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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