hyperemesis gravidarum

what is hyperemesis gravidarum?

an extreme form of 'nausea and vomiting in pregnancy' (NVP)

when does hyperemesis gravidarum usually occur?

8-12 weeks - but may persist to 20 weeks

what are the risk factors for hyperemesis gravidarum?

- increase beta-hCG

- nulliparity

- obesity

- family or personal history of NVP

what could increase beta-hCG levels?

- multiple pregnancies

- trophoblastic disease

what is associated with a decreased incidence of hyperemesis?

smoking

when do NICE recommend considering admission?

- continued nausea + vomiting and is unable to keep down liquids or oral antiemetics

- continues nausea and vomiting with ketonuria and/or weight loss (> 5% of body weight) despite oral antiemetics

- a confirmed or suspected comorbidity (e.g. cannot take antibiotics for a UTI)

when do NICE recommend lowering the threshold for admission?

co-existing condition (e.g. diabetes) that could be worsened due to n+v

what is the triad of diagnosis for hyperemesis gravidarum according to the Royal College of Obstetricians and Gynaecologists (RCOG)?

- 5% of pre-pregnancy weight loss

- dehydration

- electrolyte imbalance

what scoring system can be used to classify the severity of NVP?

pregnancy-unique quantification of emesis (PUQE)

what is the non-medical advice for those with hyperemesis gravidarum?

- rest and avoid triggers

- bland, plain food - especially in the morning

- ginger

- P6 (wrist) acupuncture

what are the first line medications for hyperemesis gravidarum?

- antihistamines

- phenothiazines

- combination drug doxylamine/pyridoxine

what are the antihistamines used?

cyclizine or promethazine

what are phenothiazines?

antipsychotic

what are the phenothiazines used for hyperemesis gravidarum?

prochlorperazine or chlorpromazine

what is pyridoxine?

vitamin B6

what are the second line medications for hyperemesis gravidarum?

- oral ondansetron

- oral metaclopramide or domperidone

what are the side effects of oral ondansetron?

small risk of cleft palate

what are the side effects of metaclopramide?

extrapyramidal side effects

what are extrapyramidal side effects?

- pseudoparkinsonism

- acute dystonia

- akathisia

- tardive dyskinesia

what is acute dystonia?

- tongue, face, neck and back spasms

- facial grimacing

- involuntary upward eye movement

- laryngeal spasms

what is akathisia?

- restless

- trouble standing still

- paces the floor

- feet in constant rocking motion

what is tardive dyskinesia?

abnormal involuntary movements

- protrusion and rolling of tongue

- chewing motion

- sucking and smacking of lips

how long can metoclopramide be used for?

5 days

what are the complications of hyperemesis gravidarum?

- AKI

- wernicke's encephalopathy

- oesophagitis

- mallory-weiss tear

- VTE

- foetal outcome - little evidence of adverse outcomes

what should be given first line in dehydration due to hyperemesis gravidarum?

IV saline 0.9% with potassium

what should be considered giving if patient presents with diplopia and ataxia?

pabrinex (vitamin B1 and C) - for Wernicke's encephalopathy

what does pabrinex contain?

- vitamins B1, B2, B6

- nicotinamide

- vitamin C

- glucose

should you ever give dextrose?

NO - can precipitate wernickes