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Hyperemesis6 12
Hyperemesis Gravidarum is a condition characterized by persistent and severe nausea and vomiting during pregnancy. It can lead to weight loss of 5% or more of the woman's pre-pregnancy weight and the presence of ketones in the urine. Potential causes include multiple gestation, trophoblastic disease, or genetic conditions like trisomy 21. Treatment focuses on managing symptoms, avoiding triggers, dietary changes, medications like antihistamines, phenothiazines, and serotonin antagonists. Intravenous fluids and supplementation of vitamins and minerals may be needed to address nutritional deficiencies and prevent complications like Wernicke's encephalopathy. Enteral nutrition through nasojejunal feeding tubes is preferable to parent
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Hyperemesis6 12
- 1. Hyperemesis Gravidarum DouglasM Montgomery, MD Kaiser Permanente Riverside Medical Center
- 2. Diagnosis Persistent vomiting Weight loss 5 % pre-pregnancy wt Ketonuria 3-4 +
- 3. Known Associations TwinsTrophoblastic Dz Triploidy Trisomy 21 Fetal hydrops
- 4. Differential Diagnoses Goodwin(1998), Clinical Obstetrics and Gynecology 41(3).
- 5. Goodwin (1998), ClinicalObstetrics and Gynecology 41(3).
- 6. Maternal Complications Wernicke’sEncephalopathy Esophageal tear Mallory-Weiss tear Pneumothorax Peripheral Neuropathy (B6/B12)
- 7. 1st Line TreatmentAvoidance of environmental triggers, especially strong odors Diet Modification (Salty/Sour) Ginger / B 6 / Doxylamine Acupressure wristbands
- 8. Persistent Weight Loss/VomitingDrug Choices
- 9. Antihistimines Dimenhydrinate (dramamine)50po q 4 Cyclizine(marezine)50 po q 4 Meclizine(antivert)50 po q 24 Promethazine (phenergan)12.5-25 po q 6 or 12.5-25 PR q 12 Diphenhydramine (benadryl)25-50 po q6 Doxylamine (unisom) 12.5 PO q 12 = ½ tab
- 10. Dopamine Receptor AntagonistPhenothiazines Butyrophenones Benzamides
- 11. Side Effects ofDopamine Antagonist extrapyramidal symptoms: dystonia, dyskinesia, akathisia, opisthotonus, and oculogyric crises. Concurrent benadryl decreases dystonic side effects. Watch for tardive dyskinesia
- 12. Phenothiazines Prochlorperazine(compazine)10 mgPO q8 or 25 mg PR q 12 Chlorpromazine ( Thorazine ) 25 mg PO q6 or 100 mg PR Q 12
- 13. Butyrophenones Droperidol (inapsine)5 mg IM Haloperidol (haldol)
- 14. Benzamides Metoclopramide( Reglan)10 PO q 8 Trimethobenzamide (Tigan) 250 PO q 8
- 15. Serotonin Antagonist Odansetron( zofran) 8 mg PO Q12
- 16. Quinlan and Hill,Am Fam Physician. 2003 Jul 1;68
- 17.
- 18. IV Fluids ConsiderLR or D5LR solution and pay close attention to replenishing vitamins, electrolytes Na/K, and minerals, such as magnesium and phosphorous. Thiamine supplementation (100 mg IV) is recommended for women who have had prolonged vomiting. Prevent Wernicke’s Encephalopathy with Thiamine prior to Dextrose
- 19. Clinically Significant NutritionalDeficiency No standard definition for pregnancy The lower the pre-pregnacy weight, the lower our threshold should be to supplement 10% of pre pregnancy weight loss 180 lbs vs 100 lbs
- 20. PICC Lines Of33 patients: 66.4% required treatment for infection and/or thromboembolism 9 % fetal loss rate after first trimester AJOG 2008;198:56.e1-56.e4
- 21. PICC lines (continued)Other reports of significant complications: Obstet Gynecol 2006;107 infection precipitated PTD @ 26 weeks with one NN death Obstet Gynecol 2006;107 Candida septicemia Am J Ob Gyn 2003;188 50% incidence of infection, thromboembolism or mechanical failure
- 22. Three separate sourcesrecommend: Avoid PICC lines Consider Enteral Nutrition alternative 1st Use Parenteral nutrition through a central line (PICC/HICKMAN) only as a last resort UTD 2008 Obstet Gynecol Survey 2008;63 Holmgren AJOG 2008; 198
- 23. Enteral Feeding forNutritional Support Two studies support NasoJejunal Feeding One study utilized NG tube One study utilized both NG and ND tube Obstet Gynecol 1996;88:343-6 Clinical Nutrition 2004;23,53-7 Clinical Nutrition 2001; 20(5): 461-464 AJOG 2008;198:56