Week 3 Powerpoint[1]


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Week 3 Powerpoint[1]

  2. 2. First Prenatal Visit for the First Trimester <ul><li>Mother changes during first trimester </li></ul><ul><ul><li>Physical changes: breast tenderness, fatigue, nausea </li></ul></ul><ul><ul><li>Emotional changes: range from excitement to anxiety </li></ul></ul><ul><ul><li>Doctor tests and checks </li></ul></ul><ul><ul><ul><li>Blood pressure </li></ul></ul></ul><ul><ul><ul><li>Weight gain </li></ul></ul></ul><ul><ul><ul><li>Immunizations (rubella, varicella, measles, and mumps) </li></ul></ul></ul><ul><ul><ul><li>Blood type and Rh factor </li></ul></ul></ul><ul><ul><ul><li>Breast Exam </li></ul></ul></ul><ul><ul><ul><li>Internal Examination </li></ul></ul></ul><ul><li>Baby development during first trimester </li></ul><ul><ul><li>Vital organs develop! </li></ul></ul><ul><ul><ul><li>Brain </li></ul></ul></ul><ul><ul><ul><li>Spinal cord </li></ul></ul></ul><ul><ul><ul><li>Heart begins to beat </li></ul></ul></ul><ul><ul><li>Fingers and toes start developing </li></ul></ul>
  3. 3. Medical Management of CR <ul><li>Hypertension (131/82 mmHg this visit) </li></ul><ul><ul><li>Lisinopril is an Angiotensin Converting Enzyme Inhibitors (ACEI) – not good for second or third trimesters </li></ul></ul><ul><ul><li>Angiotensin Receptor Blockers (ARBs) and renin inhibitors are also contraindicated </li></ul></ul><ul><ul><li>Switch to beta blocker </li></ul></ul><ul><ul><ul><li>Labetolol or Propranolol are widely used </li></ul></ul></ul><ul><li>Morning Sickness </li></ul><ul><ul><ul><li>Preggie Pops </li></ul></ul></ul><ul><ul><ul><ul><li>Flavored lollipops with flavors that decrease nausea: ginger, mint, lavender, sour raspberry, sour lemon, and sour tangerine </li></ul></ul></ul></ul><ul><ul><ul><li>Vitamin B6 </li></ul></ul></ul><ul><ul><ul><ul><li>50 mg daily has decreased pregnancy-induced nausea </li></ul></ul></ul></ul><ul><li>Weight gain </li></ul><ul><ul><li>Choose foods that contain vitamins, minerals, and protein </li></ul></ul>
  4. 4. Hypertension <ul><ul><li>- With normal pregnancy, mother’s mean arterial pressure drops 10-15 mmHg during the first half of pregnancy regardless of if she has pre-existing hypertension </li></ul></ul><ul><ul><li>Hypertension during pregnancy can decrease the blood flow to the placenta </li></ul></ul><ul><ul><ul><li>Reduces baby’s oxygen supply and nutrients </li></ul></ul></ul><ul><ul><ul><li>Slows baby’s growth </li></ul></ul></ul><ul><ul><ul><li>Risk of low birth weight </li></ul></ul></ul><ul><ul><li>Could cause placental abruption or premature delivery </li></ul></ul><ul><ul><ul><li>Placenta prematurely disconnects from uterus </li></ul></ul></ul><ul><ul><ul><li>Deprives baby of oxygen and nutrients </li></ul></ul></ul><ul><ul><ul><li>Causes heavy bleeding in mother </li></ul></ul></ul><ul><ul><li>If diastolic blood pressure is greater than 110 mmHg, then she has a risk of placental abruption and intrauterine growth restriction </li></ul></ul><ul><ul><li>If her systolic is greater than 160 mmHg then she has an increased risk maternal intra-cerebral hemorrhage </li></ul></ul><ul><ul><ul><li>If so, then start with antihyptertensive therapy </li></ul></ul></ul>
  5. 5. Hypertension <ul><ul><li>The American Association of Clinical Endocrinologists say that methyldopa or nifedepine are preferred in pregnancy </li></ul></ul><ul><ul><ul><li>If preeclampsia – use magnesium sulfate </li></ul></ul></ul><ul><ul><li>ACE inhibitors should be avoided in pregnancy because they are associated with fetal renal dysgenesis or death if used in second and third trimesters and cardiovascular or central nervous system malformations in the first trimester </li></ul></ul><ul><ul><li>Monitor </li></ul></ul><ul><ul><ul><li>CBC, electrolytes, BUN, creatinine </li></ul></ul></ul><ul><ul><ul><li>Liver enzymes </li></ul></ul></ul><ul><ul><ul><li>Urine dip for protein and a 24-hour urine collection for creatinine clearance and protein excretion </li></ul></ul></ul><ul><ul><li>Our Patient </li></ul></ul><ul><ul><ul><li>Recommend discontinuing Lisinopril since it is an ACEI and start her on a beta blocker </li></ul></ul></ul><ul><ul><ul><ul><li>Example: Labetalol or Propranolol for first line choice because it is not associated with mild fetal growth restriction like some other beta blockers are like Atenolol </li></ul></ul></ul></ul>
  6. 6. Weight Gain Monitoring <ul><li>It is important to gain a healthy amount of weight during pregnancy! </li></ul><ul><li>Even if you are overweight – pregnancy is not the time to lose weight! </li></ul>Pre-pregnancy weight Recommended weight gain Underweight (BMI < 18.5) 28 to 40 pounds Normal Weight (BMI 18.5 to 24.9) 25 to 35 pounds Overweight (BMI 25 to 29.9) 15 to 25 pounds Obese (BMI >30) 11 to 20 pounds
