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Riog005002 0078 PDF
Riog005002 0078 PDF
H
yperemesis gravidarum, or pernicious vomit- hyponatremia, hypokalemia, and a low serum urea
ing of pregnancy, is a complication of preg- level.4 Ptyalism is also a typical symptom of hyper-
nancy that affects various areas of the womans emesis.5 The symptoms of this disorder usually peak
health, including homeostasis, electrolytes, and at 9 weeks of gestation and subside by approximately
kidney function, and may have adverse fetal con- 20 weeks of gestation.6 Approximately 1% to 5% of
sequences. Nausea and vomiting are common in patients with hyperemesis must be hospitalized.7
pregnancy, affecting up to 70% to 85% of pregnant Women who experienced hyperemesis in their first
women.1 Hyperemesis affects between 0.3% and pregnancy have a high risk for recurrence.6,8,9
2.3% of all pregnancies.2 The condition is defined The differential diagnosis of hyperemesis gravi-
as uncontrolled vomiting requiring hospitalization, darum (Table 1) includes urinary tract infection,
severe dehydration, muscle wasting, electrolyte uremia, thyrotoxicosis, diabetic ketoacidosis, Addison
imbalance, ketonuria, and weight loss of more than disease, hypercalcemia, gastritis, peptic ulcer dis-
5% of body weight.3 Most of these patients also have ease, pancreatitis, bowel obstruction, hepatitis,
CNS malformation. Researchers food and fluids more often can thiamine may be diluted in 100 mL
agree that the vomiting is most help prevent mild cases of nausea of normal saline and infused for
likely not teratogenic, but the and vomiting from worsening. 30minutes to 1 hour weekly.4
untreated electrolyte disturbances, The meals should contain more
malnutrition, and maternal weight carbohydrate than fat and acid.6
loss may be harmful.10 Babies may Protein-rich meals also decrease Antiemetics
experience severe effects as a result symptoms. Lighter snacks, includ- Several common drugs are used
of the complications of maternal ing nuts, dairy products, and as antiemetics to control nausea
hyperemesis. beans, are often endorsed. Drinks and vomiting during pregnancy.
The effects of hyperemesis gravi- that contain electrolytes and other They should not be used before
darum are quite widespread. In supplements are advised. If certain 12 to 14 weeks of gestation due to
addition to feeling ill, women with foods or food preparations trigger possible detrimental effects to the
this condition report other sources nausea, they should be avoided. developing fetus.4 However, there
of distress, including time lost are data showing lack of teratoge-
from work and decreased quality nicity with the use of dopamine
of life.6 In a study of 147 patients, Lifestyle antagonists, phenothiazines, and
82.8% were restricted in their Women who are affected by this histamine receptor blockers.4
everyday activities. They reported illness should avoid stress and try In their 2004 guidelines on vom-
being limited not only due to the to get as much rest as possible. If iting in pregnancy, the American
nausea and vomiting, but also from emotional support is needed, the Congress of Obstetricians and
the psychological affliction that patient can see a psychologist Gynecologists recommended that
was caused by feeling ill for weeks to help address the debilitating the first-line antiemetic medica-
to months.6 Women have also symptoms. Supportive counsel- tions be IV dimenhydrinate, meto-
reported feeling treated differently ing or crisis intervention may be clopramide, or promethazine.1 In a
socially as well as in the workplace. necessary.6 double-blind study conducted by
Hyperemesis can result in finan- Tan and colleagues,2 promethazine
cial hardship for these patients, Intravenous Fluids and metoclopramide were found to
their places of employment, and Intravenous (IV) fluids should have similar therapeutic effects for
the health care system,6 showing be provided to replenish the lost the treatment of hyperemesis
that the effects of the disease are intravascular volume. Rehydration (P 5 .47), but there were fewer
not limited to pregnant women along with replacement of elec- adverse effects with metoclo-
alone. trolytes is very important in the pramide.2 Medications included
Recent research now provides treatment of hyperemesis. Normal promethazine, 25 mg, or metoclo-
