vomiting in pregnancy
DESCRIPTION
done by Al Yaqdhan Al Atbi Sultan Qaboos university- OmanTRANSCRIPT
Done by: Al-Yaqdhan Al-Atbi81559
VOMITING IN PREGNANCY
A case: Hx, PE, Investigations, managementPregnancy in vomiting:
IntroductionEpidemiologyRisk factorsPathogenesis Clinical featuresInvestigationTreatmentPrognosis
OUTLINE:
28years old female , G3P2 on 12th week of gestation came
to the hospital complaining of vomiting several times since few days.
She can not tolerate oral food, immediately vomit any thing she eat or drink
She denied any abdominal pain, diarrhea, or vaginal bleeding or leaking.
She had laparoscopic appendectomy in may/2012
Gynecological Hx: last menstrual period 23/11/2012. otherwise unremarkable
Obstetrical Hx: both pregnancies were uneventful
History
History
cholecystitispeptic ulcer
diseasepyelonephritisovarian torsiongastroenteritisacute fatty liver
disease of pregnancy
cerebral tumorhepatitispanreatitis
DDx:
It is important to consider and exclude other causes of nausea and vomiting, including:Hyperemesis
gravidarumhydatiform molegestational hypertension
/HELLP syndromepelvic inflammatory
disease hyperthyroidism/
thyrotoxicosisinflammatory bowel
diseaseappendicitis
O/E she is comfortable, alert, oriented, not in distress, but looks dehydrated.
Vitals: afibrile, tachycardiac 118/min, normal BP, O2 sat 99%
Chest examination: clear
Examination
Dehydration Symptoms
Important investigations for serious vomiting include: electrolytes urine ketones
Given other items on the differential, it is reasonable to consider: CBC BUN, creatinine thyroid function liver enzymes, bilirubin amylase urinalysis acid-base disturbances
Diagnostic Imaging A fetal doppler should be used to ascertain fetal viability.
If it is not able to be located, ultrasound surveillance is warranted to rule out hyadifirom mole.
Investigations
Urine dipstick: Ketones +4, proteins +2, blood +4Culture: normal
Blood tests:CBC:
RBC: 5.93 (4.10- 5,40) 10^12/L elevated Hb : 15.1 (11.0- 14.5) g/dL elevatedMCV : 73.5 (78.0- 95.0) fL decreasedHaematocrits: 0.44 ( 0.34- 0.43) L/L elevatedPlatelet: normalWBC : 13.9 (2.40- 9.50) 10^9 elevated??
Investigations
Electrolytes profile:Anion gap 21 mmol/L (5-13) elevatedHCO3- 12 mmol/L (22-29) decreaseK+ 3,4 mmol/L (3.5-5.1) decreaseNa+ 131 mmol/L (135-145) decreaseCl- 104 mmol/L (98-107) normal
Amylase and lipase: normal
Metabolic Alkalosis + hypokalemia
TFT:T4 22.4 pmol/L (7.9- 14.4) elevatedTSH 0.19 mIU/L (0,34- 5.60) decrease
LFT: unremarkable
Bed side scan: single intrauterine gestational sac and good cardiac activity
Good hydration of patientRegular antiemiticsKCl 20 unite with normal saline
treatment
Hyperemesis Gravidarum
Vomiting in Pregnancy
Nausea and vomiting in pregnancy (known as "morning sickness") are common complaints.
N/V in pregnancy can have a significant impact on jobs, activities, family relationships, and moods
Nausea and vomiting are common in pregnancy, affecting up to 70% to 85% of pregnant women.
Hyperemesis gravidarum: is severe, debilitating nausea and vomiting in pregnancy
that generally leads to more than 5 percent weight loss and may require fluid and nutritional supplement
Introduction
Nausea and vomiting in pregnancy are more common in: Primigravidae. Multiple pregnancy. History of previous hyperemesis gravidarum.
It is less common with increasing maternal age.
It tends to be a disease of Western society and is less common in developing countries, especially in rural communities.
The incidence of women with severe symptoms is not well-documented; reports vary from 0.3 to 2 percent of pregnancies
Epidimiology
women with multiple gestations women with hydatidiform mole women who did not take multivitamins either prior to 6 weeks of
gestation or during the peri-conceptional period women with heartburn and acid reflux genetic factors appear to play a role.
