Wernicke’s encephalopathy in hyperemesis gravidarum: A systematic review

Wernicke-Korsakoff syndrome despite no alcohol abuse: A summary of systematic reports

BACKGROUND

Wernicke-Korsakoff syndrome (WKS) is a neurological disorder typically found in alcohol use disorder. The fact that it also occurs in nonalcoholic patients is less well known and often ignored. For the first time, this review offers a systematic investigation of the frequency and associated features of nonalcoholic WKS in the published literature.

METHOD

We included 11 recent systematic reports, with a total of 586 nonalcoholic WKS cases following hyperemesis gravidarum (n = 177), cancer (n = 129), bariatric surgery (n = 118), hunger strike (n = 41), soft drink diet in children (n = 33), depression (n = 21), Crohn's disease (n = 21), schizophrenia (n = 15), anorexia nervosa (n = 12), ulcerative colitis (n = 10), and incidental thiamine-deficient infant formula (n = 9).

FINDINGS

Vomiting and extreme weight loss were strong predictors of nonalcoholic WKS in adults. Blurred vision was a common presenting sign in about one-fourth of the patients. The classic triad of WKS is characterized by confusion, ataxia, and eye-movement disorders. All reviewed studies reported high percentages of patients presenting with an altered mental status, while both motor symptoms were variably present.

INTERPRETATION

The foregoing observations led to several important conclusions. First, we can see that nutritional impoverishment leads to profound brain damage in the form of WKS. Second, it seems that physicians are either unaware of or underestimate the risks for nonalcoholic WKS. Physicians must be specifically vigilant in detecting and treating WKS in patients with sudden and severe weight loss and vomiting. Third, lower doses of thiamine frequently lead to chronic Wernicke-Korsakoff syndrome. We noticed that when thiamine treatment for WKS was administered, in many cases doses were too low. In line with proven interventions we therefore recommend a parenteral thiamine treatment of 500 mg 3 times per day in adults.

Restrictive diet in a patient with irritable bowel syndrome leading to Wernicke encephalopathy

Background

We present a case of a woman with a past medical history of irritable bowel syndrome (IBS) and anxiety, who presents with ophthalmoplegia, ataxia and memory loss, characteristic of Wernicke encephalopathy.

Case presentation

A 64-year-old woman presented with double vision, unsteady gait and memory loss. These symptoms began after 3 months on an unfortified restricted diet, which she initiated to alleviate IBS symptoms. Magnetic resonance imaging of the brain demonstrated hyperintense T2-weighted signal in the dorsomedial aspect of bilateral thalami, periaqueductal grey matter and around the third ventricle. The patient’s visual symptoms improved significantly after thiamine supplementation, although her memory deficits persisted.

Conclusion

Although WE is often associated with chronic alcohol abuse, this case demonstrates the importance of recognizing WE in any patient with a restricted diet and subsequent timely initiation of thiamine.

Life-threatening complications of hyperemesis gravidarum

Hyperemesis gravidarum (HG) refers to severe nausea and emesis noted during pregnancy. However, no consensus exists on the specific diagnostic criteria that can be used for this condition. The aim of the present systematic review was to summarize the available evidence regarding the severe complications observed during HG with a heightened risk of fatality. A systematic search was conducted on PubMed, Cochrane Library, EMBASE and WILEY databases for the relevant publications regarding the severe and life-threatening complications of HG. The search terms were as follows: '(Hyperemesis gravidarum)' AND ('complications' OR 'severe' OR 'adverse pregnancy outcomes' OR 'stroke' OR 'seizures' OR 'Wernicke's encephalopathy' OR 'arrhythmias' OR 'pneumomediastinum' OR 'coagulopathy' OR 'electrolytic imbalance'). Abstracts, conference presentations, letters to the editor, studies written in languages other than English and editorials were all excluded. This search identified 43 studies analyzing life-threatening complications of HG, of which 11, seven, eight and 17 articles analyzed neurological, cardiovascular, thoracic and systemic complications, respectively. Reports on life-threatening complications were exceptionally rare in HG. The most frequent severe complications noted were Wernicke's encephalopathy, electrolyte imbalance and vitamin K deficiency. The low mortality rate for patients with HG over the last decade could be explained by the high efficiency of modern therapy, and the precise management of every complication according to current guidelines.

Wernicke-Korsakoff Syndrome in Hyperemesis Gravidarum: A Case Report and Literature Review

BACKGROUND

Wernicke-Korsakoff syndrome (WKS) is a triad of ophthalmoplegia, ataxia and memory deficits due to thiamine insufficiency resulting from under- or untreated Wernicke's encephalopathy (WE), which may be associated with hyperemesis gravidarum (HEG).