additional guidelines for pro- saline or Hartmann solution are pramide, 10 mg, every 8 hours for
tection against and relief from suitable solutions; potassium 24 hours. Metoclopramide caused
hyperemesis gravidarum. These chloride can be added as needed. significantly less frequent drowsi-
treatment methods include a range While replacing electrolytes, the ness (P 5 .001), dizziness (P , .001),
of options, from routine changes to physician must consider the risks and dystonia (P 5 .02) when com-
medications and various different of rapid infusion in order to pre- pared with promethazine.2
therapies. Alterations to maternal vent such conditions as central In a study by Nageotte and col-
diet and lifestyle can have protec- pontine myelinolysis.4 leagues,17 patients using a combina-
tive effects. Medicinal methods of tion treatment of droperidol and
prevention and treatment include diphenhydramine had significantly
nutritional supplements as well as Thiamine shorter hospital stays for hyper-
alternative methods, such as hyp- Thiamine should be a routine sup- emesis, fewer days hospitalized for
nosis and acupuncture. plement in patients with protracted hyperemesis during pregnancy,
or diphenhydramine as a primary between 15 and 45 mg/d helped responses and consequent nausea
therapy.17 Droperidol was dosed ini- patients resume eating, reverse feedback.
tially at 1.0 to 2.5 mg, depending on muscle wasting, and regain lost In a double-blind, randomized,
severity of symptoms, and admin- weight from prepregnancy weight. crossover trial, 1 g of ginger was
istered over 15 minutes. A con- After discharge, maintenance administered daily for 4 days. The
tinuous infusion was then started doses of $ 15 mg/d were used from preference among the patients to
at 1.0 mg/h. If the symptoms per- 6 to 20 weeks.5 There is no clear evi- receive ginger versus placebo was
sisted, the amount was increased to dence of steroid teratogenicity.5,15 It significant.12 Concurrently, the
1.25 mg/h, and increases from that is advised that steroids only be used relief of nausea and vomiting found
point were made in 0.25-mg incre- after all other causes of vomiting with the use of ginger compared
ments every 4 hours. Droperidol is have been excluded, vomiting has with placebo was significantly
structurally related to haloperidol; continued for more than 4 weeks greater. In a study by Vutyavanich
it did not cause abnormal fetal or and is associated with dehydration, and associates,20 1 g of ginger was
neonatal outcomes, and there were and the risks and benefits of the given to women with hypereme-
no maternal adverse outcomes, treatment have been explained.5 sis for 4 days, and two measur-
including hypotension.17 In a randomized, double-blind, ing scales were implemented to
Ondansetron is a 5-HT3 antag- controlled study comparing steroids quantify patients nausea.20 The
onist that acts on the CNS and and promethazine for the treat- improvement in the nausea scores
peripheral nervous system. The ment of hyperemesis, steroids were of patients receiving ginger was sig-
primary location of action is in the found to be more effective.19 Oral nificantly greater than that of the
CNS, but it also increases gastric methylprednisolone, 16 mg, was placebo group. Also, after 4 days of
emptying. It is very effective for administered three times daily, and treatment, there was a significant
patients who experience the emetic promethazine, 25 mg, was adminis- decrease in vomiting in the ginger-
effects of chemotherapy.18 It also tered three times daily. No women treated group versus the placebo-
aids patients with postoperative were readmitted to the hospital treated group.20 However, different
nausea and vomiting. A study on who were treated with methylpred- collections of ginger may differ due
ondansetron found it to decrease nisolone, but five patients from the to their growing climates, condi-
vomiting after the first dose and promethazine group were readmit- tions, and harvesting times.20 There
decrease nausea subsequently.18 The ted to the hospital for hyperemesis have been no teratogenic effects of
patient studied was able to tolerate a within 2 weeks of discharge. Neither ginger in this or other studies.12
light diet after 2 days of treatment, drug displayed adverse effects.
