임신 중 입덧의 관리- 최준식 제일병원 산부인과 교수

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임신 중 입덧의 관리- 최준식 제일병원 산부인과 교수

  1. 1. 임신 중 입덧의 관리 , 어떻게 할 것인가 ? June Seek Choi M.D., PhD., Associate Professor The Korean Motherisk Program, Division of Maternal-Fetal Medicine, Dept. of OB & GYN., Cheil General Hospital & Women's Healthcare Center, College of Medicine, Kwandong University, Seoul, Korea
  2. 2. Contents • Introduction • Physiology of NVP (nausea and vomiting of pregnancy) • Management of Hyperemesis Gravidarum – Non-pharmacologic Treatment – Pharmacologic Treatment – Experience of Cheil General Hospital & Women’s Healthcare Center (doxylamine+pyridoxine)
  3. 3. Introduction(1) Psychologic condition manifesting the rejection of the pregnancy by the mother Normal symptom of pregnancy, a potentially life threatening disease process and a physiologic protective mechanism to optimize pregnancy outcomes.
  4. 4. Introduction(2) Nausea and vomiting of pregnancy Hyperemesis Gravidarun: weight loss, usually more than 5% of prepregnancy weight •Young age •History of motion sickness •History of migraines •Female gender of fetus •Disorder of fatty acid oxidation •Genetic predisposition Monozygotic twins Inherited glycoprotein -hormone receptor defects Risk Factors
  5. 5. Introduction(3) • Nausea is not limited to the morning as implied by the outdated term of morning sickness, and although typically presenting between 4 and 14 weeks of pregnancy, persists throughout all of pregnancy in 20% of women. • 8.5 million lost working days per year due to NVP.
  6. 6. Introduction(4) • Severe NVP is the third leading cause for hospitalization during pregnancy($17,000 per woman). • Bendectin(doxylamine, pyridoxine, and dicyclomine) until 1982 when it was withdrawn from the market unable to continue to justify the ongoing costs of litigation • Hospitalization rates for NVP doubled in both the United States and Canada,but were subsequently reduced in Canada with the introduction of Diclectin(doxylamine + pyridoxine).
  7. 7. Introduction(5) Fetal consequences of hyperemesis HyperemesisHyperemesis Major congenitalMajor congenital anomaliesanomalies < 7kg weight gain< 7kg weight gain ▪▪ Hip dysplasiaHip dysplasia ▪▪ Down syndromeDown syndrome ▪▪ Fetal coagulopathy orFetal coagulopathy or ChondrodysplasiaChondrodysplasia ▪▪ Low birth weight (RR 2.8)Low birth weight (RR 2.8) ▪▪ Preterm birth (RR 3.0)Preterm birth (RR 3.0) ▪▪ Fetal deathFetal death BailitJL. 2005 KallenB. 1987 Brunetti-Pierri N et al. 2007
  8. 8. Differential Diagnoses for NVP Gastrointestinal disorders Peptic ulcer disease/H. pylori Inflammatory bowel disease Pancreatitis Appendicitis Bowel obstruction Hepatic disorders Hepatitis Cholecystitis and cholestasis CNS disorders Vestibular disorders (Meniere’s) CNS lesions Depression/mood disorders Genitourinary conditions Pyelonephritis Ovarian torsion Pelvic Thyroid dysfunction Transient hyperthyroidism: 50-70% •Nausea beginning after 9 weeks’ gestation •Nausea and vomiting antedating the pregnancy •Abdominal pain •Fever •Headache •Goiter •Abnormal neurologic examination •Elevated white blood cell count, anemia, or thrombocytopenia
  9. 9. Physiology of NVP VestiVesti bularbular && CNSCNS nausenause aa VisceralVisceral && chemorechemore ceptorceptor triggertrigger zonezone nauseanausea NVP Histamine, Acetylcholine Dopamine, Serotonin •Genetic predisposition, •GI dysrhythmias, •Olfactory hyperacuity, •General physical & Emotional well-being, •Sleep patterns, •Hormone levels; primarily thyroid, HCG and estrogen, •Helicobacter pylori ↓Alcohol, Smoking