CASE PRESENTATION

We present a case of a 36-year-old Filipino woman in her first trimester with HEG, along with the WKS triad and abnormal hyperintense signals in the bilateral thalami and midbrain, left occipital lobe, periaqueductal gray matter and pontine periventricular areas. Neurologic deficits partially improved but persisted despite intravenous thiamine administration.

EVIDENCE REVIEW

A review of current treatments for WE, and the prevention and neurocognitive recovery of WKS was done. The beneficial effects of thiamine for acute WKS are supported by several case reports and clinical experience. Evidence from one randomized controlled trial wherein thiamine was given in various doses for treating WE or preventing WKS in an alcohol-dependent population is limited by methodological issues. Rehabilitation and pharmacotherapy for neurocognitive recovery seems promising, but they have inadequate evidentiary support. More robust studies on multi-modal strategies are warranted to facilitate the neurocognitive recovery of patients with WKS.

Original article: is the protective association between hyperemesis gravidarum and birth defects biased by pregnancy termination?

PURPOSE

We assessed whether the protective association between hyperemesis gravidarum and birth defects could be due to selection bias from exclusion of pregnancy terminations.

METHODS

We designed a cohort study of 2,115,581 live births in Canada, 1990-2016. The main exposure measure was hyperemesis gravidarum. The main outcome measure included any birth defect at delivery. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association of hyperemesis gravidarum with birth defects in log-binomial regression models, and assessed the extent of selection bias through correction factors.

RESULTS

Hyperemesis gravidarum was associated with 0.88 times the risk of birth defects in models not corrected for bias (95% CI 0.82-0.94). Correction for selection bias suggested that if screening for birth defects was associated with 1.33 times the chance of detecting birth defects and having a pregnancy termination, there would be no association with hyperemesis gravidarum. If ultrasound was associated with 2.00 times the chance of detecting birth defects and 1.50 times the risk of pregnancy termination, hyperemesis gravidarum would be associated with 1.27 times the risk of birth defects (95% CI 1.18-1.35).

CONCLUSIONS

The protective association between hyperemesis gravidarum and birth defects in previous studies may be due to selection bias.

Wernicke's encephalopathy post hyperemesis gravidarum misdiagnosed as Guillain-Barre syndrome: lessons for the frontline

We report a case of a 26-year-old pregnant woman, who presented with subacute limb weakness. This was initially suspected to be Guillain-Barre syndrome but subsequently found to be the motor neuropathy of dry beriberi (vitamin B1, thiamine deficiency) along with associated Wernicke's encephalopathy (WE). The underlying cause was revealed as hyperemesis gravidarum (HG). HG complicates up to 3% of pregnancies and if severe, without nutritional supplements, may lead to electrolyte disturbances, calorie loss and vitamin deficiency. Although the association of HG and WE was first reported in 1939, it remains an under diagnosed condition with potential for serious and permanent neurological deficits, and some mortality, in both mother and baby. Early recognition of the problem, with timely and careful fluid, electrolyte, glucose and vitamin replacement is needed to avoid complications. We highlight current best practice in the treatment of WE. An open mind to the possibility of HG complications in any pregnant woman presenting with neurological symptoms is probably the most important lesson to learn from the front line.

Behavioural effects of light intervention in people with Korsakoff Syndrome: A pilot study

Korsakoff Syndrome (KS) is commonly associated with behavioural symptoms such as agitation, apathy, and disinhibition. People with KS often reside in long-term care facilities, which reduces their exposure to natural light. Little is known regarding positive effects of light intervention in KS. Our objective was to evaluate the influence of a dawn simulation therapy on behavioural symptoms in KS. 38 patients residing in a 24-hour care facility were exposed for 6 weeks to a dawn simulation system in their bedrooms, which gradually increased from 0 lux to 290 lux. Behavioural symptoms were measured over 9 weeks. Weeks 1-3 consisted of the baseline phase and weeks 3-9 consisted of the light intervention phase. Our study showed that total severity of neuropsychiatric symptoms was less prominent during light intervention. More specifically, a decrease on the apathy, disinhibition, behaviour at night and appetite and eating behaviour subscales was found during the light intervention phase compared to the baseline phase. Additionally, a significant effect was found on decreasing emotional distress for caregivers. Results suggest that light intervention therapy has a positive effect on reducing behavioural symptoms in KS as well as the levels of stress experienced by the patients' caregivers.

Hyperemesis Gravidarum: Strategies to Improve Outcomes

Hyperemesis gravidarum (HG) is a debilitating and potentially life-threatening pregnancy disease marked by weight loss, malnutrition, and dehydration attributed to unrelenting nausea and/or vomiting; HG increases the risk of adverse outcomes for the mother and child(ren). The complexity of HG affects every aspect of a woman's life during and after pregnancy. Without methodical intervention by knowledgeable and proactive clinicians, life-threatening complications may develop. Effectively managing HG requires an understanding of both physical and psychosocial stressors, recognition of potential risks and complications, and proactive assessment and treatment strategies using innovative clinical tools.

