​Kembara Xtra - Medicine - Hyperemesis Gravidarum

​Kembara Xtra - Medicine - Hyperemesis Gravidarum 
Around 70–80% of pregnancies experience nausea and vomiting at some point during the pregnancy.
Hyperemesis gravidarum, a more severe form of morning sickness that affects 0.5–2% of pregnancies, can have serious negative medical and psychological repercussions.
One of the most frequent reasons for hospitalization during pregnancy is hyperemesis gravidarum, which is still diagnosed based on clinical judgment.
Although morning sickness is common during pregnancy, hyperemesis gravidarum is a rare condition. hyperemesis gravidarum is associated with several adverse fetal outcomes including preterm delivery, low birth weight, small for gestational age, low 5-minute Apgar scores, and neurodevelopmental delay.
● Intractable vomiting that disrupts a pregnant woman's fluid and electrolyte balance as well as nutrition is known as hyperemesis gravidarum:
It is typically present in the first 8 to 20 weeks of pregnancy and is thought to have both biological and behavioral components.
- Linked to high levels of the hormone human chorionic gonadotropin (hCG) and estrogen Symptoms typically start around two weeks after the first missed period, peak around week twelve, and disappear by week twenty.
Endocrine/metabolic, gastrointestinal (GI), and reproductive system(s) affected

Epidemiology Other risk factors include prior history of hyperemesis, preexisting diabetes, hyperthyroid disease, psychiatric illness, asthma, and GI issues. It typically affects young women, primiparous women, nonsmokers, and non-Caucasians.
Incidence
In 0.5–2% of pregnancies, hyperemesis gravidarum occurs.
Prevalence
The most typical reason for hospitalization during the first half of pregnancy and the second most typical reason for hospitalization overall for pregnant women is hyperemesis gravidarum.

Pathophysiology and Etiology 

The cause is unknown. Pregnancy hormones, hyperthyroidism, hyperparathyroidism, liver dysfunction, autonomic nervous system dysfunction, CNS tumor, Addison disease, and maybe psychological problems are some of the suggested implications.

Genetics

higher chance if hyperemesis gravidarum runs in the mother's family

Risk factors include nulliparity, many pregnancies, migraine and motion sickness histories, black or Asian women, gestational trophoblastic illness, female fetuses, and a possible link to Helicobacter pylori infection.

Prevention 

Small, frequent meals; avoiding an excessively empty or full stomach; anticipatory advice for dietary practices to prevent dehydration and nutritional depletion

Diagnosis
Although there are many different ways to define hyperemesis gravidarum, it frequently includes persistent nausea and vomiting throughout pregnancy, symptoms of dehydration, and electrolyte abnormalities after ruling out more serious causes of extreme nausea and vomiting.


Providing a history; feeling queasy; vomiting with retching more than three times per day; decreased urine production; being tired; feeling dizzy while standing; and having a poor appetite

Clinical examination, thyroid evaluation, >5% weight loss from pre-pregnancy weight, significant ketonuria, high urine specific gravity, and other signs of dehydration

Multiple Diagnoses 

Other typical reasons of vomiting need to be taken into account:
Anxiety, gastroenteritis, gastrotritis, reflux esophagitis, peptic ulcer disease, cholelithiasis, cholecystitis, Pyelonephritis, appendicitis, pancreatitis, hyperparathyroidism, hypercalcemia, thyrotoxicosis, and H. pylori infection are just a few of the conditions that can affect the digestive system.


Laboratory Results 

The purpose of the initial laboratory tests for hyperemesis gravidarum is to assess the clinical condition of the mother and rule out any other potential causes of nausea and vomiting.

Initial examinations (lab, imaging)
Glucosuria, albuminuria, granular casts, and hematuria may be seen on a urine test; ketosis is more likely to occur. Thyroid-stimulating hormone (TSH), free T4.
- Dehydration and abnormal electrolyte levels brought on by nausea and vomiting - Acidosis - Liver enzymes and bilirubin levels - Hematocrit - Hepatitis panel - Calcium - Albumin
Tests in the Future & Special Considerations
Unless there is a worry about a hydatidiform mole or multiple gestations, in which case ultrasonography may be conducted, no imaging is recommended.


Other/Diagnostic Procedures

only recommended if additional diagnoses listed in the following section need to be ruled out:
 An upper abdomen ultrasonography if nausea and vomiting are thought to be the result of cholecystitis or pancreatitis.
The suspected reason of nausea and vomiting is appendicitis, according to an abdominal MRI.

Interpretation of Tests
A positive urine analysis for ketones and a high specific gravity point to starving ketosis and volume depletion, respectively.
TSH and free T4: If TSH is suppressed with high free T4, further testing is required to rule out overt hyperthyroidism. Transient hyperthyroidism (suppressed TSH with normal free T4) may be present in about 50% of hyperemesis gravidarum cases.

Dehydration can result in low potassium, low sodium, increased BUN, and elevated levels of creatinine and electrolytes.
Liver enzymes and bilirubin levels: Mild AST and ALT elevations occur in about 50% of cases and settle on their own.
When liver enzyme levels are dramatically increased, other etiologies must be taken into account.
Hematocrit: Volume contraction due to dehydration results in an increase.
Hepatitis panel: Take into account and rule out Hepatitis A, B, and C as a possible cause of hyperemesis.
Calcium: Hypercalcemia brought on by hyperparathyroidism is a rare occurrence.
Albumin: Low albumin levels may be a sign of malnutrition brought on by nausea and vomiting.
TREATMENT
The first-line therapies for hyperemesis gravidarum are pyridoxine and doxylamine (pregnancy Category A)(1)[C]. Metoclopramide or ondansetron (pregnancy Category B) come next, and then prochlorperazine, methylprednisolone, or promethazine (pregnancy Category C), depending on the drug.