and she was discharged 14 days
after being admitted on 4 mg of Nasogastric Enteral
ondansetron three times daily. Ginger Feeding
The GI symptoms of motion sick- In one study of seven patients with
ness and hyperemesis are simi- hyperemesis, the placement of a
Steroids lar; therefore, the root of ginger, Dobhoff tube improved symp-
The mechanism of action of steroids Zingiber officinale, has been stud- toms of nausea and vomiting in
is assumed to be a direct effect on the ied to treat hyperemesis. The effec- 24hours, and symptoms continued
vomiting center of the brain. Because tiveness of ginger is thought to be to improve with enteral feedings.
such high doses are required, it is dependent on its aromatic, carmi- The mean hospitalization after
improbable that there is a lack of native, and absorbent characteris- feedings began was 4.6 days, with
pituitary adrenal reserve in this tics. It is thought to act on the GI the longest being 8 days. On dis-
illness. tract to increase motility, and its charge, one woman did not require
One study showed vomit- absorbent property may decrease enteral feedings, and the other six
ing ceased in all patients within stimuli to the chemoreceptor zone continued feedings in the outpa-
tient setting. The average duration
One study showed vomiting ceased in all patients within 3 hours of feedings was 43 days, ranging
after administration of the first dose of IV hydrocortisone. from 5 to 174 days. One patient was
content with the enteral feedings
3 hours after administration of in the medulla that sends stimuli and continued them for 174 days;
the first dose of IV hydrocorti- to the emetic center of the brain however, the second longest dura-
sone. Maintenance doses ranging stem. Ginger may also block the GI tion was only 49 days.21
This treatment has potential were defined by indirect calorim- should begin at 30 to 45 mL/h
complications, such as pneumotho- etry, and the appropriate number and increase in increments of
rax aspiration, infection, venous of calories was calculated for each 20mL/h/d.3
thrombosis, intrahepatic cholesta- patient. The group of hyperemesis Fat emulsions have been shown
sis, and fatty infiltration of the patients compared with the two to induce contractions of the
placenta. In order to minimize the control groups of healthy pregnant uterine muscle at a high infusion
possibility of aspiration, the feeding women and healthy women who rate.3,22 This may happen at any
tube was placed past the pylorus. were not pregnant had significantly point in the pregnancy. Placental
This technique, however, exposes different substrate utilization. The infarctions and placental fat depos-
the patient to radiation to check hyperemesis patients used fat, its are also a risk with fat emulsion
the position of the tube. Despite its consistent with a catabolic state. infusions, possibly resulting in pla-
expense, it is considerably cheaper The hyperemesis group also had a cental insufficiency.3,22 Fat emul-
compared with total parenteral mean respiratory quotient that was sions should not exceed 3 g/kg/d,
nutrition (TPN). This type of feed- ,1.00, an indication of a catabolic or more than 60% of the total calo-
ing is most useful in patients whose state. After treatment with TPN, ries, to avoid a fat overload.22 TPN
nausea and vomiting are associated the respiratory quotient of each should be discontinued once the
with the consumption of food.21 hyperemesis patient was . 1.00, woman is able to tolerate enteral
showing a shift to utilization of car- feedings.22 Infections are also a risk
bohydrate and protein, indicating of TPN, and vigilant observation
Total Parenteral Nutrition an anabolic state and improvement must be practiced.4 More severe
TPN is a nutrient source that may in nutritional status. The pre- and risks when using TPN include sep-
be used in pregnant women who posttreatment mean respiratory sis and cardiac complications due
suffer from severe hyperemesis or quotients of the hyperemesis group to electrolyte imbalances.1
hyperemesis from acupuncture. It Hypnosis works through a dis- the suggestion.7 It is, however, nec-
seems to inhibit nociceptive trans- sociation of content, when the essary to dispel any myths or doubt
mission and autonomic reflexes. individuals attention is focused the patients have about hypnotic
It also seems to decrease pain in on a certain task causing the rest treatment. No teratogenic effects
the system from the periaqueduc- of the information surround- were noted.7 It is also proposed that
tal gray, which partially works ing him or her to be temporarily expanding this treatment to women
through endorphinergic mecha- unreachable. An example of this with morning sickness would pre-
nisms. Because one potential cause is the unnoticed hum of a com- vent the nausea and vomiting from
of hyperemesis is reduced gastric puter motor.7 Hypnosis also acts worsening or progressing to hyper-
emptying, and acupuncture has through dissociation of context, emesis gravidarum.
