MRCOG Part 2 Essay 274: Nausea and vomiting in pregnancy

a). Hyperemesis is a diagnosis of exclusion and occurs in about 1% of all pregnancies. Ask for amount of vomiting , ability to retain any fluid and  intake .  Vomiting can be due to urinary tract infection (UTI), pyelonephritis and related symptoms like dysuria, frequency, fever are elicited. Any gastrointestinal cause like pancreatitis, appendicitis, renal calculus needs to be ruled out if she has associated abdominal pain. History of blood stained vomitus points to severity and urgent assessment. At times undiagnosed  hyperthyroidism can cause severe vomiting and tremor palpitations asked. Previous obstetric history of  hyperemesis asked as recurrence is about 50%.     Examination of hydration status , mucous membranes skin turgor is done. Pulse rate ,blood pressure recorded as there can be tachycardia, postural hypotension in severe cases needing admission. Look for icterus, abdominal tenderness in case of gastrointestinal cause.

b). Urine dipstix done for leucocytes ,midstream sample sent for urine culture to look for UTI. Urine ketones done as ketoacidosis may be present in severe cases. Full blood count CRP done to look any infective cause like UTI, appendicitis which may need   urgent surgical opinion. Liver function test , renal function test electrolytes may be altered in severe vomiting and need correction.  Ultrasound done for location of   pregnancy, viability , to detect multiple pregnancy which may have exaggerated symptoms. Molar pregnancy is ruled out as it may cause hyperemesis. Other gastrointestinal causes like gall stones can be ruled out .

c). Management of idiopathic nausea and vomiting (hyperemesis gravidarum) depends on general condition of woman, ability to tolerate fluids and severity of condition. Mild cases can be managed as outpatient with advice on bland diet ,small frequent meals, clear fluids  anti emetics like promethazine, ondansetron. Reassurance given that the condition will settle as pregnancy progresses.  In case of severe case, dehydration inpatient treatment advised. Fluid electrolyte balance corrected . She is kept nil oral till able to tolerate clear fluids. Hyponatremia corrected by hartmann solution (130 meq ), to avoid rapid correction of sodium which may cause pontine myelinolisis    . Hypokalemia corrected by potassium infusion and potassium rich fruits .  Wernicke  encephalopathy  (ataxia, diplopia )can be precipitated so dextrose containing fluids (5% dextrose) avoided.  Thiamine supplementation given first in severe cases by intravenous 100 mg per day followed by oral thiamine tablets. Antiemetics like  ondansetron , antihistaminics like promethazine, domperidone  and  given by parenteral and then oral route and are safe in pregnancy. Daily electrolytes .urine ketones measured till corrected. Twice a week weight checked.      Emotional support is important during the treatment in sensitive manner. Alternate regimens like ginger, acupressure can be tried. Corticosteriods like prednisolone 40mg per day, hydrocortisone 100 mg iv twice a day can be tried in refractory cases after consultant review.    Thromboprophylaxis  mandatory in admitted cases ,by avoiding dehydration immobility, and low molecular weight heparin as risk of thromboembolism high in first trimester. Total parenteral nutrition , enteral feeding by nasogastric tube naso jejunal tube in refractory cases may be tried as last resort. If maternal health worsening inspite of all measures review of diagnosis may be needed with termination of pregnancy for maternal well being.

A healthy 30 year old woman has been referred to the emergency clinic by her general practitioner because of severe nausea and vomiting for 24h. Her LMP was 8 weeks ago and she had a positive pregnancy test 4 weeks ago. (a) Discuss your clinical assessment [6 marks].

 I will assess the severity of vomiting by asking about number of episodes of vomiting, if she is tolerating any oral intake, and about contents whether there was blood as this is associated with Mallory Weiss syndrome. I will check for other symptoms like abdominal pain, diarrhea, fever that might point to gastroentritis. Change in urine (tea colour)or stool colour  (clay colour) may be associated with hepatitis. urinary symptoms (frequency, burning) and loin pain may point to a urinary tract infection.  Abdominal pain radiating to the back,  history of gallstones and alcoholism should be enquired about  as it is associated with acute pancreatitis.

I will check the woman's parity, whether she had previous nausea and vomiting in a previous pregnancy as hyperemesis gravidarum can recurr in a subsequent pregnancy. I will check her maternal family history of twin pregnancies as these are associated with hyperemesis gravidarum.

I will check the woman's vital signs looking for orthostatic hypotension, tachycardia, as will indicate dehydration. Weight changes are associated with severe cases of vomiting. I will look for dry mucous membranes, decreased skin turgor which also indicate dehydration. Abdominal examination should be done to check for abdominal tenderness (Murphey's sign for cholecystitis and McBurney's tenderness for appendicitis. I will try to check for lower abdominal or costovertebral angle tenderness in case of urinary tract infection. A palpable uterus that is larger than dates might raise suspiscion of a Molar or twin pregnancy.

 (b) Justify the investigations you would undertake [4 marks].

Blood test should include blood urea nitrogen, creatinine and electrolytes to check for degree of dehydration and electrolyte disturbance. Liver enzymes might be raised with hyperemesis gravidarum but should exclude high transaminases levels associated with hepatitis. Amylase is taken if there is suspicion of pancreatitis. thyroid function test may reveal hyperthyroidism which is associated with nausea and vomiting and may be present in first trimester of normal pregnancies. Urine analysis is done to check for urinary tract infection. Ultrasound should be done to exclude molar or twin gestations which are associated with higher risk of hyperemesis gravidarum.

(c) Discuss the options for treating idiopathic nausea and vomiting in pregnancy [10 marks]

For mild and moderate cases of nausea and vomiting in pregnancy in which patient is able to tolerate oral intake of fluids, the patient should be advised to take small frequent meals, avoid spicy food  which might irritate the stomach.Use of ginger and acupressure as in p6 pressure point are non pharmacologic ways, that are effective in mild to moderate cases of hyperemsis gravidarum.

patient should be weighed twice weekly to detect acute loss of weight due to dehydration. 

in cases of severe hyperemesis gravidarum in which patient is severely dehydrated as evident by loss of >3 kg of her weight, there is a need for iv hydration. This is done by avoiding dextrose containing infusion to help prevent hyponatremia and avoid precipitation of Wernicke's encephalopathy. Hypokalaemia should be corrected by careful infusion of KCL as guided by electrolyte level, as it will help prevent ileus.

antiemetics as cyclizine, metoclopramide, phenergan, domperidone can be used to control nausea. Odansetron can be used as second line antiemetic.

steroids can be used as a last resort for cases of hyperemesis. They are usually effective and should be administered under specialist supervision.

Total parenteral nutrition may sometimes be needed for refractory cases. These patient need to be encouraged to move and wear TED stocking and in case of immobility it may be necessary to give low molecular weight heparin as dehydration and immobility raise the risk of deep vein thrombosis.

monitoring of adequacy of fluid therapy is by checking vital signs every 4-6 hours, total fluid balance, daily blood electrolytes and ketone in urine can be taken in cases of presistent vomiting.

patient should be offerred support and reassured that this condition is usually self limited and resolves spontaneously by 16-20 weeks of pregnancy with its peak between 8 and 12 weeks. It is not associated with adverse fetal outcome.

Termination of pregnancy can be offerred to women if they have recurrent severe cases of hyperemesis that is lifethreatening.

                  The condition is “ Hyperemesis” complicates around 0.3 to1% of pregnancies and is often a diagnosis of exclusion. Proposed theories are high HCG levels ,low TSH and psychological basis.I will ask the woman the number of times she vomits ,how severe her nausea is and if she tolerates oral fluids.Blood in the vomitus suggests gastritis or oesophageal tears(Mallory Weiss syndrome). I will explore if it has any impact on her quality of life.For this QOL questionnaires can be used.A similar history in previous pregnancies is asked as hyperemesis  has a 50%recurrence rate. A history of pain abdomen,diarrhoea points to a gastrointestinal cause like acute appendicitis.Pain radiating to back suggests Acute Pancreatitis while right sided pain could point to Acute Hepatitis. History of fever with chills,dysuria,increased frequency,loin pain suggests an Acute Urinary infection. I will ask for any loss of weight as >3kg loss implies the severity of hyperemesis.I will look for signs of dehydration namely loss of skin turgor,dry mucous membrane.A baseline weight is checked ,helps later in judging response to treatment.Temperature,pulse rate is checked,raised in dehydration.postural drop in blood pressure also points to dehydration.Abdominal examination done to look for any tenderness,mass suggesting GI causes.Renal angle tenderness points to urinary cause.

              A full blood count is done to assess her HAEMOGLOBIN status . A high leucocyte count suggests   some infection,marginal rise can occur in hyperemesis.Platelet count also rises in severe dehydration.Urea and electrolytes are done as vomiting can lead to hyponatremia ,hypokalemia.Urine dipstix to be done for leucocyts,nitrites to look for infection, so also a MSU(midstream culture)urine ketones if present implies dehydration.A thyroid function is done as hyperthyroidism picture of a high T4,low TSH is seen in 70%of  hyperemesis patients.An Ultrasound has to be done to rule out molar pregnancy and multiple pregnancy as these are associated with hyperemesis because of the high HCG levels.