Women who are supertasters are also at increased risk; in contrast to anosmic women
Non-pregnant women who experience nausea and vomiting related to estrogen–based medication, motion, or migraine are more likely to experience pregnancy-related nausea and vomiting
Risk Factors
Alcohol use and cigarette smoking (perhaps due to the effect of nicotine) appear to be protective factors
Psychological
GastrointestinalHormonal
PathogenesisThe pathogenesis of nausea and vomiting in
pregnancy is unknown
Source Etiology Pathophysiology
•Placenta•Corpus luteum
hCG•Distention of gastrointestinal tract•Crossover with TSH, causing gestational thyrotoxicosis
Placenta •Estrogen•Progesterone
•Decreased gut mobility•Elevated liver enzymes•Decreased LES pressure•Increased levels of sex steroids in hepatic portal system
Gastrintestinal tract
Helicobacter pylori
Increased steroid levels in circulation
Hormonal changes
serum concentrations of human chorionic gonadotropin (hCG) peak during the first trimester hyperemesis gravidarum is typically seen
serum hCG concentration is higher in women with hyperemesis than in other pregnant women
A causal association between
hCG levels and hyperemesis gravidarum
has not been firmly established
hCG and hyperemesis in pregnancy
Women with the common form of NVP maintain normal vital signs and have normal physical and laboratory examinations
Symptoms usually start between 4 and 7 weeks of gestation and resolve by 16 weeks in about 90% of women.
In contrast to women with mild disease, women with hyperemesis have orthostatic hypotension, laboratory abnormalities, and physical signs of dehydration, and often require hospitalization for stabilization.
Clinical Features
Severe nausea and vomiting Loss of 5% or more of pre-pregnancy body weightDehydration symptomsDifficulty with activities of daily livingHyperolfcation: extremely sensitive to odors in
their environmentHypersalivation
some sufferers of HG will experience severe symptoms until they give birth to their baby, and sometimes even after giving birth.
Clinical Features
Laboratory evaluation indicated in women with persistent nausea and vomiting to determine the severity of disease and to exclude other diagnoses that could account for the symptoms.
standard initial evaluation of pregnant women with persistent nausea and vomiting includes: measurement of weight orthostatic blood pressures heart rate serum electrolytes urine ketones and specific gravity. An obstetrical ultrasound examination is performed to look for
gestational trophoblastic disease and multiple gestation, both of which are associated with these symptoms
Tests to exclude other diagnoses: CBC, BUN, creatinin, LFT, TFT, amylase/lipase
Evaluation
Electrolyte and acid-base derangements:hypokalemia and hypochloremic metabolic
alkalosisIncrease in hematocrit:
indicating hemoconcentration due to plasma volume depletion
elevated blood urea nitrogen and urine specific gravity.
Abnormal liver enzym:Increase ALT>AST
Serum amylase and lipase may increase as much as 5-fold and are of salivary
rather than pancreatic origin
Lab Findings
Mild hyperthyroidism:due to high serum concentrations of hCG which has
thyroid-stimulating activity
To differentiate between HG induce hyperthyroidism and hyperthyroidism of other causes are:
the vomiting,absence of goiter and ophthalmopathyabsence of the common symptoms and signs of
hyperthyroidism (heat intolerance, muscle weakness, tremor).
serum free T4 concentrations are only minimally elevated
Lab Findings
Goals of treatment:Reduce symptoms through changes in
diet/environment and by medication
Correct consequences or complications of nausea and vomiting (eg, fluid depletion, hypokalemia, and metabolic alkalosis)
Minimize the fetal effects of maternal nausea and vomiting and their treatment
Treatment
Treatment begins with advice aboutdietavoidance of triggersnon-pharmacologic interventions, such as
acupressureoral or rectal medications are added if
symptoms do not improve
Initial approach
Diet:Meals and snacks slowly and every 1-2 hr to avoid
full stomach
Woman should figure out what foods they tolerate best and try to eat those foods
Fluids are better tolerated if cold, clear, and carbonated or sour (eg, ginger ale, lemonade), and if taken in small amounts between meals
Drinking peppermint tea or sucking peppermint candies can reduce postprandial nausea
Initial approach
Nonpharmacologic interventions:Avoidance of triggers
stuffy rooms, odors (eg, perfume, chemicals, food, smoke), heat, humidity, noise, and visual or physical motion (eg, flickering lights, driving)
Acupuncture and acupressure :P6 acupressure wristbands do not require a prescription
and have become a popular self-administered intervention
Hypnosis Hypnosis has been reported to be helpful in some patients .