  10. 10. Prevention and Lifestyle Approaches • There is no one diet that is considered ideal for all women with NVP. • Eat small frequent meals avoiding both over distention and complete emptying of the stomach. • Mild to moderate NVP prefer carbohydrates; breads, cereals, crackers, pasta, and rice. • Profound NVP prefer proteins; meat, chicken, fish, and eggs.
  11. 11. Nonpharmacologic Treatment • Ginger: 250mg po q.i.d. capsule, tablets, tea safety data are not available. • Acupressure: acupressure point P6 (Neiguan) There is no theoretical risk associated with the use of acupressure.
  12. 12. Pharmacologic Treatment(1) • First line therapy is a combination doxylamine and pyridoxine. • Are the symptoms vestibular in nature and, therefore, more likely to respond to antihistamines or anticholinergics or are they visceral and, therefore, more likely to respond to dopamine or serotonin antagonists?
  13. 13. Pharmacologic Treatment(2) Vitamins and Antihistamines • Vitamin: Vitamin B6, Vitamin B12 • Antihistamine: H1 receptor antagonist, H2 receptor antagonist • Doxylamine/Pyridoxine: 2 tablets at bedtime, 1 in the morning and 1 in the afternoon Larger body mass index may need up to 8 tablets/day.
  14. 14. H1-receptor antagonist 1st-generation 2nd-generation 3rd-generation Diphenhydramine, Carbinoxamine, Doxylamine, Clemastine, Dimenhydrinate, Pheniramine, Chlorphenamine (chlorpheniramine), Dexchlorpheniramine , Brompheniramine , Triprolidine, Dimetindene, Cyclizine, Chlorcyclizine, Hydroxyzine, Meclizine, Promethazine, Alimemazine (trimeprazine), Cyproheptadine, Azatadine,Ketotifen Acrivastine, Astemizole, Cetirizine, Ebastine, Ketotifen, Loratadine, Mizolastine, Terfenadine Levocetirizine, Desloratadine, Fexofenadine Pharmacologic Treatment(3) Antihistamines(H1-receptor antagonist & H2 receptor antagonist) Cimetidine (Tagamet) Ranitidine (Zantac) Famotidine (Pepcid) Nizatidine (Axid, Tazac) H2 receptor antagonist
  15. 15. Pharmacologic Treatment(4) Dopamine Antagonists • Phenothiazines : Chemoreceptor trigger zone in the brain to reduce the nausea and are considered a second line drug • Metoclopramide: Upper gastrointestinal motility stimulant and gastric dysrhythmia is associated with NVP • Domperidone and Droperidol: Treatment of severe NVP but have very limited data available. Phenothiazines Chlorpromazine: 10-25mg q4-6h po or IM, 50-100mg q4-6h pr Perphenazine Prochlorperazine: 5-10mg q6-8h IM or po Promethazine: 12.5-25mg q4-6h IM or po Trifluoperazine Trimethobenzamide Domperidone: 10-20mg po q6-8h Droperidol: 0.5-1.0mg/h IV infusion Metoclopromide: 5-10mg q6h IV or po May be sedating or rarely cause extrapyramidal effects
  16. 16. Pharmacologic Treatment(5) Others
  17. 17. Nausea and vomiting of pregnancy: treatment algorithm Dimenhydrinate, 50 mg IV (in 50 mL saline, over 20 minutes), every 4 to 6 hours or Metoclopramide, 5 to 10 mg IV every 8 hours or Promethazine, 12.5 to 25 mg IV every 4 hours or Prochlorperazine, 5 to 10 mg IV every 4 hours (maximum dose, 40 mg/d) For patients not tolerating oral intake Goodwin, 2008 Ondansetron( 온단트 , 조프란 ), 4 to 8 mg orally or IV every 8 hours or Methylprednisolone, 16 mg orally or IV every 8 hours for 3 days. Taper over 2 weeks to lowest effective dose. If beneficial, limit total duration of use to 6 weeks. For persistent vomiting substitute
  18. 18. Experience of Cheil General Hospital & Women’s Healthcare Center (doxylamine+pyridoxine) (1) 2006.01-2010.05
  19. 19. Experience of Cheil General Hospital & Women’s Healthcare Center (doxylamine+pyridoxine) (2) 2006.01-2010.05
  20. 20. Experience of Cheil General Hospital & Women’s Healthcare Center (doxylamine+pyridoxine) (3) 2006.01-2010.05
  21. 21. Conclusions • Accurate diagnosis of nausea and vomiting • Proper treatment of individualization (Non-pharmacologic Treatment, Pharmacologic Treatment)
  22. 22. Thank you for your attention

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