            Idiopathic vomiting is managed symptomatically,the key treatment being rehydration. Mild dehydratin is managed on out patient basis with small bland frequent feeds as tolerated ,antiemetics and good counselling that  vomiting will settle by 16-20 weeks and fetus will not be affected   .If severe dehydration present,the woman is admitted,kept nill by mouth.Fuids preferred for i.v use  are normal saline or Hartmann’s solution with 40  to60 meq potassium to correct the hypokalemia.Dextrose is best avoided as it precipitates wernickes encephalopathy characterised by ataxia,diplopia the etiology being THIAMINE deficiency. Antiemetics that can be used are promethazine,cyclizine,domperidone,phenothiazine .Side effects like extrapyramidal symptoms may occur with dopamine antagonists.Ondansetron, a 5HT antagonist is used as second line.Daily monitoring of pulse,Blood pressure,temperature and twice weekly weight checked.daily intake output chart is maintained to see response to fluid correction.Thiamine is replaced i.v 100mg in 100 ml N saline run over 4 to 6 hours weekly,when condition improves changed to oral25 to 50 mg tds.Antacids like ranitidine(H2blockers),omeprazole (proton pump inhibitors)given to combat gastritis.Other   complimentary therapies like ginger powder,P6 wrist acupressure may have a role.woman needs thorough counselling possibly by a psychologist .She should be reassured that hyperemesis does not affect her pregnancy outcome.Refractory cases may need Total parenteral nutrition ( TPN )and in them, steroids prednisolone,iv hydrocortisone may help. Termination of pregnancy is only a last resort in intractable cases.She must be provided with information leaflets,support group details like www.pregnancysickness.org.uk.Contact phone numbers to be given,so also arrangement for follow up appointment.

a.The initial assessment includes a detailed history including the severity of symptoms, associated gastrointestinal and urinary problems and obstetric, medical, surgical, psychiatric and family history of significance. A detailed drug history should also be ascertained. Her immunity status against rubella and chicken pox should be enquired.

Hyperemesis gravidarum is considered as a differential diagnosis as she is pregnant. It is the diagnosis of exclusion and other causes include UTI, gastric ulceration, gall stones, appendicitis, drugs such as iron. Psycholocigal factors sometimes can play a part if the preganacy was unplanned or unwanted, but this is not of significant value.

General examination should be done including BMI, state of hydration, blood pressure etc. Hyperemesis is a condition where the vomiting is bad enough to cause at least loss of 5% of body weight. As most pregnancies are unplanned, so we have to depend on laboratory findings. Cardiovascular examination should be done if she is and immigrant.

Other relevant examination should be directed according to history.

b. Investigations should be done to exclude other differential diagnosis of hyperemesis gravidarum. It includes electrolyes which may reveal hypokalaemia, hyponatraemia and hypochloraemic alkalosis. Urine dipstick should be sent to check the ketone and exclude UTI. MSU can be sent for culture in case of suspected UTI. Liver  and renal function tests should be done. Some advocate thyroid function test, though free T4 levels can be raised in hyperemesis and does not require any treatment.

All routine booking investigations should be sent. Her rubella and chicken pox immunity status should be checked. An ultrasound should be done to exclude gallstones and also to confirm the viability, location and number of gestation.

c. When a pregnant woman presents with severe nausea and vomiting she should be admitted for conservative treatment. Rehydration with Hartmann’s solution or normal saline should be started. Dextrose saline should be avoided as it may precipitate Wernicke’s encephalopathy and are not strong solutions like normal saline or Hartmann.

Most of the women respond with rehydration therapy. But if the symptoms persist, then antiemetics can be advised. Antiemetics which are considered safe in pregnancy are antihistamines such as promethazine, phenothiazines such as chlorpromazine and also metoclopramide and domperidone. AS these drugs have sedative effects, they are better prescribed at night. The woman should be informed that these drugs do not have teratogenic effects, but phenothiazines can cause oculogyric and estrapyramidal effect.

Ondansetron, a 5HT receptor antagonist can also be used if she is non responsive to above antiemetics.

Phamacist advice should be sought for the drugs which are not commonly prescribed.

Debenbox, a doxylamine was previously popular for this use, but later on it was withdrawn from the market due to risk of teratogenicity. The teratogenicity has never been proved and it is again marketed in North America.

Sometimes H. pylori infection can cause intractable symptoms and referral to gastroenterologist may be necessary. Urea breath test can be done and appropriate antibiotic advised.

Steroids such as prednisolone or hydrocortisone can be used in non responsive cases and after 12 weeks the dose is tapered off as symptoms usually improve after that.

Thiamine as oral or IV can be given to prevent wernicke’s encephalopathy. Pyridoxine in higher doses also helps in relieving nausea.

Enteral therapy can be considered who cannot tolerate orally. But it can be troublesome for nauseated woman. Total parenteral nutrition is considered in very severe cases.

Woman may opt for TOP in severe hyperemesis gravidarum.

Complementary theparies such as ginger, acupuncture have some beneficial role, but these are mostly effective in recovery phase.

The woman should be properly explained about her diagnosis and consequent management. All informations should be clearly conveyed along with information booklet. She can be given suitable website addresses for further information.

a)I will enquire about severity of symptoms, frequency, whether able to tolerate orally.  Nausea and vomiting may be associated with UTI and gastroenteritis. I will enquire about any diarrhoea, abdominal cramps, dysuria, and frequency of micturition or haematuria. Presence of any acute abdominal pain, site, and nature may indicate acute appendicitis or pancreatitis. Any presence of severe vomiting in previous pregnancy as chance of recurrence in present pregnancy is upto 50%. Explore her social and environmental that might be precipitating her condition.

 I will undertake her physical examination including BP, HR, mucous membrane, skin turgor for degree of dehydration. I will perform abdominal examination for any tenderness, guarding or rigidity or rebound tenderness. Positive renal punch may suggest pyelonephritis.

b) I will do urine dipstix to check ketonuria to assess the severity of dehydration as well as for presence of nitrites, leucocytes, haematuria which suggest UTI. I will send blood sample for FBC (raised haematocrit in dehydration), electrolytes (may be associated with electrolyte imbalance especially hypokalaemia), baseline urea/creatinine, LFT (may be associated with mildly deranged level) and serum amylase if clinical suspicious of acute pancreatitis. I will arrange for US pelvis to confirm viability/gestation and to rule out multiple pregnancy and molar pregnancy. I will send urine for Culture if suggestive of UTI on urine dipstix.

c) I will admit her if severe vomiting and not tolerating orally. I will rehydrate her with I/V fluids (NaCL or Hartman’s solution), avoid using fluid containing dextrose as it may precipitate Wernicke’s encephalopathy. I will correct electrolyte imbalance if any and keep her NBM for at least 24 hours, start orally as tolerates. Anti-emetics like metoclopramide, domperidone, cyclizine, promethazine can all be used safely in 1^st trimester and add H1 antagonist like ranitidine to prevent gastritis.  I/V ondansetrone to use as 2^nd line if not responding to fluids and antiemetics. In severe protracted cases not responding to fluids or I/V antiemetic may consider trial of corticosteroid, some patient might need total parentral therapy.

Along with medical management, it is very important to provide emotional support to patient, reassure her that most of nausea/vomiting will resolve by 16 to 20 weeks and it is usually not associated with any adverse pregnancy outcome

Advise her to avoid spicy food and to take small frequent meals.

Monitor during her stay by taking BP/HR 6 hourly, input/output chart  4hourly, daily urine dipstix for ketonuria and daily urea/electrolyte if persistent vomiting , weekly weight.

Assess for risk factors for thromboprophylaxis while admitted in hospital. Provide her with TEDS and encourage ambulation and start LMWH if high risk.

In severe cases she might request for TOP, it may be recommended in severe protracted cases.

sorry in section (b) forgot to add

TFT as hyperthyroidism may be associated with nausea and vomitting

I know that hyperemesis gravidarum is a diagnosis of exclusion so clinical assessment should be directed  to exclude other causes of vomiting such as urinary tract infection, hepatitis ,pancriatitis. Also I have to assess severity of condition. Detailed history abuot number of vomiting episodes,ability to retain soft, liquid diet should be checked.In sever cases ,patiet cannot retain her own saliva.I will ask about any treatment received & its efficacy, history of hyperthyroidism as it is associated with hyperemesis.I will ask about urinary symp & fever to role out infection as a cause of vomiting,subjective feeling of reduced urin output in sever cases.

Examination : I will check general condition of patiet including vitals Blp,pulse(hypotention & dry mouth in dehydrated), degree of conciousness(in case of encephalopathy) , I will palpate abdomen for any masses or tenderness

B Investigation

FBC,LFT urea ,electrolytes as heamoconcentration with increased hematocrit value in dehydration,hypokaleamia is common in hyperemesis &need correction.Also complete urin analysis for pus cells in urinary infection, level of ketones to ckeck severity.

