HYPEREMESIS GRAVIDARUM GT 69

Nausea and vomiting of pregnancy (NVP)

- diagnosed when onset is 1st trimester and other causes of nausea and vomiting have been
excluded
- it typically starts between the 4w - 7w of gestation , peak at 9w and resolves by 20w
- if the initial onset is after 10w+6d , other causes need to be considered

Hyperemesis Gravidarum
- diagnosed when there is protacted NVP with the TRIAD of :
      • more that 5% prepregnancy weight loss,
      • dehydration
      • electrolyte imbalance

PUQE score ( pregnancy - unique quantification emesis ) can used to classify severity of NVP

Assesment :
• History - previous NVP/HG , severity , history to exclude other causes

• Examinations: vitals , weight , sign of dehydration, sign of muscle wasting

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• Investigations:
- urine dipstick - ketonuria
- RP and electrolytes - exclude AKI, hypokalemia , hyponatremia
- FBC - infection, aanemia , hematocrit
- Blood glucose - exclude DKA in diabetic
- Ultrasound scan - confirm viable intrauterine pregnancy , exclude mulptiple pregnancy and
trophoblastic disease
- in refractory cases/previous admission, check : TFT , LFT, Cal, Po4 , amylase , ABG

** in 2/3 of pt with HG, there may be abnormal TFT ( based on structural similarity between TSH
hormone and hCG ) with a biochemical thyrotoxicosis and raised free thyroxine levels with or
without a supressed TSH level. These pt rarely have thyroid antibodies and are euthyroid
clinically

** pathological causes that should be excluded:

-peptic ulcer
-cholecystitis
-gastroenteritis
-hepatitis
-pacreatitis
-UTI / pyelonephritis
-metabolic /neurologic conditions
-drug induced NV

** severe abdominal/epigastric pain -->may warrant further ix of serum amylase and abdominal
ultrasound , gastroduodenoscopy . Chronic H.pylori infection can be associated with NVP / HG .
And testing for H.pylori antibodies may be considered
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MANAGEMENT:

• mild NVP - tretaed with antiemetics

• ambulatory daycare management should be used for suitable patients when

community/primary
care measures have failed and where the PUQE score is less than 13

• INPATIENT manegement IF :
   - continued NV and inability to keep down oral antiemetics
   - continued NV associated with ketonuria and/or weight loss ( greated than 5% ) despite oral
antiemetics
   - confirmed or suspected comorbidity ( UTI , unable tolerate oral antibiotics)

Antiemetics
- first line : antihistamines (H1 receptor antagonist) and phenothiazines
- combination of different drugs ahould be used if does not respond to single antiemetic
- persistent or severe HG , parenteral or rectal route may be necessary
- women should be asked about previous adverse reactions to antiemetic therpaies
- Drug induced extrapyramidal symptoms and oculogyric crises can occur with the use of
phenothiazine

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- METOCLOPERAMIDE is safe and effective , but because risk of extrapyramidal effect, it
should be used as SECOND therapy
- Ondansetron (serotonin rec antagonist)- limited date , second line therapy

Histamin H1 recepto antagonist:

• promethazine (phenergen)
• cyclizine
• cinnarizine
• doxylamine
• dimenhydrinate

Phenothiazine :
• prochorperazine
• chlorpromazine
• perphenazine

Dopamine antagonist :
• metoclopramide
• domperidone

**combination of drug from different classes should be used in women who do not respond to
single antiemetic. furthermore, persistent vomiting means that oral dose are not absorbed ,
therefore Intravenous , rectal , subcutaneous , intramuscular routes may be necessary and
more effective.

Metocloperamide : due to risk of extrapyramidal effects , should be used as second therapy. It

should only be prescribed for short term use ( maximum dose 30mg/d or 0.5 mg/kg/day and
maximum duration for 5days)
Intravenous doses should be administered by slow bolus injection ovEr at least 3 minutes to
help minimise these risk.

Ondansetron : studies limited. May risk of cleft palate, cardiovascular defect. For these
reasons , the use of ondansetron should be limited to patients who are not adequately managed
on the aforementioned antiemetics and preferably used afetr the first trimester of pregnancy

*pyridoxine ( vitamin B6) and diazepam not recommended for NVP and HG

*CORTICOSTEROIDS should be reserved for cases where standard therapies has failed . The
suggested dose is IV hydrocortisone 100mg BD and once clinical improvement occurs, to
convert to T. prednisolone 40-50mg daily with the dose gradually tapered until the lowest
maintainence dose that control the symptoms reached. In most cases, the prednisolone needs
to be continued until gestational age at which HG would hv typically resolved

Complementary therapies:
- Ginger
- Acupressure and acupuncture
- Hypnosis
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Best rehydration regimen

• normal saline with additional potasium chloride in each bag - guided by daily monitoring of

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electrolytes , intravenous hydration

• Dextrose infusion are NOT appropriate unless serum sodium levels are normal and thiamine
has been administered. Dextrose-containing solutions can precipitate Wernicke’s
encephalopathy in thiamine-deficient states (see section 7.1); hence, each day intravenous
dextrose is administered, high (e.g. 100 mg)doses of parenteral thiamine should be given to
prevent Wernicke’s encephalopathy.

