A woman with thyrotoxicosis- and hyperemesis gravidarum-associated Wernicke's encephalopathy

Although hyperthyroidism arising from primary thyroid disease is rare in pregnancy, transient gestational hyperthyroidism is not uncommon. This condition can be associated with hyperemesis gravidarum (HG), and Wernicke's encephalopathy. We present the case of a woman with toxic nodular goiter complicating HG-associated Wernicke's encephalopathy. A 38-year-old Caucasian woman, who had received a diagnosis of hyperthyroidism and HG early in her pregnancy, had intrauterine fetal death at Week 16 of gestation. One day after undergoing therapeutic abortion, she was admitted to our clinic with persistent thyrotoxicosis, nausea, and vomiting. A toxic thyroid nodule was detected. She was given antithyroid medication, total parenteral nutrition. On Day 10 of hospitalization, she developed ataxia, aphasia, and somnolence. Cranial magnetic resonance imaging showed increased bilateral thalamic signalization. She was given a diagnosis of Wernicke's metabolic encephalopathy, for which she received thiamine and multivitamin preparations. She responded dramatically on the second day of thiamine therapy. Her consciousness improved rapidly and she began to speak. Her muscle tone was slightly weak and she had paresthesias in both legs. Absorption of thiamine may be particularly impaired in pregnant women with hyperemesis and hyperthyroid disease. Wernicke's encephalopathy should be considered in hyperthyroid women with HG who develop neurological abnormalities.

Therapeutic choices for nausea and vomiting of pregnancy: a critical review of a systematic review

With 80% of pregnant women suffering from some degree of "morning sickness," or nausea and vomiting of pregnancy (NVP), symptom management is a major challenge. A recent Cochrane systematic review of randomized controlled trials concluded that, to date, there is no strong evidence of effectiveness for practically any therapeutic agent used for management of NVP. Because of fears of teratogenicity and litigation, RCTs are rarely conducted in pregnancy. In the absence of the best possible evidence from RCTs, well planned and executed prospective observational studies should be used as the best available evidence to guide clinical practice.

[Psychological approach to hyperemis gravidarum]

INTRODUCTION

Hyperemesis gravidarum is a phenomenon that concerns only 1 or 2% of pregnant women who require hospitalization if their anorectic behavior does not cease. The treatment consists in complete isolation, anti-vomit drugs and rehydration therapy.

OBJECTS

Isolation has been practiced existed since 1914, and is based on the belief that these women were simulating pain in order to obtain abortion. By isolating them from their family environment, the medical staff hopes this secret desire will be revealed. We tried to evaluate the reality of this analysis.

MATERIAL AND METHOD

Two psychological interviews were conducted by a questionnaire addressed to 23 pregnant women at the time of their hospitalization for hyperemesis gravidarum in a level 3 gynecology-obstetric unit. All patients were submitted to the described treatment.

RESULTS

Four groups were found. In the first group (n=6) women were submerged by a present and conscious conflict concerning their pregnancy, which found and easy solution. In the second group (n=7), the women had lost a pregnancy a short time before the present one. These patients were suffering from this loss and could not easily accept their new baby. The third group (n=6) concerned women who were afraid of a living a dramatic event that their mother had experienced in the past. This worry, held far from their consciousness, could be recalled during the interviews. In the last group (n=4), the women had passed through major difficulties in their relationship with their mothers during childhood. Becoming a mother themselves, they feared they would reproduce the same attitudes toward their own babies. Within this group, only one woman finally asked for an abortion that was performed.

CONCLUSION

It would not appear that the patients have to be isolated for them to reveal their desire for abortion. Conversely, a psychological interview allows better understanding of the ambivalent attitudes of pregnant women and thus can be useful in avoiding systematic abortion.

