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