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Early Pregnancy Nausea/Vomiting & Hyperemesis Gravidarum - Coggle…
Early Pregnancy Nausea/Vomiting & Hyperemesis Gravidarum
Overview
Definition
Hyperemesis
RCOG: Severe nausea and vomiting beginning in early pregnancy (before 16 weeks) with inability to eat and drink normally, and strongly limiting daily living activities
Signs of dehydration are considered contributory
Previously Diagnosis of exlusion
Prolonged persistent and severe nausea and vomiting unrelated to other causes
Weight loss - usually 5% of pre-pregnancy body weight
Dehydrationand electrolyte imbalance
Shift towards subjective pt focused criteria
Risk Factors
Increased placental mass
Multiple pregnancy
Molar pregnancy
Hx of hyperemesis gravidarum
Fhx of hyperemesis gravidarum
First pregnancy
Obesity
Maternal Complications
Dehydration / electrolyte imbalance
Acute kidney injury
Weight loss
Mallory weiss tear / upper GI bleeding
Wernicke's encephalopathy due to nutritional and vitamin deficiencies
GORD / oesophagitis
VTE - due to dehydration
Impact on psychosocial functioning
Foetal Complications
Preterm delivery
Low birthweight
Small for gestational age
Serial scans to monitor growth should be offerec to all women who continue to experience HG late in 2nd trimester - 3rd trimester
Assessment - History
Presenting Complaint
Onset
Duration
Severity
Frequency of symptoms
Impact on psychosocial functioning
Additional symptoms - alternative diagnosis
Review risk factors
Medications
Medications exacerbating N/V - Iron supplements
PMhx
Diabetes - increased risk of complications
CKD - increased risk of complications
Scoring Systems
PUQE Score
Pregnancy-Unique Quantification of Emesis Score
In last 24hrs how long have you felt nauseated or sick to your stomach?
In last 24hrs have you vomited or thrown up
In last 24hrs how many times have you had retching or dry heaves without bringing anything up
https://www.doxinate.com/puqe-score#:~:text=The%20PUQE%20score%20helps%20moms-to-be%20to%20classify%20the,if%20their%20symptoms%20are%20mild%2C%20moderate%2C%20or%20severe
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HELP Score
HyperEmesis Level Prediction
https://www.hyperemesis.org/tools/help-score/
https://www.hyperemesis.org/wp-content/uploads/2020/04/HELP-SCORE_2024-791x1024.png
Assessment - Examination
Temperature
Heart rate
Tachycardia in dehydration
Blood pressure
Hypotension in dehydration
Oxygen sats
Respiratory rate
Tachypnoea in dehydration
Abdominal exam
Pain / tenderness - may indicate other causes
Subrapubic / renal angle tenderness - pyelonephritis
Epigastric / RUQ pain - pancreatitis / cholecystitis
Weight
Signs of dehydration
Sunken eyes
Dry lips / mouth
Oliguria / anuria
Tachycardai
Hypotension
Signs of malnutrition / rapid weight loss
More than 5% pre pregnancy weight loss
Muscle wasting - mid arm circumference
Neurological signs
Confusion
Nyastagmus
Ataxia
Could indicate Wernike's encephalopathy
Assessment - Investigations
FBC
Raised haematocrit
U&E
HyponatraemiaA
Hypokalaemia
High serum urea
VBG
Metabolic hypochloraemic alkalosis
Severe: Metabolic acidosis may develop
TFTs
2/3 women with HG have abnormal TFTs - structural similarities between TSH an hCG cause biochemical thyrotoxicosis
Resolves as HG improves
LFTs
Abnormal in 40% women with HG
Raised AST / ALT
Bili and amylase <-> / ↑
Improves as HG resolves
Urinanalysis
MC&U
USS
Assess if viable intrauterine pregnancy, multiple pregnancy, trophoblastic disease
Differential Diagnosis
Diagnosis of Exlusion
GU causes
Upper UTI / Pyelonephritis
Suspet if N/V reoccurs after previously resolved
Renal stones
GI causes
PUD
Acute cholecystitis
Pancreatitis
Gastroenterits
Endocrine
Thyrotoxicosis
DKA
Hypercalaemia
Neurological
Migraine
Drug induced
Iron supplements
Antibiotics
Antihypertensives
Pregnancy related
Acute fatty liver of pregnancy
Pre-eclampsia
Psych / Substance abuse
Alcohol misuse
Opioid abuse
Eating disorder
Management
Conservative
Reassure - common usualy resolve by 16-20 weeks
Lifestyle modifications
Indication
Mild-moderate N/V
Ambulatory Day Care Management
Indication
Mild-moderate symptoms failed community management
Inability to tolerate oral intake
PUQE score ≥ 13 with no complications
Location
EPAU - Early pregnancy assessment unit
EGU: Emergency gynaecology unit
May need admission for IV fluids + antiemetics
Impatient Management
Indication
Moderate-Severe N/V
PUQE score > 13
Red flag symptoms
Management
IV Fluids and electrolyte replacement
Normal saline + potassium chloride
Guidedby U&E
Antiemetics IV/IM
Thaimine (PO/IV)
All women admitted with HG
Deficiency can lead to Wernicke's encephalopathy
VTE prohylaxis
TEDs
LMWH prophylactic dose unless active bleed
PPI / Acid reducing medication for GORD / Oesophagitis
Steroids / IV hydrocortisone in severe refractory cases
Parenteral feeding (NG tube ) if indicated
Daily monitoring for
U&E
Urinalysis
Ketones
General Measures
Rest
Avoid sensory stimuli - odours, heat, noise
Plain food
Biscuits / crackers
Protein rich meals
Low carb
Low fat
Cold meals if smell related
Drinking little and often
Ginger - fresh, tea, capsule, syrup
Acupressure - P6 point on ventral aspect of wrist - using writs band or finger pressure
Pharmacological
1️⃣Line
Prescribe antiemetic
Antihistamines
Promethazine
Oral cyclizine
Dopamine antagonists
Prochloraperazine
Chlorpromazine
Combo Doxylamine / pyridoxine
Reasses after 24
If responsive - prescribe and review weekly
2️⃣Line
Prescribe antiemetic
Dopamine receptor antagonists
Oral metoclopramide
Prescribe no longer than 5 days - risk of extrapyramidal s/e
Oral domperidone
Prescribe no longer than 7 days - risk of cardiac effevts
5-HT3 receptor antagonist
Ondansetron
Prescribe no longer than 5 days - exposure during 1st trimester ↑ risk of cleft lip and/or palate
Reassess after 24 hr
Red Flags
Any PUQE score + complications
Inability to tolerate oral intake
Unresponsive to outpatient management
Clinical dehydration
Weight loss >5% body weight
Confirmed / suspected co-morbidity (UTI , DM)
Co-morbidity and unable to take medications (epilepsy, HIV, hypoadrenalism, psychiatric disorders)
Concerns regarding mental health
Greentop Guidelines
https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1111/1471-0528.17739