General Actions 
Treat electrolyte imbalances and dehydration before dealing with nausea.
Ondansetron carries an FDA warning for concerns of QT prolongation. IV fluids, either normal saline or 5% dextrose normal saline (with consideration for potential thiamine deficiency). For severe cases, consider PO thiamine 25 to 50 mg TID or IV 100 mg in 100 mL of normal saline over 30 minutes once weekly. In a pregnancy-related situation, the danger is unknown. Although the bulk of recent research seem to indicate no increased risk of prenatal deformity, this is still a contentious topic.

Medication: Pyridoxine (vitamin B6) 25 mg PO or IV every 8 hours, with a daily maximum dose of 200 mg; antihistamines (such as diphenhydramine 25 to 50 mg every 4 to 6 hours; doxylamine 12 mg PO BID; meclizine 25 mg PO every 4 to 6 hours; and dimenhydrinate 25 to 50 mg PO every 4 to 6 hours); and the combination product Diclegis (sustained-release pyridoxine
Promethazine or prochlorperazine, for example, are phenothiazines.
- Safety measures: In infants, phenothiazines are linked to extrapyramidal effects, extended jaundice, and hyper- or hyporeflexia.
Methylprednisolone 16 mg PO/IV q8h for two to three days, then taper over two weeks if the initial three-day treatment is successful; only used in severe instances with unknown benefit
Ondansetron 4–8 mg PO every eight hours
pregnant women's issues
All prenatal drugs should weigh the risks and advantages for the mother and the fetus.
Initial Line
Pyridoxine (vitamin B6) 10 to 25 mg PO or IV every eight hours helps alleviate symptoms in women with mild to moderate motion sickness and has a favorable safety profile. The daily maximum is 200 mg.
If nausea and vomiting persist, combine pyridoxine 25 mg PO every eight hours with doxylamine succinate 12.5 mg. Both drugs work better together than they do separately.
With refractory vomiting, 350 mg PO TID of ginger pills may be given.

Antihistamines like dimenhydrinate, meclizine, and diphenhydramine are on the second line. It is best to stop using doxylamine-pyridoxine before beginning a new antihistamine.
Promethazine 12.5 mg PO or rectally, Metoclopramide 10 mg PO every eight hours, and Ondansetron 4 to 8 mg PO or IV every eight hours


Referral: Inpatient management is necessary for IV fluids and antiemetics when symptoms are resistant to outpatient treatment.
Referral to gastroenterology or surgery if an other diagnosis is more consistent with the cause of the nausea and vomiting.

 If a referral to psychiatry or psychology is necessary, they may also take that into consideration.

Further Therapies 
Although their effectiveness is debatable, glucocorticoids (methylprednisolone 16 mg IV every eight hours for 48 to 72 hours) can be explored in severe and resistant instances.
Cimetidine and ranitidine as an additional therapy to lessen heartburn and acid reflux

Surgical Techniques 

Rarely, tube feeding or parenteral nourishment is used if all pharmacologic and nonpharmacologic therapies fail and weight loss persists. Parenteral feeding is recommended over enteral nutrition, which can reduce nausea and vomiting. Enteral nutrition can be administered via the gastric or duodenal routes.

Healthcare Alternatives 

Acupressure and acupuncture have conflicting results, although ginger 350 mg PO every six hours may be helpful.
In cases of severe hyperemesis, acupressure bands at the Neiguan point are a successful adjuvant therapy.
Medical hypnosis might be a useful addition to the standard course of medical treatment, but further research is required.

Admission, usually outpatient therapy, enteral volume and nutrition repletion, but early enteral tube feeding does not enhance maternal or perinatal outcomes. In rare severe cases, parenteral therapy in the hospital or at home may be necessary.


Constant Care 
10% of hyperemesis gravidarum individuals experience symptoms throughout the entire pregnancy.

Take Action 

The degree of nausea and vomiting can have an impact on one's overall quality of life and future prospects for conception.

patient observation
If the condition is severe, daily weight checks should be performed. Ketosis, hypokalemia, and acid-base abnormalities brought on by hyperemesis should all be carefully watched for.

Diet: As tolerated, bland or watery diet

 A diet high in protein and carbs, such as fruit, cheese, eggs, steak, chicken, vegetables, toast, crackers, and rice, is recommended for outpatients. High-fat foods and spicy meals should be avoided by patients. Every hour or so, encourage tiny quantities at a time.

Modification of Lifestyle 
Psychosocial problems, such as potential ambivalence regarding the pregnancy, should be paid attention to.
To prevent volume depletion, patients should be advised to routinely consume tiny amounts of fluid.
Steer clear of specific meals that are known to irritate the sufferer.
Nutrients that are wet to dry (sherbet, broth, crackers with gelatin on them, toast)

Self-limited sickness with a favorable prognosis if the patient's weight is kept at >95% of pre-pregnancy levels.
The mortality rate for pregnant patients who develop hemorrhagic retinitis is 50%.


Fetal complications: Patients with >5% weight loss are associated with intrauterine growth retardation and fetal anomalies. Maternal complications include vitamin deficiency, dehydration, and malnutrition. In severe cases, Wernicke encephalopathy secondary to thiamine deficiency, coma, and even death.
Poor weight gain is linked to a somewhat higher risk of small for gestational age births (2,500 g or less) and early births (37 weeks or less).Hemorrhagic retinitis and damage to the liver