an effect on the GI tract, another in which this narrowing of atten-
possible mechanism of action is tion briefly suspends higher-order
through somatovisceral reflexes.14 processes.7 Conclusions
In the case examples of hypnosis Nausea and vomiting are positive
treating hyperemesis performed predictors of a favorable pregnancy
Hypnosis by Simon and Schwartz,7 the treat- outcome, but excessive vomiting
Hypnosis is used to control physio- ment was found to be effective in may have negative effects on the
logic changes that are thought to be two ways. The first component is a mother and baby, including low
involuntary. Hypnotized patients deep relaxation that acts to decrease birth weight, antepartum hemor-
have, however, been able to control sympathetic nervous system rhage, preterm delivery, and fail-
sympathetic tone, vasoconstriction, arousal. This decreases the sym-
7
ure of infant testes to descend. In
and vasodilation, heart rate, and pathetic hyperaroused state. The order to alleviate this nausea and
muscle tone.7 It has been compared second component is the response vomiting, the simplest changes are
with biofeedback because patients to hypnotic suggestion of symptom to eat more frequent, smaller meals
are trained to voluntarily control removal. This response to sugges- and avoid foods or odors that trig-
these mechanisms. Biofeedback tion is independent of the sympa- ger vomiting. Another lifestyle
uses an external method of feed- thetic or parasympathetic systems alteration is to decrease stress and
back whereas hypnosis uses an and is often independent of their get more rest throughout the day.
internal control from the patient. conscious awareness or memory of Thiamine should be supplemented
TABLe 2
Summary of Treatment Agents
at 1.5 mg/d in women with hyper- Although the exact mechanism of 6. Jueckstock JK, Kaestner R, Mylonas I. Managing
hyperemesis gravidarum: a multimodal challenge.
emesis. When these methods do not action is unknown, there are no BMC Med. 2010;8:46.
help, IV fluids should be adminis- known adverse effects on the baby. 7. Simon EP, Schwartz J. Medical hypnosis for hypereme-
sis gravidarum. Birth. 1999;26:248-254.
tered to replace the lost fluid and By entering a deeply relaxed state 8. Sonkusare S. Hyperemesis gravidarum: a review. Med
electrolytes. and decreasing the sympathetic 9.
Journal Malaysia. 2008;63:272-276.
Tan PC, Jacob R, Quek KF, Omar SZ. Pregnancy out-
The medications found to state through hypnosis, women come in hyperemesis gravidarum and the effect of
laboratory clinical indicators of hyperemesis severity.
improve hyperemesis gravidarum with hyperemesis have reported J Obstet Gynaecol Res. 2007;33:457-464.
symptoms without causing detri- improvement in their nausea and 10. Tsang IS, Katz VL, Wells SD. Maternal and fetal out-
comes in hyperemesis gravidarum. Int J Gynaecol
mental effects to the fetus are listed vomiting. Obstet. 1996;55:231-235.
in Table 2. Metoclopramide, when Hyperemesis gravidarum is a 11. Kucu NK, Koyuncu F. Hyperemesis gravidarum:
current concepts and management. Postgrad Med J.
compared with promethazine, potentially severe condition that 2002;78:76-79.
proved to cause less drowsiness, diz- can cause detrimental changes in 12. Fischer-Rasmussen W, Kjaer SK, Dahl C, Asping U.
