1
|
Morrison MA, Chung Y, Heneghan MA. Managing hepatic complications of pregnancy: practical strategies for clinicians. BMJ Open Gastroenterol 2022; 9:e000624. [PMID: 35292523 PMCID: PMC8928321 DOI: 10.1136/bmjgast-2021-000624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/12/2022] [Indexed: 12/17/2022] Open
Abstract
Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.
Collapse
Affiliation(s)
| | - Yooyun Chung
- Institute of Liver Studies, King's College Hospital, London, UK
| | | |
Collapse
|
2
|
O'Donnell A, McParlin C, Robson SC, Beyer F, Moloney E, Bryant A, Bradley J, Muirhead C, Nelson-Piercy C, Newbury-Birch D, Norman J, Simpson E, Swallow B, Yates L, Vale L. Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy: a systematic review and economic assessment. Health Technol Assess 2018; 20:1-268. [PMID: 27731292 DOI: 10.3310/hta20740] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Nausea and vomiting in pregnancy (NVP) affects up to 85% of all women during pregnancy, but for the majority self-management suffices. For the remainder, symptoms are more severe and the most severe form of NVP - hyperemesis gravidarum (HG) - affects 0.3-1.0% of pregnant women. There is no widely accepted point at which NVP becomes HG. OBJECTIVES This study aimed to determine the relative clinical effectiveness and cost-effectiveness of treatments for NVP and HG. DATA SOURCES MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, PsycINFO, Commonwealth Agricultural Bureaux (CAB) Abstracts, Latin American and Caribbean Health Sciences Literature, Allied and Complementary Medicine Database, British Nursing Index, Science Citation Index, Social Sciences Citation Index, Scopus, Conference Proceedings Index, NHS Economic Evaluation Database, Health Economic Evaluations Database, China National Knowledge Infrastructure, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects were searched from inception to September 2014. References from studies and literature reviews identified were also examined. Obstetric Medicine was hand-searched, as were websites of relevant organisations. Costs came from NHS sources. REVIEW METHODS A systematic review of randomised and non-randomised controlled trials (RCTs) for effectiveness, and population-based case series for adverse events and fetal outcomes. Treatments: vitamins B6 and B12, ginger, acupressure/acupuncture, hypnotherapy, antiemetics, dopamine antagonists, 5-hydroxytryptamine receptor antagonists, intravenous (i.v.) fluids, corticosteroids, enteral and parenteral feeding or other novel treatment. Two reviewers extracted data and quality assessed studies. Results were narratively synthesised; planned meta-analysis was not possible due to heterogeneity and incomplete reporting. A simple economic evaluation considered the implied values of treatments. RESULTS Seventy-three studies (75 reports) met the inclusion criteria. For RCTs, 33 and 11 studies had a low and high risk of bias respectively. For the remainder (n = 20) it was unclear. The non-randomised studies (n = 9) were low quality. There were 33 separate comparators. The most common were acupressure versus placebo (n = 12); steroid versus usual treatment (n = 7); ginger versus placebo (n = 6); ginger versus vitamin B6 (n = 6); and vitamin B6 versus placebo (n = 4). There was evidence that ginger, antihistamines, metoclopramide (mild disease) and vitamin B6 (mild to severe disease) are better than placebo. Diclectin® [Duchesnay Inc.; doxylamine succinate (10 mg) plus pyridoxine hydrochloride (10 mg) slow release tablet] is more effective than placebo and ondansetron is more effective at reducing nausea than pyridoxine plus doxylamine. Diclectin before symptoms of NVP begin for women at high risk of severe NVP recurrence reduces risk of moderate/severe NVP compared with taking Diclectin once symptoms begin. Promethazine is as, and ondansetron is more, effective than metoclopramide for severe NVP/HG. I.v. fluids help correct dehydration and improve symptoms. Dextrose saline may be more effective at reducing nausea than normal saline. Transdermal clonidine patches may be effective for severe HG. Enteral feeding is effective but extreme method treatment for very severe symptoms. Day case management for moderate/severe symptoms is feasible, acceptable and as effective as inpatient care. For all other interventions and comparisons, evidence is unclear. The economic analysis was limited by lack of effectiveness data, but comparison of costs between treatments highlights the implications of different choices. LIMITATIONS The main limitations were the quantity and quality of the data available. CONCLUSION There was evidence of some improvement in symptoms for some treatments, but these data may not be transferable across disease severities. Methodologically sound and larger trials of the main therapies considered within the UK NHS are needed. STUDY REGISTRATION This study is registered as PROSPERO CRD42013006642. FUNDING The National Institute for Health Research Health Technology Assessment programme.
