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22/12/2014

Obstetrics & Gynecology Department

Hyper-emesis
Gravidarum

Presented by
Dastan Hadi

Hyper-emesis Gravidarum
Overview
Nausea and Vomitting are common in pregnancy
In 75-80%
Begins by 9-10 weeks of gestation
Peaks at 11-13 weeks
Resolves in most cases by 12-14 weeks
May be a protective mechanism
Hyperemesis Gravidarum is a diagnosis of exclusion
Complicates 0.3-2% of pregnancies

Epidemiology
Incidence
0.3-2%
More common in westernized industrialized
societies and urban areas than rural areas.
Race: white women > other ethnicities

Epidemiology
Risk Factors
Previous pregnancies with HEG
Low pre-pregnancy weight
Multiple gestations
Trophoblastic disease
Nulliparity
Long interval between births
Unwanted pregnancies
Low maternal age, or young unwed mothers
The risk of HEG appears to decrease with advanced maternal age.
Cigarette smoking is associated with a decreased risk for HEG.

Etiology
Genetic & Environmental
Hormonal
Psychological
Vestibular and olfaction
Hepatic dysfunction
Lipid alterations
Other (H.pylori infection)
Idiopathic/Unkown

Diagnosis
Mainly clinical
Initially, clinical findings with ketonuria (via dipstick method)
Prolonged symptoms need further investigations, like
Electrolytes
Liver function test
Renal function test
Thyroid function test

Criteria for Diagnosis


Diagnosis

persistent
vomitting

>5%
weight loss

dehydration

electrolyte
disturbance

Clinical Picture: Symptoms


vomiting, ptyalism
dizziness, sleep disturbance
hyperolfaction, dysgeusia
depression, anxiety, irritability, mood changes
decreased concentration

Clinical Picture: Signs


Dehydration
Weight loss
Sunken eye
Dry mouth
Mild fever
Hypotension

Differential Diagnosis:
Pregnancy-related conditions
Nausea and vomiting of pregnancy
Acute fatty liver of pregnancy
Preeclampsia

Differential Diagnosis:
Gastrointestinal disorders
Gastroenteritis
Biliary tract disease
Hepatitis
Intestinal obstruction
Peptic ulcer disease
Pancreatitis
Appendicitis

Differential Diagnosis:
Genitourinary tract disorders
Pyelonephritis
Uremia
Degenerating uterine leiomyoma
Torsion
Kidney stones
Drug toxicity or intolerance

Differential Diagnosis:
Metabolic disorders
Diabetic ketoacidosis
Porphyria
Addisons disease
Hyperthyroidism

Differential Diagnosis:
Neurologic disorders
Pseudotumor cerebri
Vestibular lesions
Migraine headaches
Central nervous system tumors

Imaging Studies
Obstetric U/S : evaluate for multiple gestations or
trophoblastic disease.
Upper abdominal U/S to evaluate the pancreas and/or biliary
tree
In rare cases, abdominal CT scan may be indicated if
appendicitis is under consideration.

Investigations
Urinalysis: for ketones and specific gravity
Serum electrolytes :
Low Na or K
Hyperchloremic metabolic alkalosis or acidosis

LFT: Elevated transaminase levels


TSH,free thyroxine : HEG is associated with hyperthyroidism

Investigations cont.
Urine culture: for suspected UTI
Hematocrit: may be elevated.
Hepatitis screening: Hepatitis A, B, or C

Management
1-Admission
2-Intravenous Fluids:
Normal saline or lactated Ringers solution is the mainstay of
intravenous fluid therapy
It should be given by infusion over 2-3 hours
Thiamine (Vitamin B1)

3-Enteral or Parenteral Nutrition

Pharmacotherapy
1) Vitamins
Pyridoxine (Nestrex) (Vit. B6)
Essential for normal DNA synthesis and play a role in various
metabolic processes

(Diclectin) combination of doxylamine with pyridoxine


A - Safe in pregnancy
At a dose of 10-12.5 mg PO qd/bid.

Pharmacotherapy cont.
2) Antiemetics :
Dopamine Antagonist
Useful in the treatment of symptomatic nausea
phenothiazines (i.e., chlorpromazine, perphenazine, prochlorperazine,
promethazine, trifluoperazine)
blocking postsynaptic mesolimbic dopamine receptors through
anticholinergic effects and depressing reticular activating system
C - Safety for use during pregnancy has not been established.

Pharmacotherapy cont.
Metoclopramide
An upper gastrointestinal motility stimulant.
Blocks dopamine receptors and (when given in higher doses)
also blocks serotonin receptors in chemoreceptor trigger zone
of the CNS
Metoclopramide is safe to be used for management of NVP,
although evidence for efficacy is more limited
B - Usually safe but benefits must outweigh the risks

Pharmacotherapy cont.
Serotonin 5HT-3 Antagonists
Ondansetron (Zofran)
blocking serotonin, both peripherally on vagal nerve terminals
and centrally in the chemoreceptor trigger zone
In general, 5-HT3 antagonists may be safe to use during the
first trimester, but the data are scant.

Pharmacotherapy cont.
3) Antihistamines :
Meclizine (Antivert) , Diphenhydramine (Benadryl)
Appears to be as efficacious as pyridoxine
Causes sedation; caution must be used in performing tasks
which require alertness

Pharmacotherapy cont.
4) Corticosteroids:
Methylprednisolone (Medrol, Solu-Medrol)
Recent studies revealed a small but significantly increased risk
of oral clefting associated with first trimester exposure to
corticosteroids.

Pharmacotherapy cont.
5) Antidepressents
Selective serotonin re-uptake inhibitors
Tricyclic antidepressants (TCAs)
6) Helicobacter pylori eradication.

Pharmacotherapy cont.
A doxylamine/ pyridoxine combination should be the
standard of care since it has the greatest evidence to support
its efficacy and safety.
Other drugs may also be used, primarily dimenhydrinate, in
conjunction with the doxylamine/pyridoxine combination.
If possible, corticosteroid use should be avoided in the first 10
weeks

Alternative Medicine
Hypnotherapy
Music Therapy
Acupressure
Acupuncture
Herbal Remedies
Ginger

Prognosis
HEG is self-limiting
Symptoms may persist through 20-22 weeks of gestation and, in some
cases, until delivery.
Complicated cases may lead to;
Esophageal rupture or perforation
Pneumothorax and pneumomediastinum
Wernicke encephalopathy or blindness
Hepatic disease
Seizures, coma, or death

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