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hyperemesis gravidarum


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hyperemesis gravidarum

  1. 1. Hyperemesi s Alsaleh Yassin Mahmoud gravidarum Security Force Hospital
  2. 2. ُ ْ َ َ ‫ ووصينا النسان بوالديْه إحسانا حملته‬ :‫قال تعالى‬ َ ْ ِ َ ِ َ َ َّْ َ َ ‫أ ُمه كرها ووضعته كرها‬ ْ ُ ُ َْ َ َ َ ْ ُ ُ ّ And we have commended unto man kindness toward parents. his mother bear him with reluctance, and bring him forth with .reluctance
  3. 3. Objectives  Introduction.  Epidemiology.  Clinical picture.  Investigation.  Treatment.  outcomes.
  4. 4. Introduction Nausea and vomiting in pregnancy is extremely common. The nausea and vomiting associated with pregnancy usually begins by 9-10 weeks of gestation, peaks at 11-13 weeks, and resolves in most cases by 12-14 weeks. Normal nausea and vomiting may be an protective mechanism—it may protect the pregnant woman and her embryo from harmful substances in food.
  5. 5. Definitions Motion sickness: Nausea felt by pregnant woman on getting up in the morning. Emesis gravidarum: actual vomiting in the morning. Hyperemesis gravidarum: Vomiting not confined to morning but repeated throughout the day until it affect the general condition of the patient.
  6. 6. Epidemiology Incidence: Of all pregnancies, 0.3-2% are affected with HEG . more common in westernized industrialized societies and urban areas than rural areas. Race: No clear racial predominance is noted for HEG
  7. 7. Risk factors Previous pregnancies with HEG Greater body weight Multiple gestations Trophoblastic disease Nulliparity The risk of HEG appears to decrease with advanced maternal age. Cigarette smoking is associated with a decreased risk for HEG.
  8. 8. Aetiology Unknown. Hormonal. Psychological. Vestibular and olfaction Hepatic dysfunction . Lipid alterations . Other (H.pylori infection)
  9. 9. Aetiology cont. Hormonal: Women with hyperemesis gravidarum often have high hCG levels that cause transient hyperthyroidism. High human chorionic gonado trophin (hCG) stimulate the chemo receptor trigger zone in the brain stem including vomiting center. Evidence by High hCG in : Early pregnancy. Vesicular mole. Multiple pregnancy.
  10. 10. Aetiology cont. H . pylori infection: 1-The incidence of H.pylori sero positive in patients with hyperemesis gravidarum (HG) is high in comparison with non-HG pregnant women . ive t ni efi ion o d lat  no one was able to demonstrate correlation or t N re cH. pylori and the between seropositivity for fa or c le time of onset or tduration of HG symptoms. l ip  Although H.M u pylori infection may be an importantm factor in exacerbating HG, it may not represent the sole cause of the disease.
  11. 11. Diagnosis History. Examination.
  12. 12. Clinical picture (symptoms) Vomiting through day and night ptyalism dizziness Sleep disturbance Hyperolfaction Dysgeusia Depression Anxiety Irritability Mood changes Decreased concentration
  13. 13. Clinical picture (sign) Signs: Dehydration. Weight loss. Sunken eye Dry mouth. Mild fever. Hypotension.
  14. 14. CRITERIA HEG Persistent vomiting weight loss greater than 5% Dehydration Electrolyte abnormalities
  15. 15. Differential Diagnosis               Gastrointestinal disorders Gastroenteritis Biliary tract disease Hepatitis Intestinal obstruction Peptic ulcer disease Pancreatitis Appendicitis Genitourinary tract disorders Pyelonephritis Uremia Degenerating uterine leiomyoma Torsion Kidney stones Metabolic disorders Diabetic ketoacidosis Porphyria Addison’s disease Hyperthyroidism Neurologic disorders Pseudotumor cerebri Vestibular lesions Migraine headaches Central nervous system tumors  Pregnancy-related conditions  Nausea and vomiting of pregnancy  hyperemesis gravidarum          
  16. 16. Investigations Urinalysis: for ketones and specific gravity . Serum electrolytes : -low Na or K. -hyperchloremic metabolic alkalosis or acidosis. LFT: Elevated transaminase levels . TSH,free thyroxine :HEG is associated with hyperthyroidism
  17. 17. Investigations cont Urine culture: UTI can be associated with nausea and vomiting. Hematocrit: This may be elevated. Hepatitis screening: hepatitis A, B, or C may be confused with HEG.
  18. 18. Investigations cont Imaging Studies: Obstetric ultrasonography : evaluate for multiple gestations or trophoblastic disease. upper abdominal ultrasonography to evaluate the pancreas and/or biliary tree In rare cases, abdominal CT scan may be indicated if appendicitis is under consideration.
  19. 19. Management 1-Admission: 2-Intravenous Fluids: Normal saline or lactated Ringer’s solution is the mainstay of intravenous fluid therapy. It should be given by infusion over 2-3 hours. thiamine (vitaminB1). 3-Enteral or Parenteral Nutrition.
  20. 20. Management cont DIETARY AND LIFESTYLE CHANGES  Separating solids and liquids.  Eating small, frequent meals consisting of bland     foods. Avoiding fatty foods such as potato chips. Avoiding drinking cold or sweet beverages. Eliminate pills with iron High protein snacks are helpful.