Collapse
Affiliation(s)
- Amy O'Donnell
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine McParlin
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Stephen C Robson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Beyer
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Eoin Moloney
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Jennifer Bradley
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Muirhead
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Justine Norman
- North Tyneside Clinical Commissioning Group, Whitley Bay, UK
| | - Emma Simpson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Laura Yates
- UK Teratology Information Service (UKTIS) and Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
3
|
Tang AW, Alfirevic Z, Turner MA, Drury JA, Small R, Quenby S. A feasibility trial of screening women with idiopathic recurrent miscarriage for high uterine natural killer cell density and randomizing to prednisolone or placebo when pregnant. Hum Reprod 2013; 28:1743-52. [DOI: 10.1093/humrep/det117] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
|
4
|
|
5
|
Sonkusare S. The clinical management of hyperemesis gravidarum. Arch Gynecol Obstet 2011; 283:1183-92. [PMID: 21424548 DOI: 10.1007/s00404-011-1877-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 03/07/2011] [Indexed: 10/18/2022]
Abstract
Hyperemesis gravidarum is a severe and disabling condition with potentially life-threatening complications. It is likely to have a multifactorial etiology which contributes to the difficulty in treatment. Treatment is supportive with correction of dehydration and electrolyte disturbance, antiemetic therapy, prevention and treatment of complications like Wernicke's encephalopathy, osmotic demyelination syndrome, thromboembolism, and good psychological support. There are abundant data on the safety of antihistamines, phenothiazines, and metoclopromide in early pregnancy and treatment should therefore not be withheld on the basis of teratogenicity concerns. Thiamine replacement is indicated in hyperemesis gravidarum to prevent development of Wernicke's encephalopathy.
Collapse
Affiliation(s)
- Shipra Sonkusare
- Department of Obstetrics and Gynaecology, Kasturba Medical College, Manipal University, Manipal, Karnataka 576104, India.
| |
Collapse
|
6
|
|
7
|
Jueckstock JK, Kaestner R, Mylonas I. Managing hyperemesis gravidarum: a multimodal challenge. BMC Med 2010; 8:46. [PMID: 20633258 PMCID: PMC2913953 DOI: 10.1186/1741-7015-8-46] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Accepted: 07/15/2010] [Indexed: 12/18/2022] Open
Abstract
Up to 90% of pregnant women experience nausea and vomiting. When prolonged or severe, this is known as hyperemesis gravidarum (HG), which can, in individual cases, be life threatening. In this article the aetiology, diagnosis and treatment strategies will be presented based on a selective literature review. Treatment strategies range from outpatient dietary advice and antiemetic drugs to hospitalization and intravenous (IV) fluid replacement in persistent or severe cases. Alternative methods, such as acupuncture, are not yet evidence based but sometimes have a therapeutic effect.In most cases, the condition is self limiting and subsides by around 20 weeks gestation. More severe forms require medical intervention once other organic causes of nausea and vomiting have been excluded. In addition, a psychosomatic approach is often helpful.In view of its potential complexity, general practitioners and obstetricians should be well informed about HG and therapy should be multimodal.
Collapse
Affiliation(s)
- J K Jueckstock
- First Department of Obstetrics and Gynaecology, Campus Innenstadt, Ludwig-Maximilians-University, Maistrasse 11, 80337 Munich, Germany
| | | | | |
Collapse
|
8
|
Gabapentin use in hyperemesis gravidarum: a pilot study. Early Hum Dev 2010; 86:65-6. [PMID: 20015600 DOI: 10.1016/j.earlhumdev.2009.11.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2009] [Revised: 11/03/2009] [Accepted: 11/05/2009] [Indexed: 10/20/2022]
Abstract
Among 7 subjects with hyperemesis gravidarum (HG), we found gabapentin therapy to be associated with mean reductions in nausea and emesis from Baseline to Days 12-14 of 80% and 94%, respectively. There have been 2 congenital defects among 7 exposed infants. Gabapentin may be effective in the treatment of HG.
