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MANAGEMENT OF HYPEREMESIS GRAVIDARUM

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Dr. Mamuni Sultana Rony
Bangladesh

Published in: Health & Medicine
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MANAGEMENT OF HYPEREMESIS GRAVIDARUM

  1. 1. MANAGEMENT OF HYPEREMESIS GRAVIDARUM WELCOME
  2. 2. DEFINITION Hyperemesis gravidarum is defined as unexplained intractable nausea, retching, or vomiting beginning in the first trimester, incapacitates her in day-to-day activities or sufficient to warrant hospital admission resulting in dehydration, ketonuria, and typically a weight loss of more than 5% of prepregnancy weight.
  3. 3. DIAGNOSIS: • The pregnancy is to be confirmed first. • Exclusion of other causes of vomiting • Proper history taking • Clinical examination • Relevant investigation
  4. 4. HISTORY and PATIENT PROFILE First trimester First pregnancy Familial history Younger mother Unplanned pregnancies Hydatidiform mole and multiple pregnancy Motion sickness, migraines, oral contraceptives Helicobacter pylori
  5. 5. CLINICAL FEATURE Symptoms: • Vomiting is increased in frequency with retching. • Urine quantity is diminished even to the stage of oliguria. • Epigastric pain • Constipation • Complications may appear if not treated. • Result in frequently social isolation and negative impacts on relationships with family and friends. • Excess salivation (ptyalism)
  6. 6. Signs: Features of dehydration and ketoacidosis:
  7. 7. INVESTIGATIONS Hyperemesis gravidarum is a diagnosis of exclusion investigations are performed for • Conformation of pregnancy • Exclusion of common and serious causes of vomiting • Evaluating the extent of complication
  8. 8. • Urinalysis • Biochemical serum electrolytes Sodium- hyponatremia Potassium- hypokalemia chloride • Ophthalmoscopic examination
  9. 9. • ECG • Biochemical hyperthyroidism • Abnormal LFTs • Hemoconcentration leading to rise in Hemoglobin % RBC count Hematocrit values
  10. 10. Imaging Studies 1.Ultrasound To confirm pregnancy To establish the number of fetuses To exclude hydatidiform mole To exclude other conditions such as • Pancreatitis • Cholecystitis • intracranial lesions
  11. 11. COMPLICATIONS: Maternal and Fetal Risks Maternal Risks (1) Neurologic complications — (a) Wernicke’s encephalopathy (b) Pontine myelinolysis (c) Peripheral neuritis (d) Korsakoff’s psychos (2) Stress ulcer in stomach (3) Mallory-Weiss syndrome
  12. 12. (4) Jaundice (5) Convulsions (6)Coma (7) Renal failure /acute tubular necrosis (8) Pneumomediastinum/ pneumothorax (9) Splenic avulsion (10) Psychological burden- depression, anxiety, lost work (11) Anemia (12)Hyponatremia (plasma sodium < 120 mmol/L) can cause confusion, seizures, and respiratory arrest. (13)Deep venous thrombosis /thromboembolism
  13. 13. Fetal Risks • No fetal complications • Women with HEG who gain <7 kg during the entire pregnancy have a slightly higher risk of Low birth weight / small for gestational age/ IUGR Preterm birth / born before 37 weeks’ gestation • If the mother develops Wernicke’s encephalopathy- chance of IUD
  14. 14. MANAGEMENT Prince WiIliam and Duchess Kate when they left the King Edward VII hospital in central London in 2012, the last time Kate was treated for hyperemesis
  15. 15. Hospitalization: Whenever a patient is diagnosed as a case of hyperemesis gravidarum, she is admitted
  16. 16. Fluids: Rehydration Fluid replacement therapy should be with eithe Normal saline Hartmann’s solution Dextrose-containing fluids should not be used
  17. 17. Double-strength saline Potassium supplements Thiamine supplements Enteral - nasogastric tube Parenteral feeding
  18. 18. Monitoring Urine output Ketonuria- dipsticks Body weight
  19. 19. Drugs: (a)Antiemetic drugs CAT GROUP EXAMPLE DOSE B H 1 ANTIHISTAMINES Meclizine Doxylamine- pyridoxine 12.5 to 25 mg PO four times a day SUBSTITUTED BENZAMIDES Metoclopramide 10 mg PO four times a day 5-HT3 receptor blockers Ondansetron 8 mg PO two times a day ANTICHOLINERGIC Dicyclomine C PHENOTHIAZINES Promethazine 25 mg PO or rectally every 4 to 6 hours prochlorperazine
  20. 20. Efficacy of antiemetic drug
  21. 21. (b) Hydrocortisone • Severe and resistant symptoms • Unable to tolerate fluids Intravenous hydrocortisone 100 mg three times a day Prednisolone 40 mg once daily
  22. 22. (c) Nutritional support • Vit B1 • Vit B6 • Vit B12 • Vit C
  23. 23. Diet: At first, dry carbohydrate foods • Biscuits • bread • toast Small but frequent feeds are recommended Spicy food should be avoided
  24. 24. Other Treatment Options While they are inpatients Thromboembolic deterrent stockings Thromboprophylaxis such as enoxaparine 40 mg daily
  25. 25. Nonpharmacologic measures Acupuncture Acupressure Hypnotherapy Herbal teas Ginger/ ginger tea
  26. 26. Termination of pregnancy Rarely indicated • Intractable hyperemesis gravidarum inspite of therapy • Wernicke’s encephalopathy • Jaundice • Persistant CVS change

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