  7. 7. Weight Gain <ul><li>Most women need to gain 25 to 35 pounds </li></ul><ul><li>How much weight you need to gain depends upon how much you weighed before. </li></ul><ul><ul><li>If you were slim you need to gain more </li></ul></ul><ul><ul><li>If you were heavier you need to gain less </li></ul></ul><ul><li>You should eat something every 1 to 2 hours </li></ul><ul><ul><li>Eating a large meal might make you sick </li></ul></ul><ul><ul><li>Eating an apple slice or piece of bread will make you feel better if your stomach is upset </li></ul></ul>
  8. 10. Weight Breakdown <ul><li>Distribution of kilograms, at the end of pregnancy Baby – 3.1 to 3.6 kilograms (6 to 8 pounds) Breasts Increase – 0.5 to 1.5 kilograms (1 to 2 pounds) Increase of uterus - 1 kilogram (1 to 2 pounds) Placenta – 0.5 to 1 kilograms (1 to 2 pounds) Fluids / water / - 1 kilogram (1 to 2 pounds) Blood Increase – 1.5 to 2 kilograms (3 to 4 pounds) Increased body fluids- 1 to 1.5 kilograms(2-3 pounds) Fat and protein- 3 to 4 kilograms (8-10 pounds) Total - 11 to 16 kilograms (25 to 35 pounds) </li></ul>
  9. 11. Gaining Too Much Weight <ul><li>More weight to loose after giving birth </li></ul><ul><li>Increases risk for C-section </li></ul><ul><li>Try not to gain too much weight in the beginning of the pregnancy </li></ul><ul><ul><li>The baby gains most weight in the last 2 months </li></ul></ul><ul><li>Increased risk for diabetes </li></ul><ul><ul><li>Both mother and baby </li></ul></ul><ul><li>High mortality in childbirth </li></ul><ul><li>High risk for obesity in the child </li></ul><ul><li>Backaches </li></ul><ul><li>Leg pain </li></ul><ul><li>Increased fatigue </li></ul><ul><li>Varicose veins </li></ul><ul><li>Increase in blood pressure </li></ul>
  10. 12. Not Gaining Enough Weight <ul><li>The baby can be born premature </li></ul><ul><li>Baby can be underweight </li></ul><ul><li>High mortality rate </li></ul><ul><li>before and after birth </li></ul><ul><li>Eat snacks or small </li></ul><ul><li>meals throughout the </li></ul><ul><li>day </li></ul><ul><li>Increased risk of </li></ul><ul><li>miscarriage </li></ul><ul><li>(72% more likely) </li></ul>
  11. 13. Obesity and Pregnancy <ul><li>Increased risk for gestational diabetes </li></ul><ul><li>Increased risk for high blood pressure </li></ul><ul><li>Difficulty finding heartbeat of the fetus </li></ul><ul><li>Difficulty measuring size of uterus </li></ul><ul><li>Difficulty with vaginal delivery (especially if fetus is larger than average) </li></ul><ul><li>Increased testing </li></ul><ul><ul><li>Ultrasounds </li></ul></ul><ul><ul><li>Glucose tolerance test </li></ul></ul>
  12. 14. Guidelines For Weight Gain <ul><li>Underweight (pre-pregnancy) </li></ul><ul><ul><li>First trimester </li></ul></ul><ul><ul><ul><li>Gain about 5 to 6 pounds or more </li></ul></ul></ul><ul><ul><li>2 nd and 3 rd trimester </li></ul></ul><ul><ul><ul><li>Gain about 1 to 2 pounds per week </li></ul></ul></ul><ul><li>Normal weight (pre-pregnancy) </li></ul><ul><ul><li>First trimester </li></ul></ul><ul><ul><ul><li>Gain about 5 pounds </li></ul></ul></ul><ul><ul><li>2 nd and 3 rd trimester </li></ul></ul><ul><ul><ul><li>Gain about 1 to 2 pounds per week </li></ul></ul></ul><ul><li>Overweight (pre-pregnancy) </li></ul><ul><ul><li>First trimester </li></ul></ul><ul><ul><ul><li>Gain about 1 to 2 pounds </li></ul></ul></ul><ul><ul><li>2 nd and 3 rd trimester </li></ul></ul><ul><ul><ul><li>1 pound per week </li></ul></ul></ul><ul><li>Twins – Gain about 35 to 45 pounds </li></ul><ul><li>Contact MD about excessive weight gain or loss in the 3 rd trimester </li></ul>
  13. 15. Eating for two… <ul><li>Most women only add about 200 calories to their day </li></ul><ul><li>Need to eat healthier not necessarily more </li></ul><ul><ul><li>Only eat whole wheat bread </li></ul></ul><ul><ul><li>Meats, fruits and veggies </li></ul></ul><ul><ul><li>Dairy </li></ul></ul><ul><li>3 meals a day with 2 snacks </li></ul><ul><li>6 to 8 cups of water/ fluid </li></ul>
  14. 16. Increase Calories the Right Way <ul><li>Eat breakfast everyday </li></ul><ul><ul><li>Peanut butter or cheese on toast to increase protein </li></ul></ul><ul><li>Snack between meals </li></ul><ul><ul><li>Yogurt and dried fruits (increase protein, minerals, and calcium) </li></ul></ul><ul><li>Eat more nuts, avocados, and olive oil </li></ul><ul><li>Drink juices that are high in vitamin C or beta carotene (grapefruit, orange, carrot juice and papaya nectar) </li></ul><ul><li>No junk food </li></ul>