Thyroid disorders associated with pregnancy: etiology, diagnosis, and management

Pregnancy has an effect on thyroid economy with significant changes in iodine metabolism, serum thyroid binding proteins, and the development of maternal goiter especially in iodine-deficient areas. Pregnancy is also accompanied by immunologic changes, mainly characterized by a shift from a T helper-1 (Th1) lymphocyte to a Th2 lymphocyte state. Thyroid peroxidase antibodies are present in 10% of women at 14 weeks' gestation, and are associated with (i) an increased pregnancy failure (i.e. abortion), (ii) an increased incidence of gestational thyroid dysfunction, and (iii) a predisposition to postpartum thyroiditis. Thyroid function should be measured in women with severe hyperemesis gravidarum but not in every patient with nausea and vomiting during pregnancy. Graves hyperthyroidism during pregnancy is best managed with propylthiouracil administered throughout gestation. Thyroid-stimulating hormone-receptor antibody measurements at 36 weeks' gestation are predictive of transient neonatal hyperthyroidism, and should be checked even in previously treated patients receiving thyroxine. Postpartum exacerbation of hyperthyroidism is common, and should be evaluated in women with Graves disease not on treatment. Radioiodine therapy in pregnancy is absolutely contraindicated. Hypothyroidism (including subclinical hypothyroidism) occurs in about 2.5% of pregnancies, and may lead to obstetric and neonatal complications as well as being a cause of infertility. During the last few decades, evidence has been presented to underpin the critical importance of adequate fetal thyroid hormone levels in order to ensure normal central and peripheral nervous system maturation. In iodine-deficient and iodine-sufficient areas, low maternal circulating thyroxine levels have been associated with a significant decrement in child IQ and development. These data suggest the advisability of further evaluation for a screening program early in pregnancy to identify women with hypothyroxinemia, and the initiation of prompt treatment for its correction. Hypothyroidism in pregnancy is treated with a larger dose of thyroxine than in the nonpregnant state. Postpartum thyroid dysfunction (PPTD) occurs in 50% of women found to have thyroid peroxidase antibodies in early pregnancy. The hypothyroid phase of PPTD is symptomatic and requires thyroxine therapy. A high incidence (25-30%) of permanent hypothyroidism has been noted in these women. Women having transient PPTD with hypothyroidism should be monitored frequently, as there is a 50% chance of these patients developing hypothyroidism during the next 7 years.

Hyperemesis gravidarum presenting as jaundice and transient hyperthyroidism complicated with acute pancreatitis

Hyperemesis gravidarum is an extreme form of nausea and vomiting during pregnancy. Its presenting symptoms include vomiting, disturbed nutrition, electrolyte imbalance, ketosis, extreme weight loss, renal and/or liver damage. It is rare for a hyperemesis gravidarum patient to present with jaundice, hyperthyroidism and idiopathic acute pancreatitis during the same hospitalization period. Here, we report such a case. A 25-year-old pregnant woman without underlying liver or thyroid disease was admitted due to jaundice noted for 2 days at 8 weeks of gestational age. Hyperthyroidism symptoms of tachycardia and finger tremor also bothered her. After treatment with parenteral fluid and antithyroid agents, her clinical condition improved. However, an episode of idiopathic pancreatitis occurred after nausea and vomiting subsided. Bowel rest with parenteral fluid and nutrition supplement was given and the increased pancreatic enzyme level gradually subsided. Follow-up liver and thyroid function were normal after gestational age of 26 weeks. She delivered a healthy female baby without low birth body weight at gestational age of 39 weeks. Rapid diagnosis and supportive care are important for the hyperemesis gravidarum patient with the complication of acute pancreatitis.

The Impact of Hyperemesis Gravidarum on Maternal Role Assumption

OBJECTIVES

To describe what it is like to have hyperemesis gravidarum and explore its impact on the assumption of the maternal role during the perinatal period.

DESIGN

Qualitative descriptive design.

PARTICIPANTS

Eight women who had been diagnosed with hyperemesis gravidarum were recruited through private prenatal clinics using a snowball technique. Participants were interviewed about their experiences with hyperemesis gravidarum in their homes or other suitable sites selected by them.

MAIN OUTCOME MEASURES

Transcribed interviews were analyzed using grounded theory methodology. A core category and subcategories were determined.

RESULTS

Hyperemesis gravidarum is a disorder that alters the usual response to pregnancy and birth. Participants in this study described it as so debilitating that they had little concern for anything else, including the fetus. After symptoms subsided, the participants reported that they were able to regain control over their lives and made an effort to make up for lost time in becoming attached to the baby.

CONCLUSION

Women suffering from hyperemesis gravidarum may not benefit from the usual prenatal education efforts. Additional support following delivery may be needed as the woman attaches to her infant and learns to provide care.

Is lower socio-economic status a risk factor for Helicobacter pylori infection in pregnant women with hyperemesis gravidarum?

