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Management of hyperemesis gravidarum rcog 2016

management of hyperemesis gravidarum

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Management of hyperemesis gravidarum rcog 2016

  1. 1. Management of Hyperemesis Gravidarum -Guidelines Dr Meenakshi Sharma MD (AIIMS), FICMCH Consultant Obs & Gynae, Yashoda Superspeciality Hospital Shanti Mukund Hospital
  2. 2. RCOG Guidelines 2016 Definition • Nausea vomiting of pregnancy (NVP) – NVP should only be diagnosed when onset is in first trimester of pregnancy and other causes have been ruled out. • Hyperemesis Gravidarum (HG)- HG can be diagnosed when there is intractable NVP with triad of more than 5% prepregnancy weight loss, dehydration and electrolyte imbalance.
  3. 3. Hyperemesis Gravidarum • NVP affects 80% of pregnant women • HG affects 0.3-3.6% of pregnant women • Etiology - rising levels of beta hCG, higher levels associated with multiple or molar pregnancy associated with more severity of NVP • NVP starts 4-7 weeks, peaks 9 weeks and resolves by 20 weeks in 90% of women RCOG 2016
  4. 4. Hyperemesis Gravidarum • Symptoms • Nausea • Vomiting • Enhanced olfactory senses • Food and/or fluid intolerance • Lethargy • Signs • Dehydration • Weight loss • Ketonuria • Anaemia • Tachycardia
  5. 5. Pregnancy Unique Qualification of Emesis (PUQE) score • Developed by Motherisk programme an NVP helpline Canada • PUQE Score is used to classify the severity of NVP and response to therapy (C), evidence 2+
  6. 6. NVP/HG - Evaluation History • Previous H/o NVP/HG • Quantify severity using PUQE score • History to exclude other causes • Abdominal pain • Urinary symptoms • Infection • Drug history • Chronic H. pylori infection Examination • Temperature • Pulse • Blood pressure • Oxygen saturation • Respiratory rate • Abdominal examination • Weight • Signs of dehydration • Signs of muscle wasting
  7. 7. Differential diagnosis Differential Diagnosis System Diagnosis Genitourinary UTI Uraemia Molar pregnancy Gastrointestinal Gastritis/ peptic ulcer Reflux/ oesophagitis Cholecystitis hepatitis Pancreatitis Bowel obstruction Endocrine Addison’s disease Hyperthyroidism Diabetes ketoacidosis CNS Intracranial tumours Vestibular disease
  8. 8. Complications • Maternal • Hypokalemia • Hyponatremia and central pontine myelinosis • Wernickie’s encephalopathy • Vitamin B6/B12 deficiency • Malnutrition • Mallory- Weiss esophageal tears • Venous thromboembolism • Psychological morbidity • Fetal • Growth restriction • Wernicke’s encephalopathy is associated with 40% fetal death
  9. 9. Management (RCOG 2016) • Women with mild NVP should be managed in community with antiemetics (D) • Ambulatory day care management should be used for suitable patients when Primary care measures have failed and where PUQE score less than 13 (C) • Inpatient management -if there is atleast one of following • Continued NVP and inability to keep down oral antiemetics • Continued NVP associated with ketonuria and/or weight loss (>5% body weight) despite oral antiemetics • Confirmed or suspected comorbidities (UTI) or inability to tolerate oral antibiotics
  10. 10. Management of HG • Provision of symptomatic relief • Correction of dehydration and electrolyte imbalance • Prophylaxis against recognized complications • Admit if • Symptom are severe despite 24 hrs of medication • Evidence of dehydration and ketosis • Admit earlier if coexisting conditions eg diabetes
  11. 11. Pharmacological Group of Antiemetics Class of drugs Antiemetic Phenothiazine Prochlorperazine (stemetil/ buccastem) Chlorpromazine Antihistamines (H1 receptor antagonist) Doxylamine Cyclizine Promethazine (phenergan) Meclozine Dopamine antagonists Metoclopramide Domperidone 5-HT3 (serotonin) antagonist Ondansetron
  12. 12. Antiemetic therapy (RCOG 2016) • There are safety and efficacy data for first-line antiemetics such as antihistamines (H1 receptor antagonists) and phenothiazines and they should be prescribed when required for NVP and HG (c) • Combinations of different drugs should be used in women who do not respond to a single antiemetic. • For women with persistent or severe HG, the parenteral or rectal route may be necessary and more effective than an oral regimen.
  13. 13. Antiemetic therapy (RCOG 2016) • Women should be asked about previous adverse reactions to antiemetic therapies. Drug-induced extrapyramidal symptoms and oculogyric crises can occur with the use of phenothiazines and metoclopramide. If this occurs, there should be prompt cessation of the medications. (B) • Metoclopramide is safe and effective, but because of the risk of extrapyramidal effects it should be used as second- line therapy. (B) • There is evidence that Ondansetron is safe and effective, but because data are limited it should be used as second- line therapy. (C) Some studies report increased risk of cleft palate and cardiac defects • Pyridoxine is not recommended for NVP and HG. (C)