Ginger treatment of hyperemesis gravidarum. Eur J
ziness, and dystonia. Steroids were the pregnant woman and her fetus. Obstet Gynecol Reprod Biol. 1991;38:19-24.
found to relieve symptoms better In order to decrease these effects, 13. Eliakim R, Abulafia O, Sherer DM. Hyperemesis gravi-
darum: a current review. Am J Perinatol. 2000;17:207-218.
than promethazine, but are only to managing the nausea and vomiting 14. Carlsson CP, Axemo P, Bodin A, et al. Manual acu-
be used if all other causes of vomit- as well as their consequences, will puncture reduces hyperemesis gravidarum: a placebo-
controlled, randomized, single-blind, crossover study.
ing have been excluded. Ginger was prevent harmful or undesired out- J Pain Symptoms Manage. 2000;20:273-279.
found to significantly improve the comes. The current medications 15. Nelson-Piercy C, Fayers P, de Swiet M. Randomised,
double-blind, placebo-controlled trial of corticoste-
nausea and vomiting of hypereme- and treatments reviewed here will roids for the treatment of hyperemesis gravidarum.
sis. With severe hyperemesis, more aid in proper management and 16.
BJOG. 2001;108:9-15.
Veenendaal MV, van Abeelen AF, Painter RC, et al.
invasive measures have been shown relief of this disorder. Consequences of hyperemesis gravidarum for off-
to improve symptoms. Nasogastric spring: a systematic review and meta-analysis. BJOG.
2011;118:1302-1313.
feedings relieved symptoms and References 17. Nageotte MP, Briggs GG, Towers CV, Asrat T. Droperidol
and diphenhydramine in the management of hypereme-
decreased length of hospital stay. 1. American College of Obstetrics and Gynecology.
sis gravidarum. A J Obstet Gynecol. 1996;174:1801-1805.
ACOG (American College of Obstetrics and
TPN shifted the patients from a cat- Gynecology) Practice Bulletin: nausea and vomiting
18. Tincello DG, Johnstone MJ. Treatment of hyperemesis
gravidarum with the 5-HT3 antagonist ondansetron
abolic state to an anabolic state and of pregnancy. Obstet Gynecol. 2004;103:803-814.
(Zofran). Postgrad Med J. 1996;72:688-689.
2. Tan PC, Khine PP, Vallikkannu N, Zawiah SZ.
improved their nutritional status. Promethazine compared with metoclopramide for
19. Safari HR, Fassett MJ, Souter IC, et al. The efficacy of
methylprednisolone in the treatment of hyperemesis
This method, however, does have hyperemesis gravidarum: a randomized controlled
gravidarum: a randomized, double-blind, controlled
trial. Obstet Gynecol. 2010;115:975-981.
risks. 3. Levine MG, Esser D. Total parental nutrition for the
study. Am J Obstet Gynecol. 1998;179:921-924.
20. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for
Alternative treatment with treatment of severe hyperemesis gravidarum: maternal
nausea and vomiting in pregnancy: randomized,
nutritional effects and fetal outcome. Obstet Gynecol.
acupuncture resulted in signifi- 1988;72:102-107.
double-masked, placebo-controlled trial. Obstet
Gynecology. 2001;97:577-582.
cantly less vomiting. The use of 4. Nelson-Piercy C. Treatment of nausea and vomiting in
pregnancy: when should it be treated and what can be
21. Hsu JJ, Clark-Glena R, Nelson DK, Kim CH. Nasogastric
acupuncture plus administration safely taken? Drug Saf. 1998;19:155-164.
enteral feeding in the management of hyperemesis
gravidarum. Obstet Gynecology. 1996;88:343-346.
of IV fluids improved symptoms 5. Taylor R. Successful management of hyperemesis
gravidarum using steroid therapy. QJM. 1996;89:
22. Rayburn W, Wolk R, Mercer N, Roberts J. Parental
faster than placebo plus IV fluids. 103-107.
nutrition in obstetrics and gynecology. Obstet Gynecol
Surv. 1986;41:200-214.
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