Collapse
|
9
|
Tang AW, Alfirevic Z, Turner MA, Drury J, Quenby S. Prednisolone Trial: Study protocol for a randomised controlled trial of prednisolone for women with idiopathic recurrent miscarriage and raised levels of uterine natural killer (uNK) cells in the endometrium. Trials 2009; 10:102. [PMID: 19903335 PMCID: PMC2785777 DOI: 10.1186/1745-6215-10-102] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 11/10/2009] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Idiopathic recurrent miscarriage is defined as 3 consecutive pregnancy losses with no contributing features found on investigations. At present there are no treatments of proven efficacy for idiopathic recurrent miscarriage. Uterine natural killer (uNK) cells, the most predominant leucocyte in the endometrium are adjacent to foetal trophoblast cells and thought to be involved in implantation. The exact mechanisms of how uNK cells affect implantation are not clear but are probably through the regulation of angiogenesis. Multiple studies have shown an association between high density of uterine natural killer cells and recurrent miscarriage. We have shown that prednisolone reduces the number of uNK cells in the endometrium. The question remains as to whether reducing the number of uNK cells improves pregnancy outcome. METHODS We propose a randomised, double-blind, placebo controlled trial of prednisolone with a pilot phase to assess feasibility of recruitment, integrity of trial procedures, and to generate data to base future power calculations. The primary aim is to investigate whether prednisolone therapy during the first trimester of pregnancy is able to improve live birth rates in patients with idiopathic recurrent miscarriage and raised uNK cells in the endometrium. Secondary outcomes include conception rate, karyotype of miscarriage, miscarriages (first and second trimester), stillbirths, pregnancy complications, gestational age at delivery, congenital abnormality and side effects of steroids. The trial has 2 stages: i) screening of non-pregnant women and ii) randomisation of the pregnant cohort. All patients who fit the inclusion criteria (<40 years old, > or =3 consecutive miscarriages with no cause found and no contraindications to prednisolone therapy) will be asked to consent to an endometrial biopsy in the mid-luteal phase to assess their levels of uNK cells. Women with high levels of uNK cells (> or =5%), will be randomised to either prednisolone or placebo when a pregnancy is confirmed. Follow-up includes 2 weekly ultrasound scans in the first trimester, an anomaly scan at 20 weeks gestation, growth scans at 28 and 34 weeks gestation and a postnatal follow-up at 6 weeks. TRIAL REGISTRATION Current Controlled Trials ISRCTN28090716.
Collapse
Affiliation(s)
- Ai-Wei Tang
- School of Reproductive and Developmental Medicine, University of Liverpool, Liverpool Women's Hospital, Crown Street, Liverpool, L8 7SS, UK.
| | | | | | | | | |
Collapse
|
10
|
Bottomley C, Bourne T. Management strategies for hyperemesis. Best Pract Res Clin Obstet Gynaecol 2009; 23:549-64. [PMID: 19261546 DOI: 10.1016/j.bpobgyn.2008.12.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2008] [Accepted: 12/15/2008] [Indexed: 10/21/2022]
Abstract
Nausea and vomiting occur in up to 80% of normal pregnancies. Hyperemesis gravidarum, resulting in dehydration and ketonuria, is a more severe, disabling and potentially life threatening condition affecting up to 1.5% of pregnancies. Treatment is supportive with intravenous rehydration, antiemetics and correction of vitamin deficiency to minimize complications. There are good safety data to support the use of antihistamines, phenothiazines and metoclopromide in hyperemesis gravidarum, though trials of efficacy are lacking and there is little evidence on which to chose the optimum therapy. This review discusses the diagnosis and management of hyperemesis gravidarum and the prevention, recognition and treatment of the serious complications of Wernicke encephalopathy, osmotic demyelination syndrome and thromboembolism.
Collapse
Affiliation(s)
- Cecilia Bottomley
- Department of Obstetrics and Gynaecology, St George's University of London, Cranmer Terrace, London, UK.
| | | |
Collapse
|
11
|
Abstract
Hyperemesis gravidarum is severe, intractable nausea and vomiting affecting 0.3-2% of pregnancies. It has a complex multifactorial aetiology. This review explores the current literature relating to the clinical manifestations, differential diagnosis, epidemiology, possible aetiology, maternal and fetal complications, and evidence-based management of hyperemesis.
Collapse
|
12
|
Abstract
This article thoroughly updates the authors' previous review of nutritional assessment and support during pregnancy. After briefly reviewing nutrient metabolism and requirements, the authors discuss the nutritional assessment of the pregnant woman and review the nutritional support principles in hyperemesis gravidarum and other conditions that can compromise the nutritional health of mother or fetus.
