Hyperemesis Gravidarum Alice Stek MD Basics Description Hyperemesis represents the extreme end of the continuum of nausea and

d vomiting of pregnancy. No single accepted definition for hyperemesis gravidarum !ut generally includes"
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#ersistent vomiting $ithout other etiology Measure of acute starvation such as large ketonuria %eight loss usually at least &' of prepregnancy $eight

(pidemiology Nausea and vomiting of pregnancy affects )*+,&' of pregnant $omen Hyperemesis gravidarum in -*.&+.' of pregnant $omen /isk 0actors 1ncreased placental mass 2e.g. molar gestation multiple gestation3 0amily history

History of hyperemesis in previous pregnancy %omen $ith history of nausea and vomiting after estrogen exposure 2such as 45#s3 History of motion sickness or migraine 0emale fetus

Genetics %omen $hose mothers or sisters had hyperemesis are more likely to experience hyperemesis themselves. #athophysiology (tiology is poorly understood. Higher h5G and estrogen levels correlate $ith hyperemesis. Associated 5onditions h5G is a thyroid stimulator6 up to )*' of $omen $ith hyperemesis have elevated free thyroxine and lo$ 7SH. /arely %ernicke encephalopathy due to vitamin B8 deficiency esophageal rupture or pneumothorax

Depression

Diagnosis Signs and Symptoms History Nausea and vomiting typically starting !efore 9 $eeks: gestation 5linical diagnosis of exclusion

7ypically no pain fever or headache

#hysical (xam 5linically diagnosis of exclusion No fever no tenderness no neurologic findings no goiter 7ests ;a!s

;iver en<ymes" o May !e slightly elevated 2=>** ?@;3 Serum !iliru!in"

May !e slightly elevated 2=A mg@d;3

Amylase and lipase"

May !e slightly elevated 2=& times ?;N3

(lectrolytes chemistry"
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Hypochloremic meta!olic alkalosis is possi!le

?A"
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(levated specific gravity ketonuria

1f hyperthyroidism suspected"
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7SH free thyroxine free triiodothyronine

1maging 4!stetric ?S for GA evaluate for multiple gestation molar gestation Differential Diagnosis 1f patient experiences nausea and vomiting for 8st time after 9 $eeks: gestation consider alternate diagnosis. 1nfection Gastroenteritis #yelonephritis

Appendicitis Hepatitis

Meta!olic@(ndocrine Dia!etic ketoacidosis Hyperthyroidism

Addison:s disease

7umor@Malignancy 5NS tumors 4varian torsion

Drugs Drug toxicity or su!stance a!use 4ther@Miscellaneous G1 conditions" o #eptic ulcer disease gastroparesis pancreatitis o!struction hepatitis appendicitis

G? tract"
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Nephrolithiasis pyelonephritis

Neurologic"
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#seudotumor cere!ri migraines 5NS tumor

#sychologic Acute fatty liver of pregnancy

7reatment General Measures (xclude other etiologies. 7reat early manifestations to reduce need for hospitali<ation. #regnancyBSpecific 1ssues /isks for 0etus 7he drugs listed !elo$ are generally considered safe $ith the exception of corticosteroids $hich may !e associated $ith oral clefts. ;ittle safety data on ondansetron in pregnancy

1ncreased risk for prematurity and lo$ !irth $eight if poor maternal $eight gain

Special 7herapy 5omplementary and Alternative 7herapies Ginger .&* mg po$der capsules A@d or fresh" 1n randomi<ed trials po$dered ginger $as more effective for relieving the severity of nausea and vomiting of pregnancy than place!o and of compara!le efficacy to vitamin BC. HighBprotein lo$Bcar!ohydrate lo$Bfat meals

Hypnosis has possi!le efficacy. 4ften recommended !ut no proven efficacy" /est6 freDuent small meals6 !land lo$Bfat foods6 acupressure to $rist

Medication 2Drugs3 Start $ith 8st listed and if no response continue to next treatment" o Eitamin BC 8*+.& mg [email protected].
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Eitamin BC F doxylamine 8*+8..& mg [email protected].