US to exclude multiple pregnancy & molar pregnancy which are known to be associated with hyperemesis,also check viability &dating

mild cases can be treated as outpatient with regular follow up but severe cases with dehydration & ketosis need admission. I.V. fluds to correct dehydration to start with Hartmans solution I have to avoid glucose as it may aggrevate encephalopathy & hyponatreamia.  Antiemetics by rectal or IV route such as meclizine,metclopramide can be safely given.Thiamine injection IM every other day .Assess the need for thromboprophylaxis especially if admitted ,dehydrated &immobelized.Regular weighing of patient. Psychological support of the patient and reassure her that the condition is expected to improve by the end of 1st T .Termination of pregnany is an option for severe cases nonresponsive to treatment with endanger patiets life.  

A] The patients nausea and vomiting must be due to Hyperemesis gravidarum. This is a diagnosis of exclusion. The defination  is, vomiting severe enough which causes dehydration and weight loss of atleast 3 kgs and needs hospital admission . The excat aetiology is not known  but may be due to hyperthyroidism and psychological . Take a detail history of the amount, frequency, the type of vomitus . is she able to retain any thing taken orally. rule out other causes of nausea and vomiting such as Uti, intestinal obstruction, appendicities, pancreatitis, associated diarrhoea and gastroenterities, peptic ulceration, Diabetic ketoacidosis.this is evaluated by relevant history . for uti  vomiting associated  with urinary frequency and dysuria. for appendicities vomiting  associated  with pain abdomen, fever and diarrhoea or constipation. in case of acute pancreatits ,find out if she is alcoholic. any history of flue like symptoms and vomiting for hepatitis . Examination - assess degree of dehydration by skin turgour and mucous membrane .  Temperature, blood pressure for hypotension, pulse and BMI .Per abdomen for abdominal tenderness , any palpable masses, increase in fundal height than gestation age in case of twin gestation and molar pregnancy.

B]Blood for FBC, LFT, urea and electrolytes,TFT but TSH may be suppressed in first trimester, serum amylase. There may be electrolytes imbalance causing hypokalemia and hyponatremia. low serum urea , abnormal LFT ,TFT and raised haematocrit.
 Urine  analysis for proteins, ketones, nitrites,and leucocytes. USG for viability, gestation age, to rule out twins and molar pregnancy

C] THe treatment depends on the severity of the disease . In mild to moderate nausea and vomiting out patient management is done .Reassure the patient that it is self limiting ,it peaks between 8-12 weeks and decreases after 16-18 weeks.Ask her to take small frequent meals avoid spicy foods. she can have complementary therapies such as ginger and accupuncture . anti emetics such as metoclopromide,cyclizine, promethazine. for gastritis antacids, h2 receptor antagonists and proton pump inhibitors can be given . In case of severe disease such as severe dehydration and patient cannot tolerate orally atall and is ketotic . she needs inpatient monitoring . she needs enteral and parentral feeding . Dehyration is corrected  by giving fluids containing sodium . potassium is replaced as there is risk of  hyponatremia and hypokalemia .Use of dextrose containing fluid replacement is associated with worsening of hyponatremia and precipitate wernicks encephalopathy. check BP,Pulse 4-6 hrly, Fluid input and output chart, daily electrolytes and weight every 2-3 days, daily urine for proteins and ketones.Treat vomiting with anti emetics, in severe cases steroides can be given,the use of ondasetron has limited experience.Thiamine is given to prevent wernicks encephalopathy . offer the patient psychological councelling  that it resolves after 16 weeks. take her wishes into consideration if she wants to continue with the pregnancy or go for termination .If she wants to go for termination explain the different methods of first trimester termination .  Once she is recovering allow her to take clear fluids ans subsequent small feeds. there is risk of DvT due to pregnancy, immobility, and dehydration .encourage early mobilisation, adequate hydration and ted stocking and LMWH. The maternal risks are mallory weiss tear,DVT, aspiration ,wernicks encephalopathy,dehydration, electrolyte imbalance and death. fetal risk are not much but risk of fetal growth restriction . There is high recurrance risk in subsequent pregnancies.provide information leaflet and contact details of support group .

Hyperemesis gravidarum complicates 0.1-1 % of pregnancy. My clinical assesment will be on history, examination supplemented by investigations. I will assess her by taking the history of severity of symptoms if she can keep down any fluids or solids, frequency of vomitting in last 24 hours, any blood in vomitus with associated symptoms of dyspepsia, pain in abdomen, diarrhea, burning micturation to narrow down my diagnosis. Any symptoms of vomitting, weight loss, diarrhea, tacchycardia preceeding the pregnancy are suggestive of thyrotoxicosis.

History of hyperemesis in previos pregnancy is suggestive of hyperemesis gravidarum due to its recurrent nature in subsequent pregnancies. History of travel specially if there is diarrhea component to rule out gastroenteritis. Past surgical history as adhesions may cause bowel obstruction.

I will examine to look for signs of dehydration as low pulse volume, tacycardia,low blood pressure & postural hypotension. I will examine mucous membranes of mouth to see any dehydration as well as skin turgity.I will check her weight & corelate with pre pregnancy weight as weight more than 10 loss is marker of severity along with muscle wasting. 

Abdominal examination if fundal height is larger than expected  would point out to either multiple pregnancy or molar pregnancy. If previous ER visits suggest repeated visit for hyperemesis , I would do neurological examination to look for signs of six nerve palsy , nystagmus, ataxia suggestive of wernicks encephalopathy.

Depending on history, full blood count to check for raised white cell count for infection & raised hematocrit as in dehydration. I will check for serum electrolytes including sodium , potassium, serum urea as hyperemesis gravidarum ias associated with hyponatremia, hypokalemia, metabolic hypochloraemic alkalosis. Liver enzymes as raised ALt are assoicted with dehydration as well marker of severity too. Raised T4 along with supressed TSh is suggestive of biochemical hyperthyroidisim due to same alpha subunit between HCG & TSH, However, thyroid antibosies along with history of hyperthyroidism would favour the true thyrotoxicosis.

Urine analysis to check for ketones as aresult of muscle wasting, blood in urine & nitrates positive leukocytes are suggestive of urinary tract infection.Pelvic ultrasound scan to determine gestational age, to diagnose multiple pregnancy & to exclude hydatidiform mole.

If vomitting is not severe enough she can be managed as day case in day case gynecological unit for 24 hrs , otherwise needs admission depending upon clincal circumstances.

Adequate fluid & electrolytes replacement is core component of managment. Hyperemesis is less common but associated with significant morbidity if inadequately & inappropriately treated. Intravenous one litre of normal saline 0.9% along with20-40mmol of KCl 8 hrly should be started along with careful fluid balnce charts. Rapid correction of hyponatremia should be avoided as it causes central pontine myleinolysis which is serious complication charcetrised by spastic quardiparesis, psedobulbar palsy & imapired consciousness.

If woman can tolerate oral thiamine then 25-50 mg thiamine orally TID, if not then Iv thiamine 100 mg diluted in 100 ml saline infused over 30-60 minutes. Thiamine -vitamin B1 is given to prevent Wernick encephalopathy which if not recognised at early stage can cause korsakoff psychosis with recovery rate only 50 %.

Antiemetics should be added as there is substantial evidence of it safety & lack of teratogenicity. Usually first line therapy will be antihistamines such as cyclizine 50 mg po/Im/IV, promethazine or phenothiazines or dopamine antagonist such as metoclopramide & domperidone. more frequent use of metoclopramide is associated with extrapyramidal signs which is reversible with cessation of drug.

If these first line antiemetics does not relive symptoms then ondansteron 5 mg po TID should be initiated as it has proven efficacy for treating chemotherapy induced nause/vomitting with excellent results.

If woman still not respond to all these measures , I would start corticosteroid 25-50 mg in divided doses after discussing with mother benefits of controlling symptoms with subsequent improvement in weight gain , reducing ketosis alongwith improvement in fetus growth, vs risk of masking symptoms of infection . Some women may need corticosteroid  throughout pregnancy as minority of women have hyperemesis throughout the pregnancy. It is challenging & I will use risk benefit analysis along with careful monitoring for checking sugar level.

some severe cases of hyperemesis may need total parenteral nutrition with assoicted risk of infection , jaundice & thrombosis.

Hyperemesis itself is a risk factor for thrombosis due to dehydration & lack of mobility. If woman is obese, severe dehydration, restricted mobilty , iw ill give prophylatic dose of subcutaneous LMWH.

These women need tremendous support & reassurance from nurses & medical staff.

