Transcript
Hyperemesis Gravidarum
Douglas M Montgomery, MD
Kaiser Permanente
Riverside Medical Center
Diagnosis
Persistent vomiting
Weight loss 5 % pre-pregnancy wt
Ketonuria 3-4 +
Known Associations
Twins Trophoblastic Dz Triploidy Trisomy 21 Fetal hydrops
Differential Diagnoses
Goodwin (1998), Clinical Obstetrics and Gynecology 41(3).
Goodwin (1998), Clinical Obstetrics and Gynecology 41(3).
Maternal Complications
Wernicke’s Encephalopathy Esophageal tear Mallory-Weiss tear Pneumothorax Peripheral Neuropathy (B6/B12)
1st Line Treatment
Avoidance of environmental triggers, especially strong odors
Diet Modification (Salty/Sour) Ginger / B 6 / Doxylamine Acupressure wristbands
Persistent Weight Loss/Vomiting
Drug Choices
Antihistimines
Dimenhydrinate (dramamine)50 po q 4 Cyclizine(marezine)50 po q 4 Meclizine(antivert)50 po q 24 Promethazine (phenergan)12.5-25 po q 6 or
12.5-25 PR q 12 Diphenhydramine (benadryl)25-50 po q6 Doxylamine (unisom) 12.5 PO q 12 = ½ tab
Dopamine Receptor Antagonist
PhenothiazinesButyrophenonesBenzamides
Side Effects of Dopamine Antagonist
extrapyramidal symptoms: dystonia, dyskinesia, akathisia, opisthotonus, and oculogyric crises.
Concurrent benadryl decreases dystonic side effects. Watch for tardive dyskinesia
Phenothiazines
Prochlorperazine(compazine)10 mg PO q8 or 25 mg PR q 12
Chlorpromazine ( Thorazine ) 25 mg PO q6 or 100 mg PR Q 12
Butyrophenones
Droperidol (inapsine) 5 mg IM
Haloperidol (haldol)
Benzamides
Metoclopramide( Reglan) 10 PO q 8
Trimethobenzamide (Tigan) 250 PO q 8
Serotonin Antagonist
Odansetron ( zofran) 8 mg PO Q12
Quinlan and Hill, Am Fam Physician. 2003 Jul 1;68
APGO/UTD
IV Fluids Consider LR or D5LR solution and pay close
attention to replenishing vitamins, electrolytes Na/K, and minerals, such as magnesium and phosphorous.
Thiamine supplementation (100 mg IV) is recommended for women who have had prolonged vomiting. Prevent Wernicke’s Encephalopathy with Thiamine prior to Dextrose
Clinically Significant Nutritional Deficiency
No standard definition for pregnancy The lower the pre-pregnacy weight,
the lower our threshold should be to supplement
10% of pre pregnancy weight loss 180 lbs vs 100 lbs
PICC Lines
Of 33 patients:
66.4% required treatment for infection and/or thromboembolism
9 % fetal loss rate after first trimester
AJOG 2008;198:56.e1-56.e4
PICC lines (continued)
Other reports of significant complications:Obstet Gynecol 2006;107• infection precipitated PTD @ 26 weeks with one
NN deathObstet Gynecol 2006;107 • Candida septicemiaAm J Ob Gyn 2003;188 • 50% incidence of infection, thromboembolism or
mechanical failure
Three separate sources recommend:
Avoid PICC lines Consider Enteral Nutrition alternative 1st Use Parenteral nutrition through a central
line (PICC/HICKMAN) only as a last resort
UTD 2008Obstet Gynecol Survey 2008;63Holmgren AJOG 2008; 198
Enteral Feeding for Nutritional Support
Two studies support NasoJejunal Feeding One study utilized NG tube One study utilized both NG and ND tube
Obstet Gynecol 1996;88:343-6Clinical Nutrition 2004;23,53-7Clinical Nutrition 2001; 20(5): 461-464 AJOG 2008;198:56
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