  21. 21. Management cont 5 - PHARMACOLOGICAL THERAPIES:  Vitamins Pyridoxine (Nestrex)  Essential for normal DNA synthesis and play a role in various metabolic processes (Diclectin) combination of doxylamine with of pyridoxine (vitamin B6) A - Safe in pregnancy at a dose of 10-12.5 mg PO qd/bid.
  22. 22. Management cont Antiemetics : a.DOPAMINE ANTAGONISTS: Useful in the treatment of symptomatic nausea - phenothiazines (i.e., chlorpromazine, perphenazine, prochlorperazine, promethazine, trifluoperazine) - blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system - C - Safety for use during pregnancy has not been established.
  23. 23. Management cont Metoclopramide:is an upper gastrointestinal motility stimulant. Blocks dopamine receptors and (when given in higher doses) also blocks serotonin receptors in chemoreceptor trigger zone of the CNS Metoclopramide is safe to be used for management of NVP, although evidence for efficacy is more limited B - Usually safe but benefits must outweigh the risks
  24. 24. Management cont SEROTONIN 5-HT3 ANTAGONISTS.  Ondansetron (Zofran) : blocking serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone In general, 5-HT3 antagonists may be safe to use during the first trimester, but the data are scant.
  25. 25. Management cont Antihistamines : Meclizine (Antivert) , Diphenhydramine (Benadryl) Appears to be as efficacious as pyridoxine Causes sedation; caution must be used in performing tasks which require alertness
  26. 26. Management cont Corticosteroids: Methylprednisolone (Medrol, Solu-Medrol) Recent studies revealed a small but significantly increased risk of oral clefting associated with first trimester exposure to corticosteroids.
  27. 27. Management cont A doxylamine/ pyridoxine combination should be the standard of care since it has the greatest evidence to support its efficacy and safety. Other drugs may also be used, primarily dimenhydrinate, in conjunction with the doxylamine/pyridoxine combination. If possible, corticosteroid use should be avoided in the first 10 weeks .
  28. 28. Management cont Other modalities: (antidepressent): - Selective serotonin re-uptake inhibitors - Tricyclic antidepressants (TCAs) Helicobacter pylori eradication. ACUPUNCTURE. Stimulation of the P6 point, located three-fingers’ breadth proximal to the wrist, has been used for treat nausea and vomiting Ginger (Zingiber officinale)
  29. 29. outcomes Esophageal rupture or perforation Pneumothorax and pneumomediastinum Wernicke encephalopathy or blindness Hepatic disease Seizures, coma, or death HEG is self-limited and, in most cases, improves by the end of the first trimester. However, symptoms may persist through 20-22 weeks of gestation and, in some cases, until delivery.
  30. 30. Referances Verberg MF,Gillott DJ,Al-Fardan N, Grudzinskas JG. Hyperemesis gravidarum, a literature review. Hum Reprod Update. 2007 Mar-Apr;13(2):207. Sahakian V, Rouse D, Sipes S, Rose N, Niebyl J. Vitamin B6 is effective therapy for nausea and vomiting of pregnancy: a randomized, doubleblind placebo-controlled study. Obstet Gynecol 1991;78:33-6. Leathem A. Safety and efficacy of antiemetics used to treat nausea and vomiting in pregnancy. ClinPharm 1986;5:660-8.
  31. 31. Sullivan CA, Johnson CA, Roach H, Martin RW,Stewart DK, Morrison JC. A pilot study of intravenous ondansetron for hyperemesis gravidarum. Am J Obstet Gynecol 1996;174:1565-8. Quinla JD,Hill DA . Nausea and vomiting of pregnancy. Am Fam Physician. 2003 Jul 1;68(1):121-8 Miklovich L, van den Berg BJ. An evaluation of the teratogenicity of certain antinauseant drugs. Am J Obstet Gynecol 1976;125:244-8.
  32. 32.  Harrington RA, Hamilton CW, Brogden RN, Linkewich JA, Romankiewicz JA, Heel RC. Metoclopramide. An updated review of its pharmacological properties and clinical use. Drugs 1983;25:451-94.  Safari HR, Fassett MJ, Souter IC, Alsulyman OM, Goodwin TM. The efficacy of methylprednisolone in the treatment of hyperemesis gravidarum: a randomized, double-blind, controlled study. Am J Obstet Gynecol 1998;179:921-4.  Park-Wyllie L, Mazzotta P, Pastuszak A, Moretti ME, Beique L, Hunnisett L, et al. Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Teratology 2000;62:38592.
  33. 33.  Nageotte MP, Briggs GG, Towers CV, Asrat T. Droperidol and diphenhydramine in the management of hyperemesis gravidarum. Am J Obstet Gynecol 1996;174:1801-5.  Aselton P, Jick H, Milunsky A, Hunter JR, Stergachis A. First-trimester drug use and congenital disorders. Obstet Gynecol 1985;65:451-5.  Krik E.Papagerrghiou AT,Condous G,bottomley C, Bourne T. Hyperemesis gravidarum: is an ultrasound scan necessaryd? Hum Reprod. 2006 Sep;21(9):24402. Epub 2006 May 23.  Rabenda-Lacka K,Wilczynski J,Breborowicz GH,Lesniak P,Jurga S,Radoch Z. Wernicke's encephalopathy due to hyperemesis gravidarum] Ginekol Pol. 2003 Aug;74(8):633-7.
  34. 34. ? ANY QUISTIONS