Definitve treatment is termination of pregnancy. These women need osychological support.

 with any impact on her function level

A)Hyperemesis gravidarum is diagnosis of exclusion affects 0.1 to 1% of pregnancies.Detailed history to be elicited including number of  times she has vomited, whether she is able to retain fluids or food is asked for.  Other symptoms like tiredness and feeling of dizziness when she gets up suggests severity of dehydration.Recent hospital admission for similar illness is elicited as woman may require recurrent admissions.Past obstetric history of hyperemesis is elicited as it recurs in 50% of women.History of dysuria  and frequency  asked for as UTI can cause vomiting. History of abdominal pain, diarrhoea , epigastric and right upper quadrant pain point towards GIT causes like Panceatitis ,gallstone and gastritis
       Examination is done to look at  general condition  and assess severity of dehydration by looking at mucous membrane and skin  turgor. Temperature, PR, BP to look for  tachycardia, rhythm of pulse and any evidence of postural hypotension due to dehydration.Thyroid enlargement and icterus to be looked for. Abdominal examination done for  abdominal mass and tenderness to look any  signs of appendicitis, hepatitis.Renal angle tenderness to be checked.
     b) In FBC, PCV is elevated due to dehydration. Urine dipstix for leucocytes, protein , nitrites and MSU for urine and culture to rule out UTI.Urine dipstix for ketonuria is checked as starvation ketosis is common with vomiting. Renal function test with electrolytes to look for electrolyte imbalance and prerenal azotaemia  suggests severity of dehydration and the emergency need for correction of dehydration. LFT  to look for elevated liver enzymes and bilirubin  seen in 50% of woman with hyperemesis. TFT  to look any biochemical hyperthyroidism as this alteration is seen in 60% of woman with severe vomiting.Pelvic USG  is done for location of pregnancy and to  rule out multiple pregnancy and vesicular mole as both can increase  serum beta HCG considered to be  one of the cause of vomiting in pregnancy.Abdominal USG to look for gallstones and renal pelvic calycial dilatation.
                c) If clinical examination shows mild dehydration ,can be managed as outpatient with ante emetics , dietary advice of frequent small  bland diet , avoiding spicy food and hydration. In severe dehydration woman is managed as inpatient with intravenous fluid with normal saline or Hartmann’s solution. Avoid dextrose containing solution  as it worsens Wernicke’s encephalopathy dueto hyponatraemia. Rapid correction of hyponatraemia is avoided as it causes central pontine demyelinolysis.Hypokalaemia is corrected with 40mmol/ l of KCL in IVF.Thiamine 100mgs in 100ml of ivf over 30 -60 mins weekly  as prophylactic measure followed by 25-50mgs tds orally once she tolerates orally to prevent Wernickie’s enchephalopathy.  Woman is advised nil by mouth till she can tolerate orally.Fluid balance chart advised to maintain IVF. Woman is started on  first line ante emetics like domperidone, metoclopromide or promethazine with H2 blockers like ranitidine or proton pump inhibitors. If vomiting does not stop secondline anteemetics like 5 HT antagonist ondansetron  is started. Continous emotional and physical support is provided with  reassurance about vomiting will get subsided slowly as pregnancy advances around 16-20 weeks and safety of medications  used in vomiting.  Thromoprophylaxis with TEDS and LMWH as the risk of VTE is high due to immobility, pregnancy and dehydration. In resistant cases of vomiting woman may be started on prednisolone 30mgs/day or Hydrocortisone  100mgs IV b.d  under specialist guidance.
     In refractory cases enteral (nasojejunal, Gastrostomy) or parenteral nutritional support may be started as last resort. Termination of pregnancy may be offered in intractable case of vomiting, keeping maternal condition in mind after discussing with woman and her partner with involvement of obstetric consultant.  Nonpharmacological measures like ginger, acupressure may be tried. Everyday assess her clinical condition by checking her temperature ,PR,BP and send  serum electrolytes, urine ketones, fluid balance chart to correct fluid and electrolyte imbalance.Her weight has to be checked once in 2 weeks to assess weight gain.  Woman is discharged with discharge medication to continue and a letter to GP for followup  with appointment. Patient information leaflet provided with contact details of EPU if symptom recurs. Woman is provided with support group details like pregnancysick.org.uk.
 

A healthy 30 year old woman has been referred to the emergency clinic by her general practitioner because of severe nausea and vomiting for 24h. Her LMP was 8 weeks ago and she had a positive pregnancy test 4 weeks ago. (a) Discuss your clinical assessment [6 marks]. (b) Justify the investigations you would undertake [4 marks]. (c) Discuss the options for treating idiopathic nausea and vomiting in pregnancy [10 marks]

a:     I Will ask about nature , amount ,colour of vomitings . how many times she vomited to assess the severity of problem. whether vomiting was blood stained, as it may be associated with severe gastritis , peptic ulcer, cirrhosis. associated features may point towards cause. i will ask about urinary frequency , dysuria , burning sensation that point towards Urinary tract infection. ask about diarrhea ,pain abdomen. 

inquire about previous pregnancies , whether she had excessive vomitings in previous pregnancies , it has 50% recurrence rate. i will ask about personal / family history of VTE to assess her risk for thromboembolism . 

i will assess  impairement of QOL due to nausea vomitings.

general physical examination to look for signs of dehydration like dry lips , dry mucous membranes , shunken eyes, reduced skin tugor . BP and pulse should be recorded. abdominal palpation for acute tenderness in right illiac fossa for appendicitis , renal angle tenderness for upper urinary tract infection  , renal abcess , any abdominal/pelvic mass for intestinal obstruction , hepato/splenomegaly for hepatitis.  

b:   she will need blood investigations to exclude other causes of vomitings   . full blood count to  check for anemia , raised wbc will point towards infection . liverfunction tests to exclude hepatitis , lfts may be slightly derranged , renal function tests to exclude renal failure and uremia. serum amylase if there is suspicion about pancreatitis.  serum electrolytes may show hyponatremia and hypokalemia . TFTs to assess thyroid functions , hyperthyroidism can cause nausea and vomitings ,in normal pregnancy TSH will be suppressed due to stimulatory effect of HCG on thyroid .biochemical finding of  metabolic hyperchloreamic alkalosis.

urine routine for detecting leucocytes , albumin, nitrities , rbcs , glucose , urine dipstix to  check for ketonuria. she may need plain X ray abdomen to exclude intestinal obstruction if history and examination indicates. 

usg to check viability of fetus ,  to exclude multiple and molar pregnancy as these cause excessive vomitings and nausea in pregnancy. 

c:   options for treating nausea vomitings in pregnancy depend upon the severity of condition .these options include dietary modifications , oral/i.v medications, non pharmacological options like use of ginger and B6 accupressure . 

dietary modifications like avoidance of provoking stimuli , small frequent meals , avoiding spicy / fatty foods.intake of multivitamins.avoiding drugs with GI side effects like ferrous sulphate.

pharmacological options are antihistamines, pyridoxine , ondansteron , steriods .mild cases can be treated as day cases with redydration and antiemetics.antiemetics are usually continued for 7 days to prevent recurrence.

for moderate to severe cases hospital admission is needed. 

patient should be reassured about the safety of antiemetics as non compliance causes deterioration of condition. anti emetic like cyclizine , metochlopramide , prochloperazine ,   promathazine can be used safely in pregnancy. 50mg cyclizine PO /I.M/ I.V three times a day is effective treatment. other options are metochlopramide 10mg PO/IM/IV three times a day  OR  promathazine 25mg PO . 

i.v rehydration with 0.9 % normal saline is needed , dextrose should be avoided as it can worsens hyponatremia and precipitate Wernicke encephalopathy . it presents as triad of confusion , ataxia and ophthalmoplegia ,it carries mortality rate between 10-15%.

Electrolyte imbalance should be corrected , if hypokalemia 20mmol of potassium chloride can be added to 0.9% normal saline. 

NICE recommends antihistamines should be given  to women if they need/ consider  treatment for nausea vomitings of pregnancy. 

pyridoxine 40mg per day is also found to be effective  treatment . pyridoxine in combination with doxylamine  ( antihistamine ) is effective and safe treatment . 

thiamine 50mg three times or 100mg in 100ml of normal saline once weekly should be given in moderate to severe cases. 

depending upon risk factors she may need TED stocking and  low molecular weight heparin . pregnancy itself carries risk for VTE , If complicated by dehydration and immobility risk increases further . 

refractory cases not responding to conventional antiemetic will reqiure further investigation about cause and may need steriods.

women with severe nausea vomitings may consider / request for termination of pregnancy. 

a)

Given  in the history that she is 2 months pregnant , need to rule out other medical and surgical causes for which I will take detail history . Her symptoms,  their onset , severity, duration  and associated pain in abdomen  as lower abdominal pain   may suggest UTI(if associated with dysuria)or appendicitis and upper abdominal pain  may be due to   pancreatitis or cholecystitis  or peptic ulcer, associated diarrhoea may indicate acute gastroenteritis . Any associated abnormal bleeding  with shoulder tip pain  and history of dizziness suggest ectopic pregnancy if her cycles irregular , bleeding per vagina with passage of grapes like vesicles may suggest molar pregnancy .History of loss of weight, anxiety , palpitation with eye signs may point towards thyrotoxicosis. History  of intake of alcohol and drug misuse to be taken  as it may cause vomiting.History of fever and  yellowish discolouration of skin and urine may  suggests hepatitis .

