Hyperemesis gravidarum
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Hyperemesis Gravidarum is a severe form of nausea and vomiting during pregnancy that results in dehydration, weight loss and electrolyte imbalance. It affects 0.3-3% of pregnancies. Risk factors include multiple gestation, family history and nulliparity. Nausea is caused by hormonal changes that relax the gastrointestinal tract. Treatment ranges from dietary changes for mild cases to intravenous hydration and antiemetics for severe cases. Corticosteroids may help refractory nausea and vomiting.
Hyperemesis gravidarum
- 2. Dr. Niranjan Chavan MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H Chairperson, FOGSI Oncology and TT Committee (2012-2014) Treasurer, MOGS (2017- 2018) Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016) Chief Editor, AFG Times (2015-2017) Editorial Board, European Journal of Gynecologic Oncology Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters Member, Managing Committee, IAGE (2013-2017) Member, Oncology Committee, AOFOG (2013 -2015) Recipient of 6 National & International Awards Author of 15 Research Papers and 19 Scientific Chapters Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH
- 3. INTRODUCTION • Nausea and Vomiting of Pregnancy diagnosed when onset is in the first trimester of pregnancy and other causes of nausea and vomiting have been excluded. • Hyperemesis Gravidarum is defined as protracted Nausea and Vomiting of Pregnancy with the triad of • > 5% pre pregnancy weight loss • Dehydration and • Electrolyte imbalance.
- 4. INCIDENCE • The incidence of women with severe symptoms vary from 0.3 to 3 % of pregnancies. • In a prospective study published in 2016 which included 800 patients, • 57 % reported nausea and • 27 % reported both nausea and vomiting • by 8 weeks of gestation. * Hinkle SN, Mumford SL, Grantz KL, et al. Association of Nausea and Vomiting During Pregnancy With Pregnancy Loss: A Secondary Analysis of a Randomized Clinical Trial. JAMA Intern Med 2016; 176:1621.
- 5. RISK FACTORS • Multiple gestation • Hydatidiform mole • Non-use of multivitamins before 6 weeks of gestation or during the peri-conceptional period • Heartburn and acid reflux • Nulligravida • Nonpregnant women who experience nausea and vomiting related to oestrogen-based medication
- 6. RISK FACTORS • Motion sickness • Migraine • Female fetus • Family history of Hyperemesis Gravidarum Smoking and Alcohol are protective factors.
- 9. PATHOGENESIS HORMONAL CHANGES • Estrogen • Progesterone • Beta hCG • These hormones relax smooth muscle and thus slow gastrointestinal transit time and may alter gastric emptying. • Relax the lower oesophageal sphincter
- 10. In a 2014 systematic review and meta-analysis of 26 epidemiological studies published in American Journal of Obstetrics & Gynaecology, a significant association was found between H. pylori infection and hyperemesis gravidarum/nausea and vomiting of pregnancy compared with asymptomatic controls (OR 3.21)
- 11. NATURAL COURSE • Mean onset of symptoms five to six weeks of gestation • Peak nine weeks • Subsides by 16 to 20 weeks of gestation • 60 % become asymptomatic six weeks after onset of nausea. • Persisted symptoms till third trimester 15 to 20 % • Persisted symptoms till delivery 5 %
- 12. CLINICAL PRESENTATION • Nausea and vomiting • Weight loss (> 5% of pre pregnant weight or >3 kg) • Ketonuria • Orthostatic hypotension • Physical signs of dehydration • Ptyalism (Hyper salivation)
- 13. DIAGNOSTIC SCORING SYSTEM • The Motherisk – PUQE (Pregnancy Unique Quantification of Emesis) scoring system • Rhodes score • Modified PUQE Score (symptoms over the course of the entire first trimester) Assess the symptoms for past 12 hours
- 15. RHODES INDEX: none: 0, mild: 1-8, moderate: 9-16, severe: 17-24, great: 24- 32.
- 16. MODIFIED PUQE SCORE Mild NVP 3–6 Moderate 7–12 and Severe NVP/HG ≥13
- 17. INVESTIGATIONS • Electrolyte Imbalance: hypokalemia hypochloremia hypomagnesaemia • If Mg2+ < 0.8 mEq/L resistance to parathormone Hypocalcemia • Hematocrit: due to hemoconcentration • Liver Function Test : ALT & AST (in 50%) : bilirubin (do not rise > 4) • Serum amylase and lipase (10 to 15 %) • Thyroid Function: Mild hyperthyroidism due to raise B – hCG: Transient Biochemical Hyperthyroidism is is defined as a free T4 index higher than the upper range of normal, or a thyroid-stimulating hormone (TSH) level less than 0.4 mU/L.
- 18. DIFFERENTIAL DIAGNOSIS • Multiple gestation • Hydatidiform mole • Preeclampsia, HELLP, and acute fatty liver of pregnancy (late onset) • Pancreatitis • Migraine • Hyperparathyroidism in pregnancy • Cannabinoid hyperemesis syndrome
- 20. MANAGEMENT
- 21. As per ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy. 2018 Nausea & Vomiting of Pregnancy (NVP) should be treated according to the severity • Nausea alone • Vomiting without dehydration • Vomiting with dehydration.
