim 2
-
Dr.Raghad Abdul
2
BY : TAHER ALI
Associations Unique to Nausea &Vomiting of Pregnancy:
Family history.
Female gender of fetus.
History of migraine.
Multiple gestations.
Down syndrome.
Molar pregnancy.
Note: Smoking
decrease nausea and vomiting of pregnancy because it is
associated with decreased concentration of hCG and estradiol, but remember
that smoking result in many complications in pregnancy like abortion, pre-
eclampsia and IUGR.
Diagnosis:
History and Examination:
The onset of H.G. is always in the 1
st
trimester, in addition to nausea and
vomiting and weight loss, women often report ptylism, there may be signs of
dehydration including postural hypotension and tachycardia. H.G. is a
diagnosis of exclusion and it is important to make athorough clinical
assessment and to ensure that investigations are performed for common and
serious causes of vomiting.
Investigation:
An ultrasound of the uterus should be performed to:
Confirm that woman is pregnant.
To establish the number of fetus/fetuses (to exclude multiple pregnancy).
To exclude hydatidiform mole.
Laboratory investigation commonly reveals hyponatremia, hypokalemia,
raised hematocrit. Ketonuria is frequently present.
A biochemical hypothyroidism with raised free T4 and decreased TSH (which is
transient and not require specific treatment) may also be present. Women with
biochemical hyperthyroidism examined carefully, we should ask about weight loss,
Jan 2016
nd
Halim 2
-
Dr.Raghad Abdul
3
BY : TAHER ALI
diarrhea, tachycardia prior to pregnancy, examined for goiter, and checked for
thyroid antibodies.
Other possible causes of N &V should be excluded like UTI so we should send
patients for mid stream urine test and urine for culture & sensitivity, urea &
electrolyte, cholecystitis, gastritis, peptic ulcer, torsion of ovarian cyst, diabetic
keto-acidosis and intracranial tumors.
Complications and Risks of H.G.:
1. Maternal Risks; serious maternal morbidity and mortality may result if H.G. not
managed correctly.
Wernick's encephalopathy (diplopia, nystagmus, ataxia, and confusion)
can develop as a result of thiamine (Vitamine B1) deficiency, which if
untreated may result in Korsakofs' psychosis (amnesia, impaired ability
to learn) or death.
Other vitamins deficiencies may occur for example peripheral neuropathy
and anemia resulting from vitamin B12, B6 deficiency.
Hyponatremia can cause confusion, seizures and respiratory arrest, and if
not treated too rapidly can cause pontine myelinolysis.
Deep venous thrombosis (DVT): resulting from dehydration and reduced
mobility.
Mallory-Weiss tear in the esophagus due to prolong vomiting.
2. Fetal risks: infants of mothers with severe H.G., abnormal biochemical tests,
weight loss have been reported to have lower birth weights.
Treatment:
1. Rehydration and Vitamin Supplementation:
Fluid replacement therapy should be with either normal saline (NaCl 0.9%) or
Hartmanns' solution (NaCl 0.6%). Dextrose containing fluids should not be used
because it they do not contain sufficient Sodium to correct hyponatremia and
Wernicks' encephalopathy can be precipitated by intravenous dextrose and
carbohydrate rich foods (because the small amount of thiamine remaining may be
consumed in the acute metabolism of carbohydrate load).
Normal saline 1L + 20-30 mmol KCl 8 hourly. Thiamine supplements should be
given in a daily dose of 25-50 mg tds. Monitoring of urine output and dipstick to
assess ketonuria should be done.
Jan 2016
nd
Halim 2
-
Dr.Raghad Abdul
4
BY : TAHER ALI
2. Antiemetic:
Vitamin B6 10-30 mg tds is recommended 1
st
, if symptoms persists we can add
anti-histamines like (doxylamine 10 mg, diphenhydranate 50-100 mg 6 hourly), if
symptoms persists we can add phenothiazine (prochlorperazine-stimitil- 25mg
twice daily) or dopamine antagonist-metoclopromide-5-10 mg 8 hourly orally or
intravenously.
If all these measures fail then short course of corticosteroids which are a potent
antiemetic in a form of methylprednisolone 16 mg 3 times daily for 3 days and
then tapered to the lowest effective dose for a period not exceeding 6 weeks, most
patients will respond to this treatment. Corticosteroids appear to increase the risk
of facial clefts slightly when given in the 1
st
trimester, other commonly used
antiemetic are not known teratogens.
3. Nutritional Support:
Advice the patient to eat small portions of whatever seems palatable whenever
symptoms allow. Proteins are better tolerated than fat and carbohydrates, liquid
meals are better than solid, sometimes change in location or separation from home
has some benefit in decreasing symptoms.
In few cases when the patient does not respond adequately to therapy and is unable
to maintain their weight by oral intake, nutritional support is required either by:
Enteral nutrition: supplementation using naso-gastric tube.
Parenteral nutrition: has complication of sepsis, thrombophlebitis, and
pericardial temponade.
Prevention
:
The best approach to H.G. management is by prevention:
Taking multivitamins at the time of conception and early pregnancy are less
likely to require intervention later on.
Treatment of woman who has nausea and vomiting sufficient to interfere with
their daily routine is associated with lower rate of hospital admission for H.G.
هاي المحاضرة قبل نص السنة ضربنا دوام فمشت علينا مدخلة بنص السنة بس داخلة بالنهائي: ةظحلام
... وشكرا
Good Luck