In examination I will check her weight  loss, will  check her vitals(pulse, B. P., temperature,)  and  look for clinical signs of dehydration like dry tongue ,dry skin and tachycardia. I will look for icterus and pallor. In Per abdominal examination , tenderness in epigastrium / hypochondrium /hypogastrium and  bilateral  lumber and  iliac fossa to be noted to exclude surgical cause  of cholecystitis, pancreatitis, UTI, appendicitis. Any rebound tenderness may indicate features of peritonitis should be meticulously  noted.any abnormal bleeding to be noted and vaginal examination  to  be done to know the size of uterus and any adnexal mass or adnexal tenderness.

B) FBC to be done to know  WBC count and hematocrit which may show infection and hemo-concentration. Urine analyses  to know ketones and UTI  and MSU for urine culture if she has UTI.LFT  to assess raised enzymes(transaminases) and biluribin in case of hepatitis and RFT to know  If any  electrolyte imbalance( hyponatremia , hypokalemia).Fluid balance chart should be made to know her hydration status.If signs of hyperthyroidism need to send Free t3 t4 and TSH antibodies. Ultrasound(TVS) to be done to know intrauterine  pregnancy and to rule out molar or ectopic pregnancy.Abdominal ultrasound done to find out any surgical cause.

c)The  woman is advised  to take small frequent meals . If  she is unable to maintain adequate  hydration  and is  ketotic, hospital admission is required. She may be told to stop oral feeding until she improves. The first line treatment is  rehydration with  intravenous normal saline or Hartman’s solution with potassium chloride 20-40 mmol q8 hourly or as required. Dextrose solution  should be avoided  as it may aggravate hyponatremia and precipitate wernicke’s encephalopathy.Antiemetics  such as antihistaminics ,phenothiazines or dopamine antagonist (metoclopramide) can be safely given . Adverse effecs include drowsiness and rarely extrapyramidal effects. Pyridoxine(vit. B6) appears to be more effective in reducing the severity of  nausea .Thiamine 1oomg is given intravenously  and repeated weekly for prevention of wernicke’s encephalopathy. These are safe and no evidence of teratogenicity  reported.

 Emotional support needs to be provided and and reassurance to be given that there will be gradual improvement after  first  trimester . Any underlying  psychological  problems  may need to be addressed.Thromboprophylaxis is needed for prolonged immobilization and dehydration. Ondansterone, a serotonin antagonist , is effective but safety data are still being collected so routinely it is not recommended in pregnancy.In refractory cases  corticosteroids appear to be effective. Long-term treatment is rarely required and then screening for UTI and gestational diabetes is required.

In severe  cases parenteral nutrition is required . In the last termination of pregnancy is the resort. It is difficult to predict recurrence in subsequent pregnancies as some may suffer in subsrquent pregnancies..

(A)

Iwould ask about the frequency of vomiting and the ability to retain oral fluids to assess severity of condition . history of medical disaeses should be considered as some medical diseases may be associated with vomiting e.g peptic ulcer , diabetes , cholelithiasis and migraine .history of hyperemesis in previous pregnancy as the the risk of recurrence is about 50% . ask about abdominal pain .abdominal pain is not a prominent feature of hyper-emesis and pain that precede or out of proportion to nausea and vomiting may suggest an intra-abdominal or retroperitoneal cause ( e.g GIT or renal cause ) . ask about neurologic symptoms as diplopia and ataxia as these symptoms are suggestive of neurologic complications e.g wrenickes encephalopathy .ask about urinary manifestations e.g dysuria , frequency and suprapubic pain as UTI may be a cause of vomiting in pregnancy .

During examination , check skin turgor and examine oral mucous membranes for signs of dehydration . check vital signs – the presence of fever may ssuggest an infection as the cause of vomiting . tachycardia and hypotension are signs of dehydration . abdominal examination for tenderness .

(B)

Investigations should include FBC as it may detect anaemia , increased WBC in case of infection or increased haematocrit in case of dehydration . urinalysis as increased specific gravity indicates dehydration and ketonuria indicates starvation . send mid-stream urine sample to exclude UTI as a cause of vomiting in pregnancy .urea and electrolytes as hypocalemia , hyponatraemia and low serum urea are common .liver function test as liver enzymes are abnormal in about 50% of cases . abnormal liver function may indicate primary hepatitis , but enzymes in this case is much higher ( often thousands ) .chech thyroid function test as they are commonly abnormal . abnormality is transient , does not require treatment and resolve after improvement of hyper-emesis . ultrasound  for assessment of gestational age and viability as well as exclusion of molar pregnancy and twin pregnancy as these two conditions are associated with increased vomiting in pregnancy .

(C)

Nausea and vomiting in pregnancy varies in severity from mild , intermittent vomiting ( morning sickness ) to severe , intractable vomiting ( hyper-emesis )

In mild conditions , the patient is advised to eat frequent small meals rich in simple carbohydrates ( e.g toast , crackers ) , drink plenty of fluids to keep hydrated and avoid alcohol and fatty meals . if these measures are unsucceful , then antiemetics as promethasine or metoclopromide should be considered .

In severe cases , the patient should be admitted . assessment include daily assessment of hydration status , urine sample for ketonuria and blood sample for electrolytes . intravenous fluid includes 1 litre of normal saline plus 20-40 mmol kcl every 8 hours . avoid dextrose containg fluids as this may precipitate wrenickes encephalopathy . antiemetic therapy starting with vitamin B6 with or without antihistamis e.g promethazine . if still vomiting , metoclopromide may be added . in severe , intractable cases , ondanestron or methylpredinisolone could be given .

Thiamine should be given to any woman with prolonged vomiting to prevent wrenickes encephalopathy

In severe , intractable cases , entral nutrition or total parental nutrition may be required . entral nutrition needs tube e.g nasogastric or nasoduodenal which is difficult to place and frequently declined by patients . total parental nutrition has the risk of sepsis and thrombophlebitis

In severe , intractable cases , unresponsive to previous treatment and associated with deterioration of patient condition , termination of pregnancy may be offered sensitively 

Nausea and vomiting is experienced by 80% of pregnant women to some degree, and 30% experience severe form. 0.3-1% women require hospital admission for rehydration nad correction of electrolyte  imbalance.

• Clinical assessment

Nausea and vomiting in pregnancy is a diagnosis of exclusion , hence assess the risk factors like-parity more in primiparous and is multip ask if she experienced previous pregnancy  and severity- as 50% chances of reccurence, assess the frequency and tolerance of food and fluid.

 Inquire its effect on the QOL .

Ask for symptoms of UTI , Hepatitis, pancreatitis, Gastroenteritis, appendicitis,

Any associated medical conditions-Hyperthyroidism, Diabetius,SLE.

Ask for hemoptysis, hematimesis-peptic ulcer.

Ask about her loss of weight.

On examination- Temperature- febrile if infective cause

BP-hypotensive , Pulse-tachycardic , capillary filling time-perfusion

Assess dehydration from mucosa and skin tugor.

Per abdomen- epigastric tenderness-peptic ulcer , mallory weiss tears

Acute abomen to be ruled out-pancreatitis, appendicitis, cystitis and pylonephritis.

Check on the baseline weight on admission

• Investigations- ward –dipstick urine analysis- nitrites, leucocytes, protein, blood, ketones-hydration, R/o –UTI

MSSU

Bloods-FBC- HCT- increased, PCV increased, WCC for infection

RFTs- electrolyte imbalance,

LFTs-hepatic cause, Amylase- pancreatitis.

TFTs – hyperthyroidism.

USS- exclude multiple pregnancy or molar pregnancy.

• Treatment

Admit, NBM till can tolerate clear fluids, rehydrate and correct the electrolyte imbalance ( hypokalemia)

Avoid the dextrose infusions and it will worsen hyponatraemia  and lead to wernike’s encephalopathy.

 Rapid correction of hyponatremia should be avoided as it causes central pontine myleinolysis which is serious complications. 

Consider antimetics-parenteral till able to tolerate orally

Cyclizine, prochloperzine, promethazine, metoclopramide and domperidone.

Oral promethazine or cyclizine are licensed anti-emetics in UK

Benedictine(doxylamine 10mg+ pyridoxine 10mg) four times a day has been recently considered as a first line treatment by NICE guidelines. 

Second line –Ondansetron can be considered in severe cases.

In refractory cases – can consider- steroids prednisolone or hydrocortisone following a consultant review. Have to be weaned of after 2-4 wks.

Also since women will be in bed – consider Thromboprohylaxis and compression stockings-(TEDs stockings)-prone for VTE.

Thiamine to prevent wernicke’s encephalopathy

Dietary advise- avoid spicy foods, have snack meals x6 ,

Non pharmacological treatments-ginger, and P6 accupuncture-moderate cases.

Monitoring-

P/BP check,

I/O chart  for fluid balance,

Daily ketones, u&es

Weight  twice weekly

Councelling- provide emotional support. Advise will resolve by 16wks.

In severe cases- will have to consider-NG tube for parenteral feeding and referral to dietician if significant loss of weight more than 2kgs since admission.

If untreatable and some patients may request TOP, or can recommend TOP.