  15. 17. The Well Rounded Diet <ul><li>According to American College of Obstetricians and Gynecologists: </li></ul><ul><ul><li>3 servings of milk, yogurt and cheese </li></ul></ul><ul><ul><li>3 servings of protein </li></ul></ul><ul><ul><li>3 servings of fruits </li></ul></ul><ul><ul><li>4 servings of vegetables </li></ul></ul><ul><ul><li>9 servings of whole grains </li></ul></ul><ul><ul><li>Everyday! </li></ul></ul>
  16. 18. What Not To Eat <ul><li>Fatty foods (no more than 30% of your calories) </li></ul><ul><li>Canned or manufactured food </li></ul><ul><ul><li>No deli meats </li></ul></ul><ul><li>Raw or undercooked meat and eggs </li></ul><ul><li>Seafood </li></ul><ul><ul><li>Sushi, shellfish, shark, king mackerel, sword fish </li></ul></ul><ul><li>Poultry </li></ul><ul><li>Alcohol (fetal alcohol syndrome) </li></ul><ul><li>Caffeine </li></ul><ul><li>Sweets </li></ul><ul><li>Do not diet or try to loose weight when pregnant </li></ul>
  17. 19. Exercise <ul><li>Keeps you fit </li></ul><ul><li>Decreases unwanted weight gain </li></ul><ul><li>Gives you energy </li></ul><ul><li>Avoid dangerous exercise and sports </li></ul><ul><li>Start slow and don’t over do it </li></ul><ul><li>Walking (2 hrs a day), swimming, and yoga </li></ul><ul><li>Drink enough water before, during, and after exercise </li></ul><ul><li>Light weight training </li></ul><ul><li>5 minutes to warm up and 5 minutes to cool down </li></ul><ul><li>Support (bra and shoes) </li></ul><ul><li>After the first trimester no exercise that requires you to lay on your back. </li></ul><ul><li>Don’t over stretch </li></ul><ul><li>Exercise class geared towards pregnant women </li></ul>
  18. 20. What Not to Do <ul><li>Drink alcohol </li></ul><ul><li>Smoke </li></ul><ul><li>Gain too much weight </li></ul><ul><li>Eat unhealthy foods </li></ul><ul><li>Not taking prenatal vitamins </li></ul><ul><li>“ Eat for two” </li></ul><ul><li>Contact sports </li></ul>
  19. 21. What is Preeclampsia? <ul><li>Can also be called PIH or Pregnancy induced hypertension or Toxemia. </li></ul><ul><li>Preeclampsia, which occurs after the 20th week of pregnancy, is characterized by new-onset or worsening hypertension, albuminuria, and hyperuricemia, sometimes with coagulation abnormalities. In some patients, preeclampsia may develop into a hypertensive urgency or emergency and may require hospitalization, intensive monitoring, early fetal delivery, and parenteral antihypertensive and anticonvulsant therapy. </li></ul><ul><li>Mild Preeclampsia : high blood pressure, water retention and proteinurea. </li></ul><ul><li>Severe Preeclampsia : headache, blurred vision, photosensitivity, N/V, dysuria, pain in the upper right abdomen, SOB, tendency to bruise easily. </li></ul>
  20. 22. <ul><li>Hypertension </li></ul><ul><li>Presentation of Elevated BP </li></ul><ul><li>High blood pressure (140/90) or rise in baseline of DBP of 15mmHG or SBP of 30mmHG. </li></ul><ul><li>Close observation especially with the presence of proteinuria and hyperuricemia (Uric Acid levels 6 mg/dL or higher) </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Know baseline numbers </li></ul></ul><ul><ul><li>Exercise to maintain a healthy BMI </li></ul></ul><ul><ul><li>Monitor BP </li></ul></ul><ul><ul><li>“ lying on your left side” believed that lying on your back may cause the uterus to restrict blood flow to the heart. </li></ul></ul><ul><li>Racing pulse </li></ul><ul><li>Mental confusion </li></ul><ul><li>Heightened sense of anxiety </li></ul><ul><li>Trouble catching your breath </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>If these symptoms are new to contact physician. </li></ul></ul><ul><ul><li>If they are not new be sure to mention them at next appointment. </li></ul></ul>Signs and Symptoms
  21. 23. <ul><li>Proteinuria </li></ul><ul><li>Sudden Weight Gain </li></ul><ul><li>Proteins normally found in bloodstream spilling into urine due to damage to the small blood vessels in the kidneys. (can be tested with a simple dipstick urine test at each prenatal check-up) </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Screenings at prenatal visit </li></ul></ul><ul><ul><li>24 hour urine collection for a formal lab assessment </li></ul></ul><ul><ul><li>Look for dark yellow urine to indicate inadequate fluid intake. Dark reddish or ‘brown’ cola should be brought up to the doctor. </li></ul></ul><ul><li>Weight gain of 2 or more pounds per week or 6 pounds in a month </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Avoid dieting or try to lose weight (avoid diet pills or fasting) </li></ul></ul><ul><ul><li>Maintain a healthy balanced diet </li></ul></ul><ul><ul><li>Avoid alcohol caffeine smoking and recreational drug use. </li></ul></ul><ul><ul><li>Drink plenty of water </li></ul></ul><ul><ul><li>Regular moderate exercise </li></ul></ul><ul><ul><li>Do not disguise any weight gain by skipping breakfast before prenatal visits. </li></ul></ul><ul><ul><li>Accurate weight is vital for proper diagnosis. </li></ul></ul>Signs and Symptoms
