Hyperemesis

Question 1

What is hyperemesis gravidarum?

Answer 1

DEfined as persistent vomiting in pregnancy which causes weight loss (>5% pre-pregnancy weight) and ketosis

Question 2

When is the onset of hyperemesis gravidarum?

Answer 2

Always within the first trimester

Question 3

What are risk factors for the development of hyperemesis gravidarum?

Answer 3

• Multiple pregnancies
• Molar pregnancies
• Previous hyperemesis gravidarum

Question 4

Which hormone is thought to be the causative agent for hyperemesis gravidarum?

Answer 4

BHCG

Question 5

How is BHCG correlated with symptoms in hyperemesis gravidarum?

Answer 5

Directly correlated to severity of vomiting - more BHCG there is, more vomiting

Question 6

Why does hyperemesis present in the first trimester?

Answer 6

Peak levels of HCG in pregnancy are around 6-12 weeks

Question 7

Why can those with hyperemesis have elevated free thyroxine levels?

Answer 7

HCG shares a common alpha-subunit with TSH and acts as a thyroid stimulator in patients with hyperemesis

Question 8

Why might hyperemesis be more common in those with multiple pregnancies and molar pregnancies?

Answer 8

HCG levels are higher than normal singleton pregnancy.

Question 9

What are clinical features of hyperemesis gravidarum?

Answer 9

• Inability to keep down food or fluid
• Decreased weight +/- nutritional deficiency
• Dehydration
• Tachycardia
• Postural hypotension
• Polyneuritis
• Mallowry-Weiss tears
• Liver and renal failure
• Evidence of electrolyte disturbance - hypokalaemia, hyponatraemia

Question 10

What would you consider as a differential diagnosis for someone with features of hyperemesis gravidarum?

Answer 10

• UTI
• Multiple pregnancy
• Hydatiform mole
• GORD/Peptic ulceration
• Thyrotoxicosis
• Addison’s disease
• Pancreatitis
• Enteric infection
• Hepatitis
• Hypercalcaemia

Question 11

What investigations would you consider doing in somoen with features of hyperemesis gravidarum?

Answer 11

• Bedside - Diptick, MSSU, weight
• Bloods - U+E’s, FBC, TFTs, BHCG, LFTs
• Imaging - USS

Question 12

What might you find on investigation of urine dipstick in someone with hyperemesis gravidarum?

Answer 12

• Proteinuria - UTI
• Ketones - diabetes, catabolic state
• SG - dehydration

Question 13

What might you find on investigation of MSSU?

Answer 13

UTI

Question 14

What might you find on investigation of U+E’s in someone with hyperemesis gravidarum?

Answer 14

• Hyponatraemia
• Hypokalaemia
• Low urea

Question 15

What might you find on investigation of FBC in someone with hyperemesis gravidarum?

Answer 15

Raised haematocrit

Question 16

When should TFTs be performed in someone with hyperemesis gravidarum?

Answer 16

Only if other signs of hyperthyroidism

Question 17

Why might you perform a abdominal USS in someone with features of hyperemesis gravidarum?

Answer 17

Look for signs of multiple pregnancy, mole and assess current pregnancy

Question 18

How would you manage someone with hyperemesis gravidarum?

Answer 18

• GORD management - Elevate head of bed, small meals, alginates
• Anti-emetic trials - find ones that work
  
  • If intractable on anti-emetics - Steroids
• Vitamin injection
• If severely dehydrated- admit and rehydrate with electrolyte replacement
• Consider VTE thromboprophylaxis

Question 19

What antiemetics are used in managing hyperemesis gravidarum?

Answer 19

• Cyclizine
• Prochlorperazine
• Stemetil
• Metoclopramide
• Chlopromazine
• Domperidone
• Ondansetron

Question 20

What vitamin supplementation should you give someone with hyperemesis gravidarum?

Answer 20

• Folic acid
• Pabrinex - Thiamine multivitamin

Question 21

Why should you give thiamine and folic acid replacement in someone with hyperemesis gravidarum?

Answer 21

Risk of wernicke’s encephalopathy

Question 22

What fluids would you use to correct dehydration in someone with hyperemesis gravidarum?

Answer 22

• Normal 0.9% saline - fluid of choice.
• Hartmann’s solution
• To correct hypokalemia - infusion of 40mmol/L of KCL can be used.

Question 23

Why would you not give someone dextrose solution if they had hyperemesis gravidarum?

Answer 23

Precipitates Wernicke’s encephalopathy

Question 24

Why is VTE prophylaxis advised in someone with hyperemesis gravidarum?

Answer 24

Due to dehydration combined with the fact they are pregnant, they are a thombosis risk

Question 25

When are corticosteroids used in hyperemesis gravidarum?

Answer 25

After anti-emetics and fluid replacement have not worked

Question 26

What other health professionals should be involved in the management of someone with hyperemesis gravidarum?

Answer 26

* **Dietician** * **Clinical psychologist**

Question 27

What may be needed in terms of nutritional management of someone with severe hyperemesis gravidarum?

Answer 27

Total parental nutrition

Question 28

What complications are associated with TPN?

Answer 28

* **Thrombosis** * **Phlebitis**

Question 29

If a woman with hyperemesis gravidarum presented with feeling unsteady on her feet, having blurred visionhas increased confusion, her short term memory is not what it used to be, what might you suspect purely from the symptoms is the cause of her problems?

Answer 29

Wernicke's encephalopathy

Question 30

What might you see on examination in a woman with wernicke's encephalopathy?

Answer 30

* **Thought process appears slow** * **Can obey commands** * **Hoizontal and vertical nystagmus** * **Normal limb movement and sensation** * **Ataxic gait** * **Opthalmoplegia**

Question 31

What is wernicke's encephalopthy caused by?

Answer 31

Vitamin B1 deficiency

Question 32

What is the classic triad for wernicke's encephalopathy?

Answer 32

The classic triad is of confusion, opthalmophlegia and ataxia.

Question 33

How would you treat wernicke's encephalopathy in a woman with hyperemesis gravidarum?

Answer 33

**IM thiamine injections** - prognosis depends on severity