- 23. MANAGEMENT OF NAUSEA ALONE • Diet changes : small meals every 2 hrs avoid triggers add ginger to diet • Pyridoxine: 10 to 25 mg orally every 6 - 8 hours; the maximum 200 mg/day. • Doxylamine succinate and pyridoxine:each tablet contains doxylamine 10 mg and pyridoxine 10 mg, 2 – 4 tabs/day • Acupuncture or acupressure – P6 acupressure wristbands • Hypnosis
- 25. MANAGEMENT OF VOMITING WITHOUT DEHYDRATION • Antihistaminic (H1 antagonists): Diphenhydramine, Meclizine, Dimenhydrinate • Dopamine Antagonist: Metoclopramide, Promethazine, Prochlorperazine • Serotonin Antagonist: Ondansetron, granisetron, and dolasetron • Acid-reducing agents: antacids, H2 blockers, proton pump inhibitors
- 26. MANAGEMENT OF VOMITING WITH DEHYDRATION • IV Fluid & Electrolyte Correction • Vitamins & Mineral • Antiemetics • Diet therapy
- 27. IV Rehydration and Electrolyte Correction 2 L intravenous Ringer's lactate infused over 3 – 5 hrs Isotonic saline if serum Na+ levels >120 mEq/L Dextrose 5 % in 0.45 % saline with 20 mEq KCl at 150 mL/hour to patients with normal K- levels Urine output of at least 100 mL/hour Serum K + 3.0 to 3.4 mEq/L. Treatment is usually started with 10 to 20 mEq of K+ given 2 - 4times per day (20 to 80 mEq/day)
- 28. VITAMINS & MINERALS • THIAMINE: 100mg IV for 3 days • FOLIC ACID: 0.6mg daily • VITAMIN B6: 25mg in 1 litre fluid daily • MVI: 10 ml with IV Fluid • MAGNESIUM : 2 g (16 mEq) magnesium sulfate infused as a 10 percent solution over 10 to 20 minutes, followed by 1 g (8 mEq) in 100 mL of fluid per hour.
- 29. CLASS DRUG DOSE SIDE EFFECTS FDA CATEGORY Antihistaminics Diphenhydramine 25 – 50 mg QID B Meclizine 25 mg QID Cleft palate B Dimenhydrinate 25 mg QID, MAX 400mg B Dopamine antagonist Metochlopramide 10mg PO/IV/IM 30 min before each meal Metoclopramide-induced tardive dyskinesia B Promethazine (H1 + Dopamine antagonist 12.5 – 25mg PO/PR/IV every 4 hours Sedation Dystonia Lower seizure threshold C Prochlorperazine 10 mg PO QID 25 mg PR BD QT prolongation Urinary retention Extrapyramidal symptoms C 5- hydroxytryptamine-3 (5-HT3) serotonin receptor antagonist Ondensetron 4mg PO/IV QID Headache Constipation QT prolongation Serotonin syndrome B Granisetron Can be given transdermal Same as ondensetron B
- 30. REFRACTORY CASES • The ACOG suggests consideration of testing for H. pylori infection in patients who are unresponsive to standard therapy. • CORTICOSTEROIDS: methylprednisolone (16 mg) IV/ 8 hours for 48 to 72 hours Hydrocortisone 100mg IV BD for 2 – 3 days After IV, Prednisolone 40mg for 1 day 20 mg for 3 days 5mg for 7 days • Parenteral Nutrition : continued till the women is able to take 1000kcal/day per oral
- 31. CONCLUSION • Nausea and vomiting in pregnancy is the most common indication for hospitalization in 1st trimester. • Severity of NVP should be evaluated using PUQE score and treated accordingly. • Diet changes, avoidance of the trigger and Doxylamine + Pyridoxine is the 1st line of therapy • PUQ> 13 with dehydration should be treated with IV rehydration, electrolyte correction and ondansetron. • Refractory cases might require corticosteroids and parenteral nutrition.
- 32. REFERENCES • Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy. Obstet Gynecol 2018; 131:e15. • The management of nausea and vomiting of pregnancy and hyperemesis gravidarum, Green Top Guideline No 69, June 2016 • Sartori J, Petersen R, Coall DA, Quinlivan J. The impact of maternal nausea and vomiting in pregnancy on expectant fathers: findings from the Australian Fathers' Study. J Psychosom Obstet Gynaecol 2017; :1. • Matthews A, Haas DM, O'Mathúna DP, Dowswell T. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev 2015; :CD007575. • Tan A, Lowe S, Henry A. Nausea and vomiting of pregnancy: Effects on quality of life and day-to- day function. Aust N Z J Obstet Gynaecol 2017. • Heitmann K, Nordeng H, Havnen GC, et al. The burden of nausea and vomiting during pregnancy: severe impacts on quality of life, daily life functioning and willingness to become pregnant again - results from a cross-sectional study. BMC Pregnancy Childbirth 2017; 17:75.