Thiamine deficiency unrelated to alcohol consumption in high-income countries: a literature review

Thiamine deficiency has been typically associated with alcoholism or as a prevalent problem in low‐ and middle‐income countries (LMICs) whose populations rely on staple foods with a low content of thiamine. We conducted a literature review of published and unpublished data to identify relevant adult cases with confirmed thiamine deficiency of nonalcoholic cause in developed countries. We selected 17 reports with 81 adult cases of confirmed thiamine deficiency affecting adult patients with a wide range of ages and underlying conditions (e.g., cancer, gastrointestinal diseases, heart failure, and obesity). Thiamine deficiency may have been caused by disease‐related malnutrition, bariatric surgery, chronic use of diuretics, repeated vomiting, lack of thiamine in parenteral nutrition formulas, food insecurity, and reliance on monotonous or restrictive diets. Treatment with intravenous thiamine resulted in partial or complete recovery from the symptoms (cardiac, neurologic, and metabolic disorders) for most patients. The number and variety of symptomatic thiamine‐deficient adults identified in this review demonstrates that thiamine deficiency is not exclusive to LMICs and, in high‐income settings, is not exclusive to alcoholic patients. In developed countries, this serious but treatable condition can be expected in patients suffering from various medical conditions or following certain dietary patterns.

What is known about the nutritional intake of women with Hyperemesis Gravidarum?: A scoping review

Hyperemesis gravidarum (HG) is characterised by extreme nausea and vomiting of pregnancy, which can lead to dehydration, weight loss and electrolyte disturbances. Historically research has been challenging due to a lack of diagnostic criteria and objective outcome measures. Most studies in this population group have focused on medical management of symptoms, with little known about the effect of HG on nutritional intake and how this relates to perinatal outcomes. The aim of this study was to synthesise current knowledge of the dietary intake of women with HG. A systematic search of search engines was conducted in April 2020 using the following databases: MEDLINE, Embase, CINAHL, Cochrane database, Scopus, NHS Evidence, BNI, Emcare, ClinicalTrials.gov, PROSPERO, Ethos and Open Grey. Titles and abstracts were screened independently by two reviewers against predefined inclusion and exclusion criteria. Studies were included where the authors described severe pregnancy nausea and vomiting as HG, regardless of how HG was defined. After removal of duplicates, 4402 titles were identified, of which 3992 were initially excluded based on abstract and title. Following full text review, four of 10 articles were included. Three of the studies were hospital-based case control studies, one was an observational women's cohort study. Assessment of dietary intake was heterogeneous, with both retrospective and prospective self-report methods used, over different timeframes. In three of the studies, dietary intake was reported at one time point only. In total, across all four studies, data from only 314 women were included. Overall, despite data collected from four different countries, over 30 years, with various methods, women with HG had a significantly poorer dietary intake compared to non-affected pregnant women, consuming less than 50 % of recommended intakes for most nutrients. Nutritional intake worsened with increasing severity of symptoms. As this was a scoping review, study quality was not assessed. Overall, this review has identified a paucity of data about the dietary intake of women with HG; the limited available data indicates that women with HG are at risk of malnutrition. Future research quantifying nutritional intake in women with HG at several time points during pregnancy would provide valuable reference data, enabling nutritional status and outcomes to be monitored and interventions to be evaluated.

The contribution of mamillary body damage to Wernicke's encephalopathy and Korsakoff's syndrome

Histopathological alterations of the mamillary bodies are the most conspicuous and the most consistent neuropathological features of several disorders that occur after severe thiamine deficiency, such as Wernicke's encephalopathy and Korsakoff's syndrome. Moreover, they are among the few abnormalities that are visible to the naked eye in these disorders. With a lifetime prevalence of approximately 1.3%, Wernicke's encephalopathy is by far the most frequent cause of damage to the mamillary bodies in humans. Still, there is a persisting uncertainty with regard to the development and the clinical consequences of this damage, because it is virtually impossible to study in isolation. As a rule, it always occurs alongside neuropathology in other subcortical gray matter structures, notably the medial thalamus. Converging evidence from other pathologies and animal experiments is needed to assess the clinical impact of mamillary body damage and to determine which functions can be attributed to these structures in healthy subjects. In this chapter, we describe the history and the current state of knowledge with regard to thiamine deficiency disorders and the contribution of mamillary body damage to their clinical presentations.

