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Hyperemesis gravidarumAlsaleh Yassin MahmoudSecurity Force Hospital
: تعالى ه� قال ح م لت � انا إحس ه� �د ي بو ال ان اإلنس ا ن و و ص�ي � ها �ر ك ه� و و ض ع ت � ها �ر ك م%ه�
� أ
And we have commended unto man kindness toward parents. his mother bear him with reluctance, and bring him forth with reluctance.
ObjectivesIntroduction.Epidemiology.Clinical picture.Investigation.Treatment.outcomes.
IntroductionNausea and vomiting in pregnancy is
extremely common. The nausea and vomiting associated with
pregnancy usually begins by 9-10 weeks of gestation, peaks at 11-13 weeks, and resolves in most cases by 12-14 weeks.
Normal nausea and vomiting may be an protective mechanism—it may protect the pregnant woman and her embryo from harmful substances in food.
DefinitionsMotion sickness:Nausea felt by pregnant woman on
getting up in the morning.Emesis gravidarum:actual vomiting in the morning.Hyperemesis gravidarum:Vomiting not confined to morning but
repeated throughout the day until it affect the general condition of the patient.
EpidemiologyIncidence:Of all pregnancies, 0.3-2% are affected
with HEG .more common in westernized
industrialized societies and urban areas than rural areas.
Race: No clear racial predominance is noted for HEG
Risk factorsPrevious pregnancies with HEGGreater body weightMultiple gestationsTrophoblastic diseaseNulliparity
The risk of HEG appears to decrease with advanced maternal age.
Cigarette smoking is associated with a decreased risk for HEG.
AetiologyUnknown.
Hormonal.Psychological. Vestibular and olfaction Hepatic dysfunction .Lipid alterations .Other (H.pylori infection)
Aetiology cont.Hormonal:Women with hyperemesis gravidarum often
have high hCG levels that cause transient hyperthyroidism.
High human chorionic gonado trophin (hCG) stimulate the chemo receptor trigger zone in the brain stem including vomiting center.
Evidence by High hCG in :Early pregnancy.Vesicular mole.Multiple pregnancy.
Aetiology cont. H . pylori infection:1-The incidence of H.pylori sero positive in
patients with hyperemesis gravidarum (HG) is high in comparison with non-HG pregnant women .
no one was able to demonstrate correlation between seropositivity for H. pylori and the time of onset or duration of HG symptoms.
Although H. pylori infection may be an importantm factor in exacerbating HG, it may not represent the sole cause of the disease.
No definitive
correlatio
n
Multiple fa
ctor
DiagnosisHistory.Examination.
Clinical picture (symptoms)Vomiting through day and night ptyalism dizziness Sleep disturbanceHyperolfactionDysgeusiaDepressionAnxietyIrritabilityMood changesDecreased concentration
Clinical picture (sign)Signs:Dehydration.Weight loss.Sunken eyeDry mouth.Mild fever.Hypotension.
CRITERIAHEG
Persistent vomiting
weight loss greater than 5%
Dehydration
Electrolyte abnormalities
Differential Diagnosis Gastrointestinal disorders Gastroenteritis Biliary tract disease Hepatitis Intestinal obstruction Peptic ulcer disease Pancreatitis Appendicitis Genitourinary tract
disorders Pyelonephritis Uremia Degenerating uterine
leiomyoma Torsion Kidney stones Drug toxicity or intolerance
Metabolic disorders Diabetic ketoacidosis Porphyria Addison’s disease Hyperthyroidism Neurologic disorders Pseudotumor cerebri Vestibular lesions Migraine headaches Central nervous system
tumors Pregnancy-related conditions Nausea and vomiting of
pregnancy hyperemesis gravidarum Acute fatty liver of
pregnancy Preeclampsia
InvestigationsUrinalysis: 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 contUrine culture: UTI can be associated
with nausea and vomiting.Hematocrit: This may be elevated.Hepatitis screening: hepatitis A, B, or C
may be confused with HEG.
Investigations contImaging Studies:
Obstetric ultrasonography : evaluate for multiple gestations or trophoblastic disease.
upper abdominal ultrasonography to evaluate the pancreas and/or biliary tree
In rare cases, abdominal CT scan may be indicated if appendicitis is under consideration.
Management1-Admission:2-Intravenous Fluids:Normal saline or lactated Ringer’s
solution is the mainstay of intravenous fluid therapy.
It should be given by infusion over 2-3 hours.
thiamine (vitaminB1).3-Enteral or Parenteral Nutrition.
Management contDIETARY AND LIFESTYLE CHANGES Separating solids and liquids. Eating small, frequent meals consisting of
bland foods. Avoiding fatty foods such as potato chips. Avoiding drinking cold or sweet beverages. Eliminate pills with iron High protein snacks are helpful.
Management cont5 - PHARMACOLOGICAL THERAPIES: Vitamins Pyridoxine (Nestrex) Essential for normal DNA synthesis and
play a role in various metabolic processes
- (Diclectin) combination of doxylamine with of pyridoxine (vitamin B6)
- A - Safe in pregnancy - at a dose of 10-12.5 mg PO qd/bid.
Management contAntiemetics : a.DOPAMINE ANTAGONISTS: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.
Management contMetoclopramide:is 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
Management contSEROTONIN 5-HT3 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.
Management contAntihistamines :Meclizine (Antivert) , Diphenhydramine
(Benadryl) Appears to be as efficacious as pyridoxine Causes sedation; caution must be used in
performing tasks which require alertness
Management contCorticosteroids:Methylprednisolone (Medrol, Solu-
Medrol) Recent studies revealed a small but
significantly increased risk of oral clefting associated with first trimester exposure to corticosteroids.
Management contA 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 .
Management contOther modalities:(antidepressent):- Selective serotonin re-uptake inhibitors- Tricyclic antidepressants (TCAs) Helicobacter pylori eradication.ACUPUNCTURE.Stimulation of the P6 point, located three-
fingers’ breadth proximal to the wrist, has been used for treat nausea and vomiting
Ginger (Zingiber officinale)
outcomesEsophageal rupture or perforationPneumothorax and pneumomediastinumWernicke encephalopathy or blindnessHepatic diseaseSeizures, coma, or death
HEG is self-limited and, in most cases, improves by the end of the first trimester. However, symptoms may persist through 20-22 weeks of gestation and, in some cases, until delivery.
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