Eitamin BC F doxylamine F prometha<ine 8..&+.& mg DAh #4 or rectal Add metoclopramide &+8* mg D,h 1M or #4 or prometha<ine 8..&+ .& mg DAh 1M #4 or rectal or trimetho!en<amide .** mg DC+,h rectal

1f dehydrated"
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1E fluids $ith correction of ketosis and vitamin deficiencies thiamine Dimenhydrinate &* mg 1E DA+Ch or metoclopramide &+8* mg 1E D,h or prometha<ine 8..&+.& mg 1E DAh Add methylprednisolone 8C mg D,h for > days6 taper to stop or to lo$est effective dose over . $eeks or ondansetron , mg 1E D8.h 1f una!le take food #4 and losing $eight"

#eripheral parenteral nutrition $ith highBlipid formula for several days only 7#N for longerBterm needs. 5onsider #155 line.

#.>9& 0ollo$up Disposition 1ssues for /eferral Hospitali<ation if 1E hydration and therapy needed #rognosis #rognosis for resolution of symptoms and normal pregnancy outcome is good. Ho$ever there is a risk for recurrence $ith su!seDuent pregnancy. 5omplications Depression %ernicke encephalopathy

5omplications of hospitali<ation@intravenous treatments@7#N 7ransient hyperthyroidism

#atient Monitoring Hydration status %eight gain

(lectrolytes (valuate for anemia Monitor for preterm la!or

Bi!liography

A54G #ractice Bulletin No. &." Nausea and Eomiting of #regnancy. %ashington D5" A54G6 April .**A. Borrelli 0 et al. (ffectiveness and safety of ginger in the treatment of pregnancyB induced nausea and vomiting. 4!stet Gynecol. .**&68*&",A9+,&C. Dodds ; et al. 4utcomes of pregnancies complicated !y hyperemesis gravidarum. 4!stet Gynecol. .**C68*)".,&+.9.. Safari H/ et al. 7he efficacy of methylprednisolone in the treatment of hyperemesis gravidarum" A randomi<ed dou!leB!lind controlled study. Am G 4!stet Gynecol. 899,68)9"9.8+9.A. Smith 5 et al. A randomi<ed controlled trial of ginger to treat nausea and vomiting in pregnancy. 4!stet Gynecol. .**A68*>"C>9+CA&. Eutyavanich 7 et al. Ginger for nausea and vomiting of pregnancy" /andomi<ed dou!leBmasked place!oBcontrolled trial. 4!stet Gynecol. .**869)"&))+&,.. Eutyavanich 7 et al. #yridoxine for nausea and vomiting of pregnancy" A randomi<ed dou!leB!lind place!oBcontrolled trial. Am G 4!stet Gynecol. 899&68)>",,8+,,A. Miscellaneous 5linical #earls H Nausea and vomiting of pregnancy is very common and may progress to hyperemesis. H (arly treatment is !eneficial. H (ffective treatment thought to !e safe for the fetus is availa!le and prognosis is good. A!!reviations H GAIGestational age H h5GIHuman chorionic gonadotropin H 45#sI4ral contraceptive pills H #155 lineI#eripherally inserted central catheter H 7#NI7otal parenteral nutrition H 7SHI7hyroidBstimulating hormone 5odes 15D9B5M H CA>.* Mild hyperemesis gravidarum H CA>.8 Hyperemesis gravidarum $ith meta!olic distur!ance H CA> (xcessive vomiting in pregnancy #atient 7eaching H /eassurance a!out favora!le pregnancy outcome H Dietary advice H Ginger H #ossi!le acupressure #revention H Daily multivitamin" %omen taking daily multivitamin at the time of conception had less severe hyperemesis. H Small highBprotein meals H (valuate and treat nausea and vomiting of pregnancy early.