Advise will reccur in subsequent pregnancies, early prescription of  doxylamine pyridoxine combination prevents nausea and vomiting in pregnancy from being severe form.

a)  I will assess the severity of vomiting by asking regarding the frequency and nature of the vomitus.  I will also exclude other causes of vomiting. Questions pertaining to gastrointestinal symptoms such as diarrhoea, severe epigastric pain radiating to the back may be caused by pancreatitis.  Other genitourinary symptoms such as loin pain, fever, dysuria or frequency of micturation will point towards urinary tract infection.  I will also assess the impact of her condition towards her quality of life.

The degree of dehydration will be assessed by examining the mucous membrane, capillary refill time, skin tugour, pulse rate and also blood pressure to look for postural hypotension.

I will establish intravenous line for fluid resuscitation depending on the degree of hydration.  This woman will also need an admission to the ward.

b)  I will send her blood for a full blood count, urea and electrolytes and liver function test.  In severe nausea and vomiting I would expect the electrolytes to be deranged (hyponatraemia or hypokalaemia).  Liver enzymes can also be slightly raised.  However,  hepatitis need to be excluded.  If there is clinical suspicion of pancreatitis I will send for a serum amylase.  A thyroid function test can be sent if there is clinical suspicion of thyrotoxicosis. Urine should also be sent for microscopy and dipstick to detect leucocytes, nitrites, protein and ketones.  An ultrasound will be helpful to exclude molar and multiple pregnancy.

c)  The most important step in managing this woman is to re hydrate and correct the electrolyte imbalance.  I will avoid the use of dextrose solution as it may worsen hyponatraemia and can precipitate Wernicke's encaphalopathy.  Anti emetics such as metoclopromide will be helpful.  Non pharmacological approach such as ginger or acupressure can also be offered.

Keeping the woman fasted then to encourage sips of clear fluid will be helpful. I will advise her to avoid spicy and greasy food and to take small but regular meals.  In cases of severe nausea and vomiting I would consider parenteral or enteral nutrition.  I would also consider thiamine therapy to prevent Wernicke's encephalopathy.

The risk of venous thromboembolism is high especially with dehydration and immobility and therefore I would consider low molecular weight heparin and thromboembolic deterrant stockings.

In the woman is not responding to these therapies I would consider oral prednisolone or intravenous hydrocortisone.

Continous emotional support to the woman and family is important.  I will reassure the woman and her family that this condition will normally resolve by 16-18 weeks.  This condition is not usually associated with poor pregnancy outcome.  However in very severe cases termination of pregnancy may be recommended.  A written information must also be provided to the woman

A)

Regarding clinical assessment,I will take detalied history of the complaint to assess the severity of the condition.i will ask about duration,frequency,relation to meals,amount ,any provoking or relieving factors. I will ask about other symptoms as diarrhea, constipatio n,abdominal pain,frequency, or dysuria to exclude other gastrointestinal or genitourinary causes of vomiting.i would also explore the effect of this condition on herQol.

On examintation,I will assess general condition by checking blood pressure,pulse and temperature.iwill also assess dehydration by examining skin turgors and mucous memberanes. Abdominal examination would be done to exclude any abdominal masses or tenderness.

B)

I will do FBCto exclude anaemia,WBC count for infection, and HCT to exclude hemoconcentration which may point to dehydration. Urine dipstix also should be done for leucocytes,protein,nitrites, and ketons to exclude urinary tract infection. LFT may be elevated which would neccessate exclusion of hepatitis.amylase testing should be done if there doubt about pancreatitis as possible cause for vomiting.U&E to correct any electrolyte imbalance.USS to exclude multiplie pregnancy or molar pregnncy.TFT to exclude hyperthroidism whoever TSH is low in normal first trimester pregnancy.

C)

Regarding treatments, I will start with rehydration and correction of hypokalaemia.antiemetic drugs asmetoclopramide or cyclizine can be used as first line drug treatment.ondansetron can be used as second line treatmentscorticosteroids are effective as oral predinsolone or intravenous hydrocortisone but shoud be given under specialist supervision.

regarding dietary management,NBM initially then clear oral fluid .thiamine should be given to guard against wernicks encephalopathy.if vomiting is sevre, parentral nutrition may be required.

as there is increased risk of VTE duo to pregnancy, dehydration, and immbolity, prophylaxis against VTE should be offered with TEDS and LMWH

mointoring of BP and pulse every 4-6 hours. Daily urine dipstix for ketones.fluid chart to assess urine input and output.If vomiting persists,dailyU&E should be done.also twice weekly assessment of weight gain.

Dietary advice should be given to thae patient to avoid spicy food and small regular meals.GIT irritating drugs as ferrous sulphate should be also avoided.

Reassurance and emotional support with counselling that nausea and vomiting usually spotinously  resolve by 16-20 weeks and not usually assocciateed with adverse pregnancy outcome. Wishes of the patient should be explored as some patient may requireTOP which can be recommended in very severe cases of vomiting.

Hyperemisis gravidarum is a diagnosis of exclusion. I will take clinical history to exclude urinary tract infection(urgency,frequency,dysuria,loin pain) and gastrointestinal conditions as gastro enteritis and acute appendicitis. Presence of abdominal pain suggests other condition.

I will take history to assess severity of the condition as frequency of vomiting, ability to tolerate oral fluids or food , and weight loss.

I will do clinical examination.Pyrexia suggests infection. Will assess the severity of the condition by the level of dehydration where I would find dryness of mouth, tachycardia and postural hypotension. Abdominal tenderness or mass suggests intra abdominal pathology. Renal angle tenderness suggests renal cause.

　

B) Will do Urine dipstix for evidence of infection (nitritis). Also presence of ketonuria point to severe condition.If evidence of urinary tract infection will do urine culture and sensitivity.Will do FBC & CRP to exclude infection. Will do Urea and electrolytis for renal function ans to see if there is hypokalemia which point to severe condition.Will do liver function tests as they can be abnormal in severe conditions. Will do ultrasound to exclude multiple pregnancy or molar pregnancy.

　

C) Mild cases are managed as out patient. She is assured that this associated with pregnancy and will disappear within the next 3 weeks. Will give dietary advice to spread food intake over 6 small meals. Ginger is good for nausea.Will give oral thiamine and if still symptomatic will start oral antiemitics as chloropropamide after discussing its side effects as drowsness and involuntary movements.

In severe cases prompt treatment is required to prevent severe dehydration,electrolyte imbalance and complictions of thiamin deficiency as Wernikes encephalopathy. I will admit the patient. Will put wide IV line and rehydrate the patient and correct electrolyte imbalance. Will commence IV anti emetics as chloroprpamide and if no response Ondansterone .Will give IV Thiamine. Will keep nil by mouth initially and gradually introduce fluids.

Iwill monitor weight and electrolytes.I will take measures for thromboprophylaxis. I will give emotional support and dietary advice as in previously discussed.In rare cases Total parentral nutrition may be of value and also termination of pregnancy may be life saving 

A)i will take detailed history about this episode of nausea and vomiting .if this is the first attack of sever nausea &vomiting or has happened before in this pregnancy.if the vomitus associated with bleeding.i will take detalied history about causes of nausea and vomiting . GIT symptoms like diarrhea or stool and abdominal pain.urinary symptoms of UTI like loin pain, rigors ,dysuria, and frequency.Any changes in the colour of the stool or urine .i will take her past obstetric history about diagnosis and treatment of hyperemessis gravidarum in previous pregnancies as risk of recurrence reach up to 50%..iwill ask about complications of sever vomiting like wernichs encephalopthy  such as diplopia and dizness.i will ask if the vomitus associated with bleeding to suspect Mallory wiess syndrome.i will ask her about the medication that she has taken to decrease the nausea and vomiting or tonics contains iron.

i will assess risk of the TED again as dehydration increase risk of it.

Then i will do examination .i will measure her weight now.Then calculate the difference between it and booking weight.loss of up to 20% of weight help in the diagnosis of hyperemisis gravidarum. iwill measure her bp and pulse to assess severity of the vomiting.i will check the jaundice.Abdominal examintion to check renal angle tenderness. 

B) I will make investigation to identify any causes for nausea and vomiting,and to assess severity of it.

thyroid function test as thyrotoxicois is presented by sever nausea and vomiting.liver function test as hyperemesis associated with elevation of ALT and AST .urine analysis and mid stream urine culture (MSU) for presence of  nitrates ,protine and pus cells. check specific gravity and to check prescence of ketone bodies.urea and electrolytes such as prescence of hyponatremia,hypercalcemia and hypocalmia.ABG to detect metabolic alkalosis.abdominal u/s for liver disease.

i will make u/s to check viability, multiple pregnancy or presence of vesicular mole.

C)  The patient will be hospitalized.  with psycological support.

she will have supportive treatment in the form of iv fluidslike saline solution or hartman soultion,but avoide use of dextrose as it may participate wernicks encephalopthy.if she can not toleartes foods so total parental nutrition.then gradually introduce liquid fluid . medications to decrease nausea and vomiting such as Antiemetics all have same effects .dopamine antagonist  such as metocopromide 10 mg po,IM.IV or PR TDs.nti histamine antagonist such as cyclizine.