BACKGROUND/AIMS

Lower socio-economic status was demonstrated to be a major risk factor for infection with H. pylori infection in the general population. The aim of the present study was to investigate any possible association between infection with H. pylori and hyperemesis gravidarum and between socio-economic status and H. pylori infection in pregnant women with hyperemesis gravidarum.

METHODS

Fifty-six pregnant women with hyperemesis gravidarum and 90 control pregnant women were enrolled in the study. Forty-five (80.4%) subjects in the hyperemesis gravidarum group and 72 (80%) subjects in the control group were assessed as lower socio-economic status by questionnaire. Specific serum immunglobulin G for H. pylori was assayed by fluorescent enzyme immunoassay method for both groups.

RESULTS

Serologically positive H. pylori infection was detected in 46 (82.1%) subjects of the hyperemesis gravidarum group and in 58 (64.4%) of the controls (p=0.024). With respect to the patients with lower socio-economic status, 40 (88.9%) of the 45 patients with hyperemesis gravidarum and 49 (68.1%) of the 72 controls were positive for H. pylori (p=0.013).

CONCLUSIONS

This study supports the studies suggesting an association between H. pylori and hyperemesis gravidarum. In addition, the lower socio-economic status may also be an important risk factor for infection with H. pylori in pregnant women with hyperemesis gravidarum.

A case of primary Addison’s disease with hyperemesis gravidarum and successful pregnancy

We followed up a pregnant woman with Addison's disease diagnosed before conception. She presented with hyperemesis gravidarum. Throughout pregnancy, she received prednisone and the basic disease did not deteriorate during pregnancy. She was delivered by caesarean section due to breech presentation. The fetal prognosis was good.

[A teenager presenting with vomiting, general malaise and weight loss]

A 16-year-old girl had symptoms of vomiting, malaise and weight loss for two months. Blood tests revealed an elevated activity of liver enzymes and hyperthyroidism. Although the patient at first denied the possibility of pregnancy, a pregnancy was subsequently confirmed. Hyperemesis gravidarum was diagnosed based on the combination of the clinical symptoms, pregnancy and increased serum human chorionic gonadotrophin and oestradiol. Hyperemesis gravidarum also explained the demonstrated biochemical hyperthyroidism and elevated liver enzyme levels. Rapid alleviation of all the clinical symptoms was seen after termination of this unwanted pregnancy. Although vomiting, malaise and weight loss in children can have many different causes, in girls at a sexually mature age a pregnancy with possible hyperemesis gravidarum should certainly also be considered and a gynaecological examination performed.

Solid pseudopapillary pancreatic tumor in pregnancy. A case report

BACKGROUND

Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm, occurring predominantly in young African American women. Tumor growth, which is typically slow, may be accelerated during pregnancy secondary to the influence of progesterone.

CASE

We report a rare case of an 8-cm SPT in the head of the pancreas presenting as hyperemesis gravidarum during pregnancy. In contrast to previous case reports, surgical resection of the tumor at 16 weeks' gestation, although successful, did not ameliorate the patient's abdominal pain, nausea or vomiting. With intravenous nutritional support, she delivered a healthy infant near term.

CONCLUSION

SPT may present as hyperemesis gravidarum. Patients with refractory hyperemesis gravidarum should be evaluated for thyroid disease, gastroesophageal reflux, cholestasis and pancreatitis. If these more common etiologies are excluded, then one may consider SPT in the differential diagnosis, particularly in African American patients. SPT may grow during pregnancy due to progesterone responsiveness. Surgical resection during pregnancy is possible without harmful fetal effects but may not correct gastrointestinal dysfunction during pregnancy.

Serologic assay of Helicobacter pylori infection. Is it useful in hyperemesis gravidarum?

OBJECTIVE

To assess the association of Helicobacter pylori seropositivity with hyperemesis gravidarum.

STUDY DESIGN

A prospective study was performed on 160 pregnant women who were admitted to an outpatient clinic for prenatal care from November 2000 to December 2001. Eighty patients with hyperemesis gravidarum and 80 asymptomatic, pregnant women were examined for serum anti-H pylori IgG antibodies. Serum anti-H pylori IgG antibodies were evaluated using a commercially available enzyme-linked immunosorbent assay (ELISA)-based kit. Statistical analysis was conducted by using the Student t, chi 2 and Mann-Whitney U test. A P value < .05 was considered significant.

