Hyperemesis gravidarum: A case of starvation and altered sensorium gestosis (ASG)

The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69)

An objective and validated index of nausea and vomiting such as the Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can be used to classify the severity of NVP and HG. [Grade C] Ketonuria is not an indicator of dehydration and should not be used to assess severity. [Grade A] There are safety and efficacy data for first line antiemetics such as anti (H1) histamines, phenothiazines and doxylamine/pyridoxine (Xonvea®) and they should be prescribed initially when required for NVP and HG (Appendix III). [Grade A] There is evidence that ondansetron is safe and effective. Its use as a second line antiemetic should not be discouraged if first line antiemetics are ineffective. Women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed HG. [Grade B] Metoclopramide is safe and effective and can be used alone or in combination with other antiemetics. [Grade B] Because of the risk of extrapyramidal effects metoclopramide should be used as second-line therapy. Intravenous doses should be administered by slow bolus injection over at least 3 minutes to help minimise these. [Grade C] Women should be asked about previous adverse reactions to antiemetic therapies. If adverse reactions occur, there should be prompt cessation of the medications. [GPP] Normal saline (0.9% NaCl) with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, is the most appropriate intravenous hydration. [Grade C] Combinations of different drugs should be used in women who do not respond to a single antiemetic. Suggested antiemetics for UK use are given in Appendix III. [GPP] Thiamine supplementation (either oral 100 mg tds or intravenous as part of vitamin B complex (Pabrinex®)) should be given to all women admitted with vomiting, or severely reduced dietary intake, especially before administration of dextrose or parenteral nutrition. [Grade D] All therapeutic measures should have been tried before considering termination of pregnancy. [Grade C].

Gestational malnutrition, hyperemesis gravidarum, and Wernicke's encephalopathy: What is missing?

Hyperemesis gravidarum (HG), or the severe nausea and vomiting of pregnancy, is one of the most dreaded complications of gestation, affecting between 1.5% and 3.0% of pregnant women. From the late 1800s to the mid-1980s, the etiology was frequently cited to have psychological and/or-later-perhaps hormonal origins, which have numbered at least 10. Current research has unearthed a genetic basis for HG that implicates growth differentiation factor 15, insulin-like growth factor binding protein 7, and hormone receptors (namely, glial cell line-derived neurogenic factor family receptor alpha-like and the progesterone receptor). Whatever the origins of this disease, it has caused immeasurable physiological and psychological damage to women, their fetuses, and their families. The psychological trauma includes a high rate of suicidal ideation as well as posttraumatic stress disorder. Whereas the healthcare costs are substantial for the mother with HG, the lifetime costs to the neonate include that which accompanies reduced employment earnings related to cognitive compromise. Another devastating outcome of severe HG can be Wernicke's encephalopathy (WE), which has a high fetal and maternal mortality rate. Our study explored 18 current reports of HG and WE. We highlighted additional presenting features we believe also accompany, and sometimes replace, the classically taught triad components of WE: ataxia, confabulation, and nystagmus. We agree with the conclusion made by Sheehan and Ironside in 1939 that thiamin alone may not reverse WE, and we offer possible explanations. Lastly, we offer suggestions for remediation.

CLINICAL FEATURES OF PREGNANT WOMEN WITH EARLY GESTOSIS

Aim: to determine the clinical features of women with early gestosis. Materials and Methods. The retrospective study included 200 pregnant women. The main group included 150 pregnant women with early gestosis. The control group included 50 women with physiological pregnancies. Results. Among pregnant women with early gestosis, the share of unemployed women (30.0%), workers in enterprises and agriculture (24.0%) and female students (22.0%) was significant, (р<0,001). Cigarette smoking was identified in 20.0% of women in the main group. In childhood, 32.0% of women with early gestosis suffered from childhood infectious diseases. In women with early gestosis, somatic pathology was probably more common: diseases of the gastrointestinal tract (52.0%), diseases of the cardiovascular system (40.0%); anemia (38.0%); pathology of the urinary system (18.0%); endocrine diseases (20.0%), psycho-emotional disorders (38.0%), (р<0,001, c2 =13,20). Abnormal uterine bleeding are observed in 18.0% of women in the main group. The rate of inflammatory diseases of the pelvic organs among pregnant women with early gestosis was 32.0%, cervical pathology - 16.0%; the level of artificial abortions was 26.0%, (р<0,001, c22 = 22,74). Discussion. Nausea and vomiting in pregnant women is one of the most common pregnancy disorders. Symptoms occur mainly in the first trimester, although in some patients they may persist throughout pregnancy and affect a woman's quality of life. The pathogenesis of early gestosis remains unclear, but there is a consensus that these disorders are multifactorial and that various genetic, psychological, endocrine, and infectious factors may be involved. Our retrospective analysis of the premorbid background in women with early gestosis revealed its peculiarities. The high level of somatic morbidity and smoking in women with early gestosis in comparison with pregnant women of the control group corresponds to modern ideas about the importance of extragenital pathology and bad habits in the etiopathogenesis of pregnancy complications. Conclusions. The results of this study show that women with early gestosis are characterized by a high level of somatic diseases and psycho-emotional disorders, smoking, relatively unsatisfactory social conditions. Relationship with research programs, plans and topics. This work is a fragment of the scientific work of the I.D. Lanovyi Department of Obstetrics and Gynecology "Development of diagnostic tactics and pathogenetic substantiation of effective methods of preserving and restoring reproductive potential and improving the quality of life of women in obstetric and gynecological pathology" (state registration number 0121U109269).

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.