Assurance is the very important step in the treatment   of hyperemesis gravidarum.The patient should be reassured that improving of nausea and vomiting usually occure on 16-20 wks . 

To give thiamineIf there are thiamine dificency.

Thromboprophylaxis according to risk factors for her ,as brd rest and dehydration increase risk of TED.

In cases of refractory cases we can give prednisolne PO  40-50mg/d in divided dose or hydrocortisone 100mg bid.

in life threatning condition termination of pregnancy should be offered and discussed with the patient.

 i

 ESSAY 274

A)  Regarding her obstetric history ask about outcomes and nausea/vomiting in prior pregnancies as hypremesis gravidarum recurs in 50% of pregnancies. Regarding severity of vomiting ask her to rate severity on a number scale. Ask about the frequency of vomiting episodes and whether she is able to tolerate oral intake. Ask about decreased urine output and dark concentrated urine as  these signs indicate dehydration. Regarding gastrointestinal causes of nausea and vomiting ask about diarrhea, constipation and abdominal pain. Regarding urinary causes, ask about urinary frequency, dysuria and haematuria. Ask about the effect of nausea and vomiting on her quality of life (QOL). On examination, look for signs of dehydration which include decreased skin turgor and dry mucous membranes. Assess her pulse rate and blood pressure because tachycardia and hypotension suggest dehydration/hypovolaemia. Assess for postural hypotension as this indicates hypovolaemia/dehydration. Measure her weight and use this value as a baseline because weight loss indicates worsening of her condition. Calculate her BMI because a BMI>30kg/m2 increases her risk of VTE. Perform an abdominal examination for masses and tenderness. Elicit renal angle tenderness which suggests a UTI.

B)  Regarding investigations, perform a urine dipstick looking for haematuria, leucocytes and proteinuria which would suggest a UTI. Ketonuria indicates starvation and resolution indicates improvement of her condition. Regarding blood investigations, perform a CBC looking for leucocytosis which indicates an infection. Look for an elevated haematocrit which indicates dehydration. Perform liver function tests looking for elevated liver enzymes which may be seen with hepatitis. Recognise that liver enzymes may be mildly elevated with idiopathic vomiting in pregnancy.  Perform renal function tests looking for elevated creatinine which suggests dehydration and for electrolyte abnormalities like hypokalaemia, which indicate severe vomiting. Hypokalaemia is an indication for potassium replacement. Perform a thyroid function test as hyperthyroidism is associated with vomiting in pregnancy. Recognize that in the first trimester TSH levels may be physiologically depressed and may not indicate hyperthyroidism. Perform serum amylase because elevated values indicate pancreatitis. Perform a pelvic ultrasound looking for a molar or multiple gestation as these conditions are associated with hyperemesis gravidarum.

C)  Regarding treatment options, this depends on the severity of vomiting, its impact on her quality of life and the patient’s preference. Expectant management may be appropriate for very mild cases with infrequent nausea and vomiting and minimal impact on her quality of life. Pharmaceutical therapy with anti-emetics may improve nausea and decrease frequency of vomiting. Oral anti-emetics include metochlopramide, dimenhydrinate, prochlorperazine, cyclizine and domeperidone.  Oral H2 antogonists such as ranitidine or PPI’s like omeprazole may be given to reduce symptoms of esophageal reflux. Advise that these agents are safe in pregnancy and are not teratogenic. Advise that improvement may be seen with wrist (P6) acupressure and ginger. Dietary advice includes avoidance of spicy/oily foods and reduction of  meal portions. Advise her to discontinue any medication that has GI side effects such as oral iron supplements. Severe nausea and vomiting requires inpatient management. The patient is kept fasted or advised to have only clear fluids orally until vomiting is improved. Her pulse rate and blood pressure are monitored 4-6 hourly. Her weight should be measured twice weekly as weight loss indicates worsening and weight gain indicates improvement. Her urine should be checked for ketones daily as resolution indicates improvement. Monitor adequacy of fluid replacement with fluid balance charts. Administer intravenous fluids using either normal saline or lactated ringers. Avoid dextrose solutions because this may worsen hyponatraemia and precipitate Werneckie’s encephalopathy. Supplement intravenous fluids with 20-40meq/L of potassium to avoid hypokalaemia and thiamine to avoid Werneckie’s encephalopathy. Administer first line anti-emetics intravenously. These include metochlopramide and dimenhydrinate. Second line anti-emetics include Ondansetron. Consider use of corticosteroids if no improvement with first and second line anti-emetics. Use corticosteroids under specialist supervision.  Administer intravenous H2 antagonists or PPI’s to avoid symptoms of esophageal reflux. Ensure good hydration, encourage mobilization and advise TED stockings to provide thromboprophylaxis. Administer prophylactic LMWH if deemed high risk for VTE. Provide counseling and reassure her that nausea and vomiting usually improves between weeks 16 and 20 of pregnancy and is not indicative of pregnancy outcome. If nausea and vomiting are very severe with no response to treatment offer enteral or total parenteral nutrition. Offer termination of pregnancy to secure maternal well being. Discharge when better with written information about hyperemesis gravidarum and offer follow up appointments.   

 (b) Ketouria or UTI is excluded by urine dipstick. I would perform Urea and Electrolytes and full blood count looking for any hyponatraemia,hypokalaemia and high hametocrit which can occur  in excessive vomiting and dehydration. I would also order Liver function tests with amylase  and thyroid function tests. Liver transaminases and thyroid tests might be abnormal in severe vomiting but this settles down with hydration. If T4 and t3 are high and TSH are low ,then we need to perform thyroid antibodies to exclude graves disease. I would urgently request a transvaginal scan to exclude any adnexal masses (ectopic), molar pregnancy or multiple pregnancy,as well as confirming fetal viability. If suspecting upper Gastrointestinal disease (as above) I would also perfrom upper abdominal US looking for gall stones,liver pathology.

(c) I would admit to the gynae ward for daily observations and rehydration. If vomiting is severe, we could keep nil my mouth for a few hours. Rehydrate with hartmans solution or normal saline slowly to prevent central pontine myelolysis (if hyponatraemia exists),add 20 mmol of potassium chlodide. I would advice TEDstockings and LMWH prophylaxis as pt is at risk of VTE (dehydration and pregnancy). I would give thiamine supplement to prevent wernickes encephalopathy and antiemetics such as cycline or metoclopromide as a first line. I would check daily U+E and ketonuria so fluid replacement is done more accurately. I would advice on diet- small,frequent meals with no greasy ,spicy food.Avoid citrus fruit. Prefer isotonic drinks to prevent ketosis. Reassurance is needed (if intrauterine pregncny) that severe vomiting rarely affects pregnancy outcome and this usually resolves by latest 16-17 weeks of gestation ,although this does vary in individuals. Offer psychological support and enquire who is at home for support. Aim home when pt able to tolerate small snacks and fluids and has home support. Warn that despite all the above pt might need to still come to to hospital for IV hydration. On discharge we also need to advice the importance of continuing the antiemetics and frequent small sips of fluid.

(a)I would assess the severity of the condition by history taking (any weight loss,onset of vomiting,last time meal was kept down) and examining any signs of dehydration.These are tachycardia,dry tongue,sunken eyes,dry skin. Surgical causes of N+V need to be excluded which are ectopic pregnancy(since pt never had a scan previously in this pregnancy,ectopic is a possibility),appendicitis,cholecystitis. In these cases associated abdominal pain is pronounced and PV bleed occasionally. Examining the patient I would look for peritonitic abdomen(guarding,rebound tenderness,adnexal tenderness if ectopic),shoulder tip pain. Medical causes also need to be excluded such as hyperthyroidism (thyrotoxicosis),diabetes,hepatitis,pancreatitis,peptic ulcer (excluding Mallory weis tear from excessive vomiting)urinary tract infection or pyelonephritis.in the history taking I would then ask about pre-existing hyperthyroidism or any autoimmune diseases,any history of jaundice(hepatitis,gallstones obstructed cholecystitis) haemoptysis(peptic ulcer or Mallory weis tear),fever(UTI),history of hepatitis,drug iv abuse,excessive alchohol ingestion. The other differentials we shouldn’t forget are the possibility of a multiple pregnancy which is higher chance in assisted reproduction – I would enquire in the history and also molar pregnancy which I would also ask if there is any history of. In my examination I would take vital signs looking for tachycardia,hypotension,temperature, oxygen saturation. I would examine mental status excluding wernickes encephalopathy which occurs in severe hyperemesis and B1 deficiency. I would also examine for goitre,any exompthalmos and resting tremor to excude clinically hyperthyroidism

I'd take a history to assess the severity of her condition,that'd include whether she is able to eat and drink at all,the frequency of nausea and vomiiting, any blood or bile in the vomit,the medicines that she has taken before for this, any history of twins or molar pregnancy in past, any history of thyroid dysfunction. On examination, i'd check her hydration status by seeing her toungue( if dry, suggents dehydration), routine Pulse, BP ,RR. On abdominal examination i'd palpate to rule out uterus large for dates ( rule out multiple gestation, or H mole) as thats associated with severe Nausea/vomitting .

i'll take blood tests for serum electrolytes to find out any imbalance due to her vomitting, urine test for ketones as starvation ketosis is easily set in because of not able to eat . routine FBC,U & E,LFT,Uninanalysis for  rule out infection, UTI. If history suggests, then serum ultra TSH. I'll arrange a ultrasound scan if indicated by abdominal examination. Serum thiamine level if clinically indicated.