  14. 14. Antiemetic therapy (RCOG 2016) • Corticosteroids should be reserved for cases where standard therapies have failed. (A) • I/V Hydrocortisone 100 mg BD for 48 hrs • Oral prednisolone 30 – 40 mg/day -1 week then tapered gradually 5mg reduction every week • Diazepam is not recommended for the management of NVP or HG. (B)
  15. 15. Management – Rehydration therapy ( RCOG 2016) • Normal saline with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, is the most appropriate intravenous hydration. (D) • Dextrose infusions are not appropriate unless the serum sodium levels are normal and thiamine (100mg thiamine) has been administered. (D) • Dextrose solution can precipitate Wernicke’s encephalopathy • Avoid double strength saline even in cases of severe hyponatraemia
  16. 16. Thromboprophylaxis • Increased risk of VTE due to dehydration and immobilization in hospitalized pts. • Clexane should be given if the risk factor score for VTE is 3 or more
  17. 17. Pre-existing risk factors Score Previous recurrent VTE 3 Previous unprovoked or estrogen related 3 Previous VTE provoked 2 Family history of VTE 1 Known thrombophilia 2 Medical comorbidity 2 Age (> 35 years) 1 Obesity 1 or 2 * Parity (≥ 3) 1 Smoker 1 Gross varicose vein 1 Obstetric risk factors 1 Pre-eclampsia 1 Dehydration/ Hyperemesis/ OHSS 1 Multiple pregnancy or ART 1 Transient risk factors Current systemic infection 1 Immobility 1 Surgical procedure in pregnancy 2 Total score Risk assessment for Venous Thromboembolism (VTE) *Score 1 for BMI >30 *Score 2 for BMI >40
  18. 18. Complementary Therapy - Ginger • Ginger may be used by women wishing to avoid antiemetics in mild to moderate NVP. (A) • Three systematic reviews addressed effectiveness of ginger in NVP –1 review- 4 RCT all found ginger more effective than placebo for NVP • Another review 10 RCT, Ginger compared with placebo (5), Vitamin B6, (4), dimenhydramine (1). Ginger superior to placebo and equal to Vitamin B6 and dimenhydramine in improving NVP • Ginger was superior to placebo but less effective than metoclopramide in a RCT, 102 patients with NVP. • One review highlighted potential maternal adverse effects-anticoagulant effect, stomach irritation and a potential interaction with beta blockers and benzodiazepines. Tiran D, Complement Ther Clin Pract 2012
  19. 19. Complementary Therapy – Acustimulation • Women may be reassured that acustimulations are safe in pregnancy. Acupressure may improve NVP (B) • Acustimulations - acupuncture, acupressure and electrical stimulation) • Pericardium 6 point (PC6)- 2.5 finger breadths up from the wrist crease on the inside of the forearm, between the tendons of palmaris longus and flexor carpi radialis • Review of 14 studies and metanalysis demonstrated acupressure applied by finger pressure or wristband and electrical stimulation both reduced NVP, but acupuncture methods did not. Helmreich RJ, Explore (NY) 2006 • A review of 6 RCT, 399 women, 5 RCT shows positive result of acupressure including 2 RCT in patients with HG (102women) Lee EJ, J Pain Symptom Manage 2011
  20. 20. Monitoring and Adverse effects • Urea and serum electrolyte levels should be checked daily in women requiring intravenous fluids. • H2 receptor antagonists or PPI may be used for women developing GE reflux, oesophagitis or gastritis. (D) • Thiamine supplementation (either oral or intravenous) should be given to all women admitted with prolonged vomiting, especially before administration of dextrose or parenteral nutrition.
  21. 21. Monitoring and Adverse effects • Women admitted with HG should be offered thromboprophylaxis with LMHW unless there are specific contraindications such as active bleeding. Thromboprophylaxis can be discontinued upon discharge. (C) • When all other medical therapies have failed, enteral or parenteral treatment should be considered with a multidisciplinary approach. (D) • All therapeutic measures should have been tried before offering termination of a wanted pregnancy. (D)
  22. 22. Monitoring and Adverse effects • Women with severe NVP or HG who have continued symptoms into the late second or the third trimester should be offered serial scans to monitor fetal growth. • Early use of lifestyle/dietary modifications and antiemetics that were found to be useful in the index pregnancy is advisable to reduce the risk of NVP and HG in the current pregnancy. (c)
  23. 23. Conclusions • Women with mild NVP should be managed in the community with antiemetics • Antihistamines (H1 receptor antagonists) and phenothiazines are first line antiemetics, Metoclopramide and Ondensetron are second line therapies • Normal saline with KCL should be ideal iv fluid for hydration • Thiamine supplementation should be given to all women admitted with prolonged vomiting • Women with HG who are admitted to hospital should receive thromboprophylaxis with LMHW unless contraindicated