  22. 24. <ul><li>Nausea or Vomiting </li></ul><ul><li>Changes in Vision </li></ul><ul><li>Significant with sudden onset </li></ul><ul><li>Especially in the 2 nd and 3 rd trimesters </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Contact MD to have Urine check proteinuria AND BP (BOTH) </li></ul></ul><ul><ul><li>N/V can be confused with the flu </li></ul></ul><ul><li>Temporary loss of vision </li></ul><ul><li>Sensations of flashing lights </li></ul><ul><li>Auras </li></ul><ul><li>Photosensitivity </li></ul><ul><li>Blurry vision or spots </li></ul><ul><li>Above symptoms are associated with irritation of CNS. (may indicate cerebral edema) </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Contact physician, not a symptom that should be left until the morning! </li></ul></ul>Signs and Symptoms
  23. 25. <ul><li>Epigastric pain &/or </li></ul><ul><li>Right Shoulder Pain </li></ul><ul><li>Lower Back Pain </li></ul><ul><li>Stomach pain usually under the right-side ribs- often confused with heartburn, gallbladder problems, flu, indigestion or fetus activity. </li></ul><ul><li>Referral pain because it radiates from the liver under the right ribs. </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Contact physician immediately </li></ul></ul><ul><li>Very common pregnancy complaint. </li></ul><ul><li>Can indicate liver problems especially when coupled with other s/s of preeclampsia. </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Contact physician immediately </li></ul></ul>Signs and Symptoms
  24. 26. <ul><li>Hyperreflexia </li></ul><ul><li>Headaches </li></ul><ul><li>Enhanced (strong) reflexes </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Not a symptoms that can be notices unless bumped or at a prenatal visit. </li></ul></ul><ul><ul><li>May warrant a call to physician if discovered. </li></ul></ul><ul><li>Dull throbbing relentless </li></ul><ul><li>Often described as migraine-like </li></ul><ul><li>Pt Prevention : </li></ul><ul><ul><li>Keep MD informed especially if there is photosensitivity and OTC medications provide no relief. </li></ul></ul><ul><ul><li>It is acceptable to request to see the doctor that day. </li></ul></ul>Signs and Symptoms
  25. 27. Increased Risk for Preeclampsia <ul><li>Approximately 5-8% of all pregnancies. </li></ul><ul><li>First pregnancy </li></ul><ul><li>Preeclampsia in a previous pregnancy </li></ul><ul><li>Diabetes before or during pregnancy </li></ul><ul><li>Women with preexisting hypertension or kidney disease prior to pregnancy. </li></ul><ul><li>Multiple gestations </li></ul><ul><li>Age: Over 40 or under 18 years of age </li></ul><ul><li>Large interval between pregnancies </li></ul><ul><li>Overweight (BMI>30) </li></ul><ul><li>Polycystic ovarian syndrome </li></ul><ul><li>Lupus or other autoimmune disorders </li></ul><ul><li>Family history: </li></ul><ul><ul><li>Preeclampsia on mother’s or father’s side of the family </li></ul></ul><ul><ul><li>High blood pressure or heart disease </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul>
  26. 28. Is CR Preeclamptic? <ul><li>BP- 131/85 </li></ul><ul><li>Wt- up to 215 from 180; a 35lb weight gain in her 10 week pregnancy which would be 3.5lb per week. </li></ul><ul><li>Negative for proteinurea, visual disturbances abdominal pain </li></ul><ul><li>Although CR was at higher risk for preeclampsia due to her preexisting HTN, however CR’s current BP is not considered Hypertensive. </li></ul><ul><li>However, the weight gain is a concern and the ACEI (Lisinopril) should be changed. </li></ul>
  27. 29. Lisinopril and Pregnancy <ul><li>According to JNC7, the preferred HTN medications for fetus safety are: </li></ul><ul><ul><li>Methyldopa </li></ul></ul><ul><ul><li>BB </li></ul></ul><ul><ul><li>Vasodilators </li></ul></ul><ul><li>AECI and ARBs Should not be used in pregnant patients, due to potential fetal defects. </li></ul><ul><ul><li>Avoid in women who are pregnant or likely to become pregnant </li></ul></ul>
  28. 30. What Is Used To Treat Preeclampsia? <ul><li>The only cure is delivery. </li></ul><ul><ul><li>Pregnant women are at an increased risk of seizures, placental abruption, stoke, and severe bleeding until blood pressure decreases. </li></ul></ul><ul><li>The doctor might ask patient to come in every 2 weeks between the 20 th and 32 nd week of your gestation, and weekly after that until delivery. </li></ul>
