Hyperemesis Gravidarum

00:01 So now let's discuss Hyperemesis Gravidarum.

00:05 Let's start with a case.

00:08 A 25 year old Gravida 1 Para 0 female at 8 weeks gestation presents to the emergency room with complaint of nausea vomiting.

00:17 She says she is unable to keep anything down.

00:20 She reports a 10 pound weight loss throughout the pregnancy.

00:24 On physical exam she appears dehydrated.

00:27 Vital signs are stable and she is afebrile.

00:30 Her basic metabolism panel shows a potassium of 2.9 and a sodium of 131.

00:36 What is her diagnosis? Let's explore the lecture to find out.

00:41 So hyperemesis gravidarum, what are the signs and symptoms? First, intractable nausea and vomiting. Now it's very common in pregnancy to have nausea and vomiting in the 1st trimester.

00:51 And this usually resolves by 13 weeks.

00:54 However, with hyperemesis gravidarum this is intractable and it usually can continue into the 2nd trimester.

01:01 Patients with hyperemesis gravidarum usually have weight loss that can be anywhere from 5 to 10 pounds all the way up to 15 to 20 pounds.

01:10 They also experience electrolyte disturbance.

01:13 This is usually manifest in a low potassium.

01:15 Sometimes low sodium as well.

01:19 Another symptoms is a hypokalemic, hypochloremic metabolic alkalosis.

01:24 So how do we treat hyperemesis gravidarum? Well the first thing we want to do is IV hydration.

01:30 Now it's very important that this hydration be first with normal saline.

01:35 Why is that? Well, pregnancy is a state that can make you thyamine deficient.

01:40 If you begin to hydrate with something that contains D-5 or some type of a glucose solution, that can worsen the thyamine deficiency.

01:49 And actually lead to something called Wernicke's Encephalopathy.

01:52 The other thing about hydration is you need to make sure it is slow.

01:56 If you hydrate too quickly, you can cause central pontine myelinolysis.

02:00 We want to avoid that.

02:02 So electrolyte disturbances.

02:05 You want to correct those.

02:06 Again pregnancy is a time when thyamine is low.

02:10 It's going to be worse by hyperemesis gravidarum.

02:13 So we want to correct that.

02:15 We also want to correct the other electrolyte disturbances such as a low sodium or low potassium.

02:20 Next we want to treat the nausea vomiting.

02:24 And this is a clinical pearl.

02:26 So we have a lots of options for treating nausea vomiting in pregnancy as well as hyperemesis gravidarum.

02:32 Our first line treatment is vitamin B6 and doxylamine.

02:36 They work synergistically together to help with the nausea vomiting that we see with pregnancy.

02:40 If that's not effective we can move on to our other anti-emetic.

02:44 Let's discuss a few.

02:46 One is ondansetron.

02:48 Ondansetron is a medication that works very well for nausea vomiting.

02:52 However, the side effect is constipation.

02:55 You want to make sure your patients are aware of this, because constipation can be a common problem in pregnancy.

03:01 The next medication is Metoclopramide.

03:04 This medication has a side effect of extrapyramidal movements.

03:08 So you want to make patients aware of that if they start to feel very anxious or weird or start making movements that they feel that they can't control.

03:17 They want to stop taking the medicine.

03:19 Another clinical pearl are those extrapyramidal side effects can be reverse by Benadryl.

03:25 The next medication is Phenergan.

03:27 Phenergan also works very well for nausea vomiting.

03:30 But it has a side effect of sleepiness.

03:33 I should mention that the most recent guidelines recommend avoiding Zofran prior to ten weeks if possible, primarily because of the increased risk of oral clefts and VSD.

03:47 Let's go back to our case.

03:48 Again this is a 25 year old Gravida 1 Para 0 female at 8 weeks gestation that presents to the emergency room complaining of nausea vomiting.

03:58 She states she is unable to keep anything down.

04:00 She has a 10 pound weight loss throughout the pregnancy.

04:04 And on physical exam she appears dehydrated.

04:07 Her vital signs are stable.

04:08 She doesn't have a fever.

04:09 Her basic metabolism panel shows a potassium of 2.9 and a sodium of 131.

04:16 What is her diagnosis? Is it A. Anorexia.

04:20 B. Bulimia C. Hyperemesis Gravidarum or D. Morning sickness.

04:27 Let's think about all the answer choices.

04:30 Anorexia.

04:31 Anorexia manifests a little differently.

04:34 These are patients that are not eating.

04:35 And it really has nothing to do with pregnancy.

04:38 Bulimia, these people with bend eat and then induce vomiting.

04:42 Again unrelated to pregnancy.

04:44 Is Hyperemesis Gravidarum our answer here.

04:48 Let's check out the stem again.

04:50 The patient had a 10 pound weight loss and she has some electrolyte disturbance.

04:55 Her potassium is low as well as her sodium.

04:58 In this case hyperemesis gravidarum is the answer.