• There is no evidence to determine which fluid regimen is most appropriate but given that most
women admitted to hospital with HG are hyponatraemic, hypochloraemic,
hypokalaemic and ketotic, it seems appropriate to use normal saline and potassium chloride

• General adult fluid management guidance can be found in NICE clinical guideline 174.

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Monitoring for NVP and HG

- RP and electrolytes - should be checked daily

• Histamine H2 receptor antagonist ( ranitidine) or Proton pump inhibitors amy be used for
women developing GERD , esophagitis or gastritis .

• Oesophageal gastroduodenoscopy is safe in pregnancy and indicated if there is

haematemesis or severe epigastric pain. A therapeutic trial with a proton pump inhibitor is
appropriate for treatment and prevention and is safe in pregnancy.

• Wernicke’s encephalopathy due to vitamin B1 (thiamine) deficiency classically presents with

blurred vision, unsteadiness and confusion/memory problems/drowsiness and on examination
there is usually nystagmus, ophthalmoplegia, hyporeflexia or areflexia, gait and/or finger–nose
ataxia

• Wernicke’s encephalopathy is a potentially fatal but reversible medical emergency. In the

context of HG, it is totally preventable and studies have stressed the association between
Wernicke’s encephalopathy and administration of intravenous dextrose and parenteral nutrition.
One of these studies reported that complete remission occurred in only 29% and permanent
residual impairment was common. The overall pregnancy loss rate including intrauterine deaths
and terminations was 48%. Therefore thiamine supplementation is recommended for all women
with protracted vomiting.

• Thiamine supplementaion ( oral or IV) should be given to all women with prolonged vomiting ,
esp before administration dextrose or parenteral nutrition

HG - ( Odds ratio for VTE 2.5 ) should offer VTE prophylaxis unless there is contraindications .
Thromboprophylaxis can be discontinued upon discharge

Oral iron can cause nausea and vomiting. Women with NVP or HG should consider avoid iron-
containing preparations if this exacerbate the symptoms

In women with severe NVP or HG, input may be required from other professionals, such as
midwives,
nurses, dieticians, pharmacists, endocrinologists, nutritionists and gastroenterologists, and a

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mental health team, including a psychiatrist.

When all other medical therapies have failed, enteral or parenteral treatment should be
considered
with a multidisciplinary approach. they often employed as a last resort when all other medical
therapy has failed and the only other practical option is termination of the
pregnancy

Enteral feeding options to consider include nasogastric, nasoduodenal or nasojejunal tubes, or

percutaneous endoscopic gastrostomy or jejunostomy feeding. Parenteral feeding with a
peripherally inserted central catheter (PICC line) is often better tolerated than enteral feeding;
however, it carries a higher risk of infection and vascular perforation. Hence enteral feeding is
more effective and safer than parenteral feeding.

Total parenteral nutrition is a complex high-risk intervention; however, it may be useful in

refractory cases to ensure sufficient calorie intake. It should only be used as a last resort when
all other treatments have failed as it is inconvenient, expensive and can be associated with
serious complications such as thrombosis, metabolic disturbances and infection.

In women with severe NVP or HG, input may be required from other professionals
(multidisciplinary approach) , such as midwives, nurses, dieticians, pharmacists,
endocrinologists, nutritionists and gastroenterologists, and a mental health team, including a
psychiatrist.

TOP ( termination of pregnancy) - offer when ALL therapeutic measures have been tried.
Treatment options of antiemetic , corticosteroid , enteral/parenteral feeding , correction of
electrolytes/metabolic acidosis should be considered before deciding of TOP. A psychiatric
opinion should be sought, and the decision of termination needs to be multidisciplinary , with
documentation of therapeutic failure if this is the reason for termination.
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Discharge and follow up : Women with severe NVP and HG who hv continued symptoms into
late second and thirt trimester, should be offered serial scans to monitor fetal growth

At the time of discharge, it is essential that women are advised to continue with their antiemetics
where appropriate and that they know how to access further care if their symptoms and/or signs
recur (e.g. persistent vomiting, dehydration or ketonuria). Earlier treatment may reduce the need
for hospital admission

Observational study shows women with HG and low pregnancy weight gain <7kg --> increased
risk of preterm labour and low birth weight

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Postnatal : women with previous HG should be advised risk of recurrence in future pregnancy

Early use of lifestyle/dietary modifications and antiemetics that were found to be useful in the
index pregnancy is advisable to reduce the risk of NVP and HG in the current pregnancy.

practitioners should assess a woman’s mental health status during the pregnancy and
postnatally

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and refer for psychological support if necessary.