  29. 31. What Medications Are Used To Treat Preeclampsia? <ul><li>Antihypertensive </li></ul><ul><ul><li>Lower blood pressure until delivery </li></ul></ul><ul><li>Corticosteroids </li></ul><ul><ul><li>Can temporarily improve liver and platelet functioning to help prolong your pregnancy </li></ul></ul><ul><ul><li>Can help your baby’s lings become more mature in as little as 48 hours </li></ul></ul><ul><li>Anticonvulsive </li></ul><ul><ul><li>In severe cases, doctors will prescribe magnesium sulfate, to prevent a first seizure </li></ul></ul>
  30. 32. What Are Other Ways To Treat Preeclampsia? <ul><li>Bed Rest </li></ul><ul><ul><li>Can help lower the pregnant woman’s blood pressure and increase blood flow to the placenta, giving the baby time to mature. </li></ul></ul><ul><ul><li>Doctors recommend this early in pregnancy in mild cases and in severe cases the mother may have to go through bed rest at the hospital. </li></ul></ul><ul><li>Delivery </li></ul><ul><ul><li>If diagnosis occurs near the end of pregnancy, doctors may induce labor right away. </li></ul></ul><ul><ul><li>In more severe cases, it may not be possible to consider your baby’s gestational age. In this case, induction of labor or a scheduled C-section occurs. </li></ul></ul>
  31. 33. What Is Morning Sickness? <ul><li>Morning sickness if the nauseated feeling women experience during pregnancy. </li></ul><ul><ul><li>The nausea occurs because the body is experiencing an increase in hormones. </li></ul></ul><ul><ul><li>It can be accompanied by vomiting. </li></ul></ul><ul><li>Nausea and vomiting are usually one of the first signs of pregnancy. </li></ul><ul><ul><li>This usually begins around the 6 th week of pregnancy. </li></ul></ul><ul><ul><li>It will occur around the same time of day. </li></ul></ul><ul><ul><li>Usually the nausea and vomiting stops around the 12 th week of pregnancy. </li></ul></ul>
  32. 34. Is Morning Sickness Normal? <ul><li>It is not uncommon for a women to experience morning sickness during pregnancy. </li></ul><ul><ul><li>Between 70-80% of pregnant women experience it. </li></ul></ul><ul><li>Many health care providers believe it is a good sign because it shows that the placenta is developing well. </li></ul>
  33. 35. Do’s And Don’ts Of Morning Sickness <ul><li>Do: </li></ul><ul><ul><li>Eat small meals often </li></ul></ul><ul><ul><li>Drink fluids ½ hour before or after a meal, but now with meals </li></ul></ul><ul><ul><li>Drink small amounts of fluids during the day to avoid dehydration </li></ul></ul><ul><ul><li>Eat soda crackers 15 minutes before getting up in the morning </li></ul></ul><ul><ul><li>Avoid foods and smells that increase nausea </li></ul></ul><ul><ul><li>Get plenty of rest and nap during the day </li></ul></ul><ul><ul><li>Avoid warm places </li></ul></ul><ul><ul><li>Sniff lemons or ginger, drink lemonade, or eat watermelon to relieve nausea </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><li>Don’t: </li></ul><ul><ul><li>Lie down after eating </li></ul></ul><ul><ul><li>Skip meals </li></ul></ul><ul><ul><li>Cook or eat spicy foods </li></ul></ul>
  34. 36. Does Morning Sickness Cause Any Harm To The Baby? <ul><li>When the mother has morning sickness, it does not cause any physical harm to the mother and the baby. </li></ul><ul><li>If the mother experiences excessive vomiting and is unable to keep her food down, the mother might have hyperemesis gravidarum. </li></ul>
  35. 37. <ul><li>Morning Sickness </li></ul><ul><li>Hyperemesis Gravidarum </li></ul><ul><ul><li>Nausea sometimes accompanied by vomiting </li></ul></ul><ul><ul><li>Nausea that subsides at 12 weeks or soon after </li></ul></ul><ul><ul><li>Vomiting that does not cause severe dehydration </li></ul></ul><ul><ul><li>Vomiting that allows you to keep some food down </li></ul></ul><ul><ul><li>Nausea accompanied by severe vomiting </li></ul></ul><ul><ul><li>Nausea that does not subside </li></ul></ul><ul><ul><li>Vomiting that causes severe dehydration </li></ul></ul><ul><ul><li>Vomiting that does not allow you to keep any food down </li></ul></ul>The Difference Between Morning Sickness And Hyperemesis Gravidarum
  36. 38. What Is Hyperemesis Gravidarum (HG)? <ul><li>It is a serious disease that occurs during pregnancy that can be very debilitating for the mother and can lead to a cascade of other complications. </li></ul><ul><li>It is uncommon, out of the 70-18% of pregnant women who experience morning sickness, 1% will experience HG. </li></ul><ul><li>It is often misdiagnosed or untreated. </li></ul><ul><ul><li>This results in approximately 25% of </li></ul></ul><ul><ul><li>HG pregnancies are terminated. </li></ul></ul>