The Inferior Colliculus in Alcoholism and Beyond

Post-mortem neuropathological and in vivo neuroimaging methods have demonstrated the vulnerability of the inferior colliculus to the sequelae of thiamine deficiency as occurs in Wernicke-Korsakoff Syndrome (WKS). A rich literature in animal models ranging from mice to monkeys-including our neuroimaging studies in rats-has shown involvement of the inferior colliculi in the neural response to thiamine depletion, frequently accomplished with pyrithiamine, an inhibitor of thiamine metabolism. In uncomplicated alcoholism (i.e., absent diagnosable neurological concomitants), the literature citing involvement of the inferior colliculus is scarce, has nearly all been accomplished in preclinical models, and is predominately discussed in the context of ethanol withdrawal. Our recent work using novel, voxel-based analysis of structural Magnetic Resonance Imaging (MRI) has demonstrated significant, persistent shrinkage of the inferior colliculus using acute and chronic ethanol exposure paradigms in two strains of rats. We speculate that these consistent findings should be considered from the perspective of the inferior colliculi having a relatively high CNS metabolic rate. As such, they are especially vulnerable to hypoxic injury and may be provide a common anatomical link among a variety of disparate insults. An argument will be made that the inferior colliculi have functions, possibly related to auditory gating, necessary for awareness of the external environment. Multimodal imaging including diffusion methods to provide more accurate in vivo visualization and quantification of the inferior colliculi may clarify the roles of brain stem nuclei such as the inferior colliculi in alcoholism and other neuropathologies marked by altered metabolism.

Wernicke Encephalopathy as a Complication of Hyperemesis Gravidarum: Case Report

Wernicke encephalopathy (WE) is an acute neurological disorder resulting from vitamin B1 deficiency, which is common in chronic alcoholism. We report a rare case of WE due to hyperemesis gravidarum in a 25-year-old pregnant patient at 13 weeks and 5 days of gestation. Initially, the disease manifested as weakness, mental confusion, anterograde amnesia, and visual and auditory hallucinations. The diagnosis was established after the detection of suggestive findings of WE in the thalamus by magnetic resonance imaging (MRI) and a rapid improvement in the patient's clinical status subsequent to treatment with thiamine. Hyperemesis is a rare cause of WE, which makes the reported case important in the literature and reinforces the need for attention in clinical practice to rare but important complications of this common condition (hyperemesis gravidarum).

Comprehensive review of Wernicke encephalopathy: pathophysiology, clinical symptoms and imaging findings

Wernicke's encephalopathy (WE) is a severe and life-threatening illness resulting from vitamin B1 (thiamine) deficiency. The prevalence of WE has been estimated from 0.4 to 2.8%. If not treated properly, severe neurologic disorders such as Korsakoff psychosis and even death may occur. The classical triad of clinical symptoms (abnormal mental state, ataxia, and ophthalmoplegia) is found in only 16-33% of patients on initial examination. The originally described underlying condition of WE is alcoholism, but it accounts for about 50% of causes of WE. Nonalcoholic patients are also affected by WE and likely to present symptoms and radiological imaging findings different from patients with alcoholism, which further complicates the diagnosis of WE. Being familiar with predisposing causes, symptoms and radiological imaging findings of WE is important for radiologists and clinicians when making the diagnosis to start immediate treatment. This review discusses pathophysiologies, underlying causes, clinical symptoms, imaging findings and their mimics.

Current Resources for Evidence-Based Practice, May 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of a new National Academy of Medicine report on planned place of birth and implications during the SARS-CoV-2 pandemic and commentaries on reviews focused on anorectal sexually transmitted infections and feeding methods following cleft lip repair in infants.

Nausea and vomiting of pregnancy and hyperemesis gravidarum

Nausea and vomiting of pregnancy (NVP) is a common condition that affects as many as 70% of pregnant women. Although no consensus definition is available for hyperemesis gravidarum (HG), it is typically viewed as the severe form of NVP and has been reported to occur in 0.3-10.8% of pregnant women. HG can be associated with poor maternal, fetal and child outcomes. The majority of women with NVP can be managed with dietary and lifestyle changes, but more than one-third of patients experience clinically relevant symptoms that may require fluid and vitamin supplementation and/or antiemetic therapy such as, for example, combined doxylamine/pyridoxine, which is not teratogenic and may be effective in treating NVP. Ondansetron is commonly used to treat HG, but studies are urgently needed to determine whether it is safer and more effective than using first-line antiemetics. Thiamine (vitamin B1) should be introduced following protocols to prevent refeeding syndrome and Wernicke encephalopathy. Recent advances in the genetic study of NVP and HG suggest a placental component to the aetiology by implicating common variants in genes encoding placental proteins (namely GDF15 and IGFBP7) and hormone receptors (namely GFRAL and PGR). New studies on aetiology, diagnosis, management and treatment are under way. In the next decade, progress in these areas may improve maternal quality of life and limit the adverse outcomes associated with HG.