RESULTS

The overall prevalence of H pylori seropositivity was 65.6%. Fifty-six of 80 hyperemesis patients (70%) and 49 of 80 control subjects (61.2%) were positive for anti-H pylori IgG antibodies. No significant difference in H pylori seropositivity was found between the groups.

CONCLUSION

H pylori seropositivity is not significantly associated with hyperemesis gravidarum. Since we could not absolutely demonstrate that seropositivity for H pylori is associated with hyperemesis gravidarum, routine serologic analysis for H pylori is not encouraged. Understanding the role of H pylori infection in the pathogenesis of hyperemesis gravidarum necessitates further studies.

[Hyperemesis gravidarum--etiology and treatment]

Hyperemesis gravidarum is a common pathology encountered by the obstetrician in 0.1-2% of all pregnancies. The purpose of our review, along with other literature, is to report general outline of the syndrome, with etiology, complications and some guidelines about conventional and newer therapy.

[Wernicke's encephalopathy due to hyperemesis gravidarum]

A report of 33 years old female with Wernicke's encephalopathy is presented. The disease was secondary to hyperemesis gravidarum, started from the 6th week of pregnancy. Neurological symptoms as nystagmus, headache, vertigo, disturbance of consciousness and ataxia are described, as well as difficulties in finding out the right diagnosis. We present the therapy with vitamin B1. The subsequent course of the pregnancy was uncomplicated and resulted in a birth--by caesarean section of a healthy male infant, weighted 2790 grams. However, four months later after the delivery, the patient is not yet completely recovered and still demands thiamine supplementation.

Spontaneous esophageal rupture following severe vomiting in pregnancy

Spontaneous esophageal perforation is an uncommon finding requiring prompt diagnosis and immediate surgery because of its high mortality rate. Esophageal rupture secondary to severe vomiting in pregnancy is extremely rare and only four cases have been published in the literature. We report the case of a 20-year-old female in whom severe vomiting in early pregnancy resulted in esophageal perforation with subcutaneous emphysema. The diagnosis was made 48 h later. The patient had undergone surgical treatment and the postoperative period was uneventful. The unusual cause and the interesting clinical course of esophageal rupture are described.

[Wernicke's encephalopathy induced by hyperemesis gravidarum (case report)]

One of the life-threatening complications of hyperemesis gravidarum is Wernicke's encephalopathy, the main etiological factor of which is a lack of thiamine (vitamin B1). Most frequently Wernicke's encephalopathy is found among persons suffering from excessive drinking. The aim of the report was to present a case of Wernicke's encephalopathy induced by hyperemesis gravidarum. The course of the disease, clinical signs, diagnostics, treatment and its results are presented. Also a review of the literature on Wernicke's encephalopathy secondary to hyperemesis gravidarum is introduced.

Diffusion weighted MR imaging of acute Wernicke's encephalopathy

We report a case of Wernicke's encephalopathy in which diffusion-weighted MR images demonstrated symmetrical hyperintense lesions in the paraventricular area of the third ventricles and medial thalami. Apparent diffusion coefficient mapping showed isointensity in the aforementioned areas. Diffusion-weighted MR images may provide evidence of vasogenic edema associated with thiamine deficiency, proven in the histopathology of experimental animals. In addition, diffusion-weighted MRI has many advantages over T2 or FLARE-weighted brain MRI in detecting structural and functional abnormalities in Wernicke's encephalopathy.

Acute renal failure in association with severe hyperemesis gravidarum

BACKGROUND

Severe hyperemesis gravidarum is a rare but potentially devastating complication of pregnancy. Among its many potential complications are dehydration, electrolyte imbalance, malnutrition, Wernicke encephalopathy, and compromised renal function.

CASE

We report the case of a 21-year-old woman at 15 weeks' gestation presenting to the emergency department with severe hyperemesis gravidarum associated with acute renal failure. Her initial serum creatinine and blood urea nitrogen were 10.7 mg/dL and 171 mg/dL, respectively. The patient underwent daily hemodialysis for 5 days with subsequent return of renal function to normal.

CONCLUSION

Women with severe hyperemesis gravidarum may be at risk for acute renal failure caused by severe intravascular volume depletion.