  37. 39. Signs And Symptoms Of HG <ul><li>Severe nausea and vomiting </li></ul><ul><li>Food aversions </li></ul><ul><li>Weight loss of 5% or more </li></ul><ul><li>of pre-pregnancy weight </li></ul><ul><li>Decrease in urination </li></ul><ul><li>Dehydration </li></ul><ul><li>Headaches </li></ul><ul><li>Confusion </li></ul><ul><li>Fainting </li></ul><ul><li>Jaundice </li></ul><ul><li>Rapid heart rate </li></ul><ul><li>Overactive thyroid </li></ul><ul><li>Low blood pressure </li></ul><ul><li>Gall bladder dysfunction (stones) </li></ul><ul><li>Ketosis </li></ul><ul><li>Anemia </li></ul><ul><li>Liver enzyme elevation </li></ul><ul><li>Vitamin/electrolyte deficiency </li></ul>
  38. 40. What Are Some Complications Of HG? <ul><li>In severe cases, HG complications can be life-threatening. </li></ul><ul><ul><li>Internal bleeding in the stomach & throat </li></ul></ul><ul><ul><li>Severe malnutrition & dehydration </li></ul></ul><ul><ul><li>Electrolyte imbalances </li></ul></ul><ul><ul><li>Preterm labor </li></ul></ul><ul><ul><li>Organ rupture </li></ul></ul><ul><ul><ul><li>Which can lead to organ failure, specifically the kidneys or heart failure, and eventually death </li></ul></ul></ul><ul><ul><li>Bleeding in the eyes </li></ul></ul><ul><li>The adverse effects last beyond pregnancy and require an average of 5-8 months for recovery, or generally 1-2 months for each month the mother was ill. </li></ul><ul><li>It can not be prevented but there are ways to manage it. </li></ul>
  39. 41. How Does HG Threaten Daily Living? <ul><li>Most women can not work, drive, prepare meals, or care for there families and themselves when they have HG. </li></ul><ul><li>They become isolated and totally dependent on others for even basic needs. </li></ul><ul><li>Watching TV or reading worsens the nausea and vomiting, so mothers may have to remain in a dark room void of stimulation. </li></ul><ul><li>The emotional trauma often leads to chronic depression, anxiety, and sleep disorders. </li></ul><ul><li>Postpartum recovery is difficult, especially if the mother is on bed rest for weeks or months. </li></ul>
  40. 42. What Are The Risk Factors For HG? <ul><li>Pregnant women who: </li></ul><ul><ul><li>Weigh 170+ pounds before they become pregnant </li></ul></ul><ul><ul><li>Nonsmoker </li></ul></ul><ul><ul><li>Trophoblastic disease </li></ul></ul><ul><ul><li>20 years old or younger at the time of becoming pregnant </li></ul></ul><ul><ul><li>Untreated asthma </li></ul></ul><ul><ul><li>High saturated fat diet </li></ul></ul><ul><ul><li>Posttraumatic stress disorder (PTSD) </li></ul></ul><ul><ul><li>Multiple gestation (twins or more) </li></ul></ul><ul><ul><li>Food cravings & aversions before & during pregnancy </li></ul></ul><ul><ul><li>Epilepsy </li></ul></ul><ul><li>History of: </li></ul><ul><ul><li>Nausea and vomiting during pregnancy </li></ul></ul><ul><ul><li>Motion sickness </li></ul></ul><ul><ul><li>Sensitivity to oral contraceptives </li></ul></ul><ul><ul><li>Nausea premenstrually </li></ul></ul><ul><ul><li>Migraine headaches </li></ul></ul><ul><ul><li>Allergies </li></ul></ul><ul><ul><li>Gall bladder disease </li></ul></ul><ul><ul><li>Gastritis or ulcers </li></ul></ul><ul><ul><li>Mother/sister with HG </li></ul></ul><ul><ul><li>High blood pressure </li></ul></ul><ul><ul><li>Liver disease </li></ul></ul><ul><ul><li>Kidney disease </li></ul></ul><ul><ul><li>Poor diet </li></ul></ul>
  41. 43. Treatment Protocol <ul><li>The diagnosis of hyperemesis gravidarum should lead to immediate hospitalization of an affected individual in order to restore fluids and replace electrolytes by infusing medication and fluids intravenously. </li></ul><ul><ul><li>D5 NS bag containing 100mg thiamine given IV (banana bag) </li></ul></ul><ul><ul><li>Electrolyte deficiences are treated: K, Mg, and P are replaced as needed </li></ul></ul><ul><li>Vitamin supplementation (particularly vitamins B6, C and thiamine) may also be recommended. Thiamine supplementation is specifically recommended to prevent the development of Wernicke's encephalopathy. </li></ul><ul><li>With these treatments, in many cases, vomiting may stop. If vomiting continues, antiemetic drug therapy may be recommended. </li></ul>
  42. 44. Treatment Protocol <ul><li>Food should not be given orally until vomiting stops and dehydration has been corrected. </li></ul><ul><ul><li>Tube feeding or parenteral feeding is appropriate. </li></ul></ul><ul><li>After vomiting stops, affected individuals should receive enteral nutritional supplementation as needed to calm nausea. Physicians should then slowly and carefully reintroduce fluids and small, frequent meals into an affected individual's diet. Meals should consist of foods that are high in carbohydrates and low in fat. </li></ul>