To treat idiopathic nausea vomitting in pregnancy the options are dietary advice like eating small frequent meals, try food that doesnt trigger N/V like dry toast early in morning even before brushing teeth. Antiemetics like cyclizine,promethazine, stemetil are all sefe in pregnancy. Even ondansetron has been said to be safe, esp in severe N/V . Mostly can be managed on an outpatient basis. Reassurance that most women have nausea / vomitting in pregnancy. If severe, will need admission , IVfluids - hartmanns 3 -4 litres for 24 hours,each over 3-4 hours.I'll avoid dextrose containing fluids as can precipitate Wernicke's encephalopathy.pregnancy. Thiamine orally/Iv  to prevent Wernike's encephalopathy.Monitor electrolytes and correct any deficiencies.Antiemetics, monitor symptomatically and check urine ketones daily. Avoid rapid correction of Na deficiency as can precipitate pontine myelinosis.

a) I would take a detailed history to illicit how long the nausea and vomiting has been going on for and to work out whether she has been able to tolerate and diet or fluids in the last 24 hours. I will also take a complete medical and surgical history to rule out other differentials including diabetic ketoacidosis and appendicitis. I will assess her mood and ask how this nausea and vomiting is affecting her life as it can be a very difficult time for her and is associated with depressive illness. I would reassure her that although nausea and vomiting is very debilitating in pregnancy, it is unfortunately very common and usually resolves at 16-20 weeks gestation.

I would carry out an examination looking for signs of dehydration including tachycardia, hypotension, dry mucus membranes and concentrated urine. I would weigh her as if she has lost more than 5% of her prepregnancy weight she may have hyperemesis gravidarum which is associated with a poorer pregnancy outcome. I will carry out an abdominal examination to assess whether her uterine size correlates with her dates as if it is a molar pregnancy she could have worse nausea and vomiting in pregnancy and a uterus which palpated large for dates. I would also assess for signs and symptoms of hyperthyroidism which could present at this gestation as the human chorionic gonadotrophin hormone (hCG) is similar to thyroid stimulating hormone and rises in hCG  can cause transient hyperthyroidism. I would also commence a fluid input and output chart to monitor her fluid balance.

b) I would undertake a urine dipstick to assess for the presence of ketonuria which is likely if she has sever nausea and vomiting, if there was also glycosuria I would consider diabetic ketoacidosis as this is an important differential to exclude. I would also send off a mid stream urine sample for culture and sensitivity to exclude a urinary tract infection. I would organise an ultrasound scan to accurately date the pregnancy and exclude twin or molar pregnancy which has higher levels of nausea and vomiting in pregnancy. I would do her weight and calculate BMI as this is a sign of severity of nausea and vomiting and BMI will be important to calculate her risk of thromboembolism if she is admitted as seh may require thromboprophylaxis. I will carry out blood tests looking at the full blood count which may show a raised haematocrit, urea and electrolytes which may show hyponatraemia, hypokalaemia and raised serum urea in severe cases. The hypokalaemia will also be important to assist us with appropriate fluid relacement, if the potassium was under 3 I would also test the magnesium levels. I would do liver function tests which may show mildly elevated transaminases and also raised bilirubin and I would consider doing thyroid function tests depending on her signs and symptoms as this may show a normal or raised T3 and T4 with low thyroid stimulating hormone if she has transient hyperthyroidism associated with raised hCG.

c) I would consider both non pharmacological and pharmacological treatments for nausea and vomiting in pregnancy. For the non pharmacological methods I would advise bed rest, light diet - eating small amounts little and often. I would also advise a diet which was high in carbohydrates and low in fat  which she should find easier to tolerate. I would explain there has been some studies which have shown improvements with ginger either biscuits or tablets and she can try ginger buscuits or light diet 20 minutes before getting out of bed in the morning to try and keep ood down. I would also advise her she could try wrist acupuncture. I would get a dietician involved early on the management for advice and support. If she needed admission for fluid replacements and antiemetics I would manage her initially with Hartmanns IV fluids with likely potassium replacement depending on her blood tests and her diet and fluid tolerance. I would avoid using dextrose fluids as this can precipitate an oculogyric crisis. With regards to pharmacological measures I would use prochlorperazine (12.5mg IM or 5-10mg PO/PR TDS) or cyclizine (50mg PO/IV/IM TDS) as first line antiemetics, if these did not work or if she needed additional antiemetics I would use ondansetron (4-8mg IV or 8mg PO 12 hourly) or metoclopramide (10mg TDS PO/IM) as second line. I would also consider a vitamin supplement of thiamine 50mg TDS PO to prevent Werniche's encephalopathy, if she could not tolerate this orally I would consider IV pabrinex. If she was still not tolerating diet and fluids I would consider adding in a couse of steroids starting with hydrocortisone 100mg BD followed by prednisolone 20mg BD for a 7 day course in total. As a last resort and with close consultation with both the dietician and obstetric consultant I would consider total parenteral nutrition. Whilst the patient was admitted and also as an outpatient depending on her risk factors I would advise her to mobile and stay adequately hydrated if possible, to wear thromboembolic stockings and I would consider SC clexane for thromboprophylaxis.

Q. A healthy 30 year old woman has been referred to the emergency clinic by her GP because of severe nausea and vomiting for 24 hours .Her LMP was 8 weeks ago and she had appositive pregnancy test 4 weeks ago.

a. Discuss your clinical assessment?

The patient has come with the complaints of severe nausea and vomiting for the past 24 hours .I would take  history of previous episodes if any and treatment  given .I would also enquire about pain abdomen to  exclude  cholecystitis  and appendicitis which are associated with nausea and vomiting and pain in the upper  right  and right iliac fossa  respectively.

I would also enquire about urinary symptoms and fever to exclude pyelonephritis .History of bowel symptoms should also be taken to exclude gastroenteritis. I would also enquire about the urinary output.

Previous  history of thyroid  disorders ,diabetes mellitus and molar pregnancy needs to be ascertained.

I would examine her to assess the severity of symptoms and exclude other diagnosis. The examination would include assessment of the tongue and skin to assess dehydration status, pulse for tachycardia, BP and weight of the woman. I would also palpate the abdomen to elicit tenderness in the right hypochondrium and  Mcburney’s point to exclude  cholecystitis  and appendicitis respectively. I would also look for renal angle tenderness and undue uterine enlargement which may be a feature of hydatidiform mole.

b. Justify the investigations you would undertake?

I would ask for  a  Full blood count for leucocytosis  ,Urea and electrolytes ,Liver function tests and thyroid function tests.

Severe vomiting  is associated with electrolyte imbalance in the form of hypokalaemia and hyponatraemia  and altered liver function tests and Thyroid function tests. An MSU would be arranged to exclude urinary infection. An ultrasound would be arranged to exclude multiple pregnancy and molar pregnancy besides pregnancy viability and gestational age.

C. Discuss  the  options  of treating  idiopathic  nausea  and vomiting in pregnancy?

Women with severe  vomiting would need in patient management initially for correction of fluid and electrolyte imbalance. A500 ml Normal  saline  drip containing 20-40mmolof KCL would be commenced 8 hourly till she is able to tolerate oral feeds Thiamine 100mg in 100ml of normal saline is given weekly to prevent wernicke’s encephalopathy. Antiemetics used IM/IV include cyclizine 50 mg or metoclopomide 10 mg QID. IV antacids are recommended too.She should also be supported as psychological upset is often present in thes patients.

In the absence of severe symptoms oral  antihistaminics are recommended  such as doxylamine, promethazine, cyclizine. The role of pyridoxine in preventing nausea is established and  upto 40 mg can be used without concern regarding fetal effects.

Dietary advice and support plays an important role in the management of this condition.

KINDLY SEE THE EVIDENCE AND REFERRENCES FOR MY ANSWER :

ACOG : The following recommendations for the prevention and treatment of nausea and vomiting of pregnancy are based on consistent scientific evidence:

• Taking a multivitamin at the time of conception may decrease the severity of symptoms.
• Taking Vitamin B6 or Vitamin B6 plus doxylamine (an antihistamine) is safe and effective and should be considered a first-line treatment.

OGRM :  MARCH2011 :  Management: a protocol for management of hyperemesis is given in Table 2. It is important to give the patient adequate reassurance as to the safety of anti-emetics in pregnancy as poor compliance is a major reason for failure of treatment. Mild cases can be managed as day cases giving intravenous rehydration and anti-emetics

PLEASE CHECK , NO MARK GIVEN TO ME FOR ( CORRECTION OF ELECTROLYTE IMBALANCE ) , AS GIVEN TO OTHERS.