Psychotherapy
Initial approach
Pharmacological treatment:Complementary and alternative medications
(CAM):Ginger:
RCT studies suggest that powdered ginger is more effective than placebo, and equivalent to vitamin B6 (pyridoxine) for treatment of nausea and vomiting of pregnancy
safety of ginger in pregnancy has been questioned due to in vitro mutagenic properties
Initial approach
Pyridoxine (vitamin B6):Pyridoxine improves mild to moderate nausea, but does
not significantly reduce vomiting
used as a single agent or in conjunction with doxylamine succinate
Antihistamines (H1 antagonists):E.g.: doxylamineSingle agent or with vit B6 these agents significantly reduced pregnancy-related
nausea and vomiting In meta-analysis: found that H1-receptor blockers appeared
to have a protective effect on risk of malformationsADE: sedation, dry mouth, lightheadedness, and
constipation.
Initial approach
Without dehydration: First-line therapy: Antihistamines (H1 antagonists)
E.g.: Diphenhydramine, Meclizine, Dimenhydrinate Have good fetal and meternal safty ADE: Sedation, urinary retention, blurred vision, exacerbation of
narrow-angle glaucoma Second-line therapy: Dopamine antagonists
E.g.: phenothiazines (promethazine and prochlorperazine), butyrophenones (droperidol), and benzamides (metoclopramide)
metoclopramide during the first trimester of pregnancy found no significant increase in risk of congenital malformations, low birth weight, preterm delivery, or perinatal death compared with nonexposed infants.
ADE: Sedation, extrapyramidal effects, QT prolongation, severe hypotension; rarely, seizures, agranulocytosis, neuroleptic malignant syndrome, blood dyscrasias
Third-line: Serotonin antagonists E.g.: Ondansetron, granisetron, and dolasetron ADE:QT prolongation, QRS widening, hypersensitivity reactions
Secondary Approach
Adjunctive therapy:Acid reducing agent:
E.g.: antacids, H2 blockers, PPI
Acid reducing agent + antiemetic's significant effect
Antacids containing aluminum or calcium are safe and preferable to those containing bismuth or bicarbonate
With dehydration:Indications for admition:
Failure of initial intervention
Women who have severe vomiting, weight loss, ketonuria,, poor skin turgor, dehydration, hypotension, alkalosis from hydrochloric acid loss, hypokalemia, or nutritional deficiencies are admitted to the hospital
Secondary Approach
Fluids correction:2 L intravenous Ringer’s lactate infused over 3-5Hr,
supplemented with appropriate electrolytes and vitamins
Relief of symptoms is common within one to two days of rehydration
Vitamins and menirals:provide thiamine (vitamin B1) supplementation Early
administration of thiamine is important to prevent a rare maternal complication, Wernicke's encephalopathy
administer a multivitamin (MVI) intravenously pluse folic acid
IV fluid is usually dextrose 5% in 0.45% saline with 20 mEq KCl given at 150 mL/hour
Hypomagnesemia: magnesium sulfate
Secondary Approach
Nausea and vomiting in pregnancy is generally mild and self-limiting
Almost 50% of cases resolve by week 14 gestation, and 90% by week 22
Maternal consequences include: dehydration electrolyte or acid-base imbalances Mallory-Weiss tear Wernicke's encephalopathy Death
Fetal consequences are rare, but include Intra-Uterine Growth Restriction (IUGR)
Prognosis
http://www.patient.co.uk/doctor/nausea-and-vomiting-in-pregnancy-including-hyperemesis-gravidarum
http://ezproxy.squ.edu.om:2265/contents/clinical-features-and-evaluation-of-nausea-and-vomiting-of-pregnancy?source=search_result&search=hyperemesis&selectedTitle=2%7E42
http://www.ncbi.nlm.nih.gov/pubmed/3341360
Reference
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