  43. 45. Medical Treatment <ul><li>No drug is universally approved for treatment of hyperemesis gravidarum and few drugs are considered completely safe during pregnancy. </li></ul><ul><li>Choose the drug that targets the main symptom trigger (e.g. motion) she experiences. If there are many triggers, and/or her nausea and vomiting are more severe, start with serotonin antagonists . Intervene early if she has a history of hyperemesis gravidarum . </li></ul><ul><li>The risks associated with the medication must be assessed against the potential complications associated with prolonged starvation and dehydration. </li></ul><ul><ul><li>Both present risks for mother and child. </li></ul></ul>
  44. 46. Serotonin Antagonists <ul><li>Often effective in mothers who have multiple triggers (smell, motion, etc.), a history of hormone sensitivity, and/or moderate to severe vomiting. If a woman has a history of HG that responded to serotonin antagonists, it should be used early and as a first line drug to minimize severity. </li></ul><ul><li>IMPORTANT : Effects are dose dependent. Expensive intravenous therapies may sometimes be avoided if higher doses are used. Best taken on a strict schedule and weaned very slowly when asymptomatic for over two weeks. It is not uncommon for women to require this medication until delivery. Different brands may have different effects. </li></ul>Highly selective antagonists of 5-HT3 receptors in the vagus, chemotrigger zone and gut. Mostly Class B drugs Ondansetron (Zofran) Granisetron (Kytril) Mirtazapine (Remeron) Palonosetron (Aloxi) Dolasetron (Anzemet)
  45. 47. Antihistamines <ul><li>Effective for MILD cases of nausea and vomiting during pregnancy or as adjunctive therapy with more potent medications. Women mostly sensitive to motion may benefit most. Antihistamines with sedative effects can be helpful for sleep. </li></ul><ul><li>Common side-effects: Drowsiness, dry mouth, blurred vision, constipation, urinary retention, restlessness, insomnia, sedation, upset stomach, nervousness, headache. Mostly Class B Drugs </li></ul>Dimenhydrinate (Dramamine) Doxylamine (Diclectin) Diphenhydramine (Benadryl) Hydroxyzine (Vistaril) Trimethobenzamide (Tigan)
  46. 48. Antireflux Medications <ul><li>This class of drugs is helpful both for reflux and for prevention of gastric irritation which worsens nausea. They should be considered whenever a woman is vomiting frequently and/or cannot eat and drink sufficiently. Studies suggest they are safe during pregnancy. Mostly Class B drugs. </li></ul><ul><li>Common side-effects: Headache, dizziness, difficulty sleeping, constipation, diarrhea. </li></ul>Ranitidine (Zantac) Famotidine (Pepcid) Lansoprazole (Prevacid) Cimetidine not recommended during pregnancy due to antiandrogenic effects in humans.
  47. 49. Metoclopramide (Reglan) <ul><li>May be helpful in women who typically vomit after eating/drinking. Their main symptoms often are GI specific (motion sickness or sensitivity to light/sound) and these women may or may not respond to other medications such as Zofran. These drugs are sometimes used in conjunction with meds such as Zofran. Use with antihistamines to minimize side-effects. </li></ul><ul><li>Common side-effects: Drowsiness, dizziness, abdominal pain, diarrhea, restlessness, EPS, depression. </li></ul><ul><ul><li>Extrapyramidal symptoms include: involuntary movements, tremors and rigidity, body restlessness, muscle contractions and changes in breathing and heart rate. </li></ul></ul><ul><li>FDA recommends this drug be taken for up to 12 weeks. Risks of serious side-effects increase thereafter. </li></ul>Blocks dopamine receptors in the CTZ and increases the CTZ threshold & decreases the sensitivity of visceral nerves that transmit afferent impulses from the GI tract to the vomiting center. Class B Drug
  48. 50. Corticosteroids <ul><li>Not recommended until after 10 weeks of gestation. </li></ul><ul><ul><li>Complications including reduced birth weight, increased risk of preeclampsia, increased risk of oral and lip clefts, and impaired fetal brain development have been reported when corticosteroids were administered during early pregnancy. </li></ul></ul><ul><li>Women with hypothyroidism may have an exaggerated response to corticosteroids; thus any steroid should be used with caution in these mothers. Also, women with Type 1 Diabetes may require as much as a 40% increase in their insulin when high dose steroids are started. </li></ul><ul><li>Methylprednisolone is classified as pregnancy category C. Prednisone is classified as category B. </li></ul><ul><li>Corticosteroids cross the placenta. </li></ul>Methylprednisolone Prednisone Hydrocortisone
  49. 52. Pharmacologic Therapy for Nausea and Vomiting in Pregnancy <ul><li>American Academy of Family Physicians </li></ul>Medication Dosage Preg. Category Pyridoxine 25mg PO TID A Doxylamine 25mg PO QD * Antiemetics Chlorpromazine 10-25mg PO 2-4x/day C Prochlorperazine 5-10mg PO 3-4x/day C Promethazine 12.5-25mg PO Q4-6H C Trimethobenzamide 250mg PO 3-4x/day C Ondansetron 8mg PO 2-3x/day B Droperidol 0.5-2mgIV or IM Q3-4H C Antihistamines Diphenhydramine 25-50mg PO Q4-8H B Meclizine 25mgPO Q4-6H B Dimenhydrinate 50-100mg PO Q4-6H B Motility Drug Metoclopramide 5-10mg PO 3x/day B Corticosteroid Methylprednisolone 16mg PO 3x daily; then taper C
  50. 53. Complementary and Alternative Medicine <ul><li>Complementary and alternative medicine can be helpful in treating less severe nausea and vomiting of pregnancy. </li></ul><ul><li>While it may not completely alleviate the symptoms, it often provides some relief and may be used in conjunction with antiemetics for an enhanced response. </li></ul><ul><li>The following treatments may alleviate some of the nausea at different times during a pregnancy. It is typically a process of trial and error based on individual symptomology and response… </li></ul>
  51. 54. Non-Pharmacological Treatment <ul><li>Chiropractic massage </li></ul><ul><ul><li>Women on bed rest often have significant pain due to atrophy, musculoskeletal changes and immobility. It often increases in the third trimester due to rapid fetal weight gain and growth. Use of these treatment modalities often assists in muscle relaxation and toxin release, thus having some increase in her sense of well-being. </li></ul></ul><ul><li>Herbs </li></ul><ul><ul><li>Horehound – has been used in traditional medicine to relieve morning sickness. Consult with an expert in botanical medicine before using during pregnancy. </li></ul></ul><ul><ul><li>Ginger – Three RCTs and one randomized crossover trial found that ginger reduced nausea and vomiting in early pregnancy. </li></ul></ul><ul><ul><li>Pepperment Candy </li></ul></ul><ul><ul><li>Raspberry and Chamomile Teas </li></ul></ul>
  52. 55. Non-Pharmacological Treatment <ul><li>Acupressure & Acupuncture </li></ul><ul><ul><li>The classic acupuncture point for nausea and seasickness, called Pericardium 6 is located in the middle of the inner wrist, three finger breadths away from the wrist crease, between the two tendons. RCTs show varying effectiveness. </li></ul></ul><ul><li>Light Therapy </li></ul><ul><ul><li>If a woman is unable to leave her home due to HG, consider full spectrum lighting to ease potential depression . </li></ul></ul><ul><li>Hypnosis </li></ul><ul><ul><li>Medical hypnosis may be used as an adjunctive treatment option for women with hyperemesis gravidarum. Controversy surrounds the benefit of hypnosis, but it has been studied in some cases of hyperemesis gravidarum and has been shown to be beneficial. </li></ul></ul><ul><li>Psychological counseling may be considered </li></ul>
  53. 56. References <ul><li>American Pregnancy Association </li></ul><ul><ul><li>www.americanpregnancy.org </li></ul></ul><ul><li>HER Foundation: Hyperemesis Education & Research </li></ul><ul><ul><li>www.hyperemesis.org </li></ul></ul><ul><li>Preeclampsia Foundation </li></ul><ul><ul><li>www.preeclampsia.org </li></ul></ul><ul><li>JNC7 </li></ul><ul><li>Merck </li></ul><ul><ul><li>http://www.merck.com/mmpe/sec18/ch263/ch263h.html </li></ul></ul><ul><li>Kids Health – Pregnancy Calendar </li></ul><ul><ul><li>Shows you what you go through as a mother and what is happening with the baby week by week </li></ul></ul><ul><ul><ul><li>http://kidshealth.org/parent/pregnancy_calendar/pregnancy_calendar_intro.html </li></ul></ul></ul><ul><li>Journal Article on medscape: Gibson, Paul. &quot;Hypertension and Pregnancy.&quot; WebMD (2009). </li></ul><ul><ul><li>Gives guidelines, medications, monitoring, and follow-up </li></ul></ul><ul><ul><ul><li>http://emedicine.medscape.com/article/261435-treatment </li></ul></ul></ul><ul><li>MayoClinic – Pregnancy week by week </li></ul><ul><ul><li>http://www.mayoclinic.com/health/pregnancy/PR00125 </li></ul></ul>
  54. 57. References <ul><li>http://www.medscape.com/viewarticle/456478 </li></ul><ul><li>http://www.squidoo.com/pregnancyweightgain </li></ul><ul><li>http://www.reuters.com/article/idUSTRE54R4QS20090528 </li></ul><ul><li>http://www.americanpregnancy.org/pregnancyhealth/eatingfortwo.html </li></ul><ul><li>http://www.sciencedaily.com/releases/2006/12/061204081933.htm </li></ul><ul><li>http://emedicine.medscape.com/article/254751-treatment </li></ul><ul><li>http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Hyperemesis%20Gravidarum%20 </li></ul>