Collapse
Affiliation(s)
- Elie Hamaoui
- Maimonides Medical Center, 4802 Tenth Avenue, Brooklyn, NY 11219, USA.
| | | |
Collapse
|
13
|
Kaplan PB, Gücer F, Sayin NC, Yüksel M, Yüce MA, Yardim T. Maternal serum cytokine levels in women with hyperemesis gravidarum in the first trimester of pregnancy. Fertil Steril 2003; 79:498-502. [PMID: 12620429 DOI: 10.1016/s0015-0282(02)04699-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare serum cytokine levels in patients with hyperemesis gravidarum with levels in healthy pregnant and nonpregnant women. DESIGN Case-control study. SETTING Clinical and academic research center. PATIENT(S) Thirty women with hyperemesis gravidarum, 30 healthy women in the first trimester of pregnancy, and 30 healthy nonpregnant women. MAIN OUTCOME MEASURE(S) Serum levels of interleukin-1beta, interleukin-2 receptor, interleukin-6, interleukin-8, and tumor necrosis factor (TNF)-alpha. RESULT(S) Median serum levels of interleukin-2 receptor and interleukin-8 did not differ significantly among the three groups. Serum levels of interleukin-1beta and interleukin-6 were significantly higher in healthy pregnant women than in healthy nonpregnant women. Median TNF-alpha levels were significantly higher in women with hyperemesis (25.8 pg/mL [range, 4.9-140 pg/mL]) than in healthy pregnant and nonpregnant women (10.85 pg/mL [range, 4.1-35.8 pg/mL] and 12 pg/mL [4.3-68.2 pg/mL], respectively). CONCLUSION(S) Levels of TNF-alpha were significantly higher in patients with hyperemesis gravidarum than in healthy pregnant and nonpregnant women. Thus, TNF-alpha may be involved in the etiology of hyperemesis gravidarum.
Collapse
Affiliation(s)
- Petek Balkanli Kaplan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Trakya University, Edirne, Turkey.
| | | | | | | | | | | |
Collapse
|
14
|
Abstract
Health care providers and pregnant women share a concern for protecting the fetus from unnecessary and potentially teratogenic influences. Since the introduction of steroids for the induction of fetal surfactant production, there has been considerable experience in the use of corticosteroids during pregnancy. While the use of corticosteroids for surfactant induction in the preterm fetus has become commonplace, steroids are used for other obstetric and medical indications during pregnancy. Thus, finding a balance between drug benefits and possible side effects remains a critical issue.
Collapse
Affiliation(s)
- Deborah Cooper McGee
- Obstetrix Medical Group of Colorado, and Department of Nursing, Regis University, Denver, USA
| |
Collapse
|
15
|
Magee LA, Mazzotta P, Koren G. Evidence-based view of safety and effectiveness of pharmacologic therapy for nausea and vomiting of pregnancy (NVP). Am J Obstet Gynecol 2002; 186:S256-61. [PMID: 12011897 DOI: 10.1067/mob.2002.122596] [Citation(s) in RCA: 151] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our goal was to review the safety and effectiveness of available antiemetics for treatment of nausea and vomiting of pregnancy. STUDY DESIGN We performed a quantitative and qualitative overview of observational controlled studies for drug safety in pregnancy and randomized controlled trials for drug effectiveness for nausea and vomiting in pregnancy. RESULTS All of the following are safe and effective for treatment of varying degrees of nausea and vomiting in pregnancy: Bendectin/Diclectin (doxylamine, pyridoxine, dicyclomine), antihistamine (H(1)) blockers, and phenothiazines; however, the magnitude of effect, particularly for phenothiazines, is in question and may differ among individual agents. Pyridoxine and vitamin B(12)are safe and may be effective. Metoclopramide, droperidol, and ondansetron may be effective, but safety data are insufficient to recommend them as first-line agents. Corticosteroids may not be as beneficial as first thought, and there may be a small teratogenic risk. The relative effectiveness of various agents is largely unknown. CONCLUSION Many medications, particularly H(1)-antagonists and phenothiazines, are safe and effective for treatment of varying degrees of NVP.
Collapse
Affiliation(s)
- Laura A Magee
- Department of Specialized Women's Health, BC Women's Hospital and Health Centre, Vancouver, Canada.
| | | | | |
Collapse
|
16
|
Tratamiento con sonda de yeyunostomía en hiperemesis gravídica refractaria. CLINICA E INVESTIGACION EN GINECOLOGIA Y OBSTETRICIA 2002. [DOI: 10.1016/s0210-573x(02)77161-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
17
|
Abstract
Gastrointestinal diseases in pregnancy can be divided into diseases specific to pregnancy, for example, hyperemesis gravidarum, obstetric cholestasis, HELLP syndrome and acute fatty liver of pregnancy, and diseases incidental to pregnancy, for example, inflammatory bowel disease, dyspepsia, peptic ulcer disease and viral hepatitis. Disorders in the second category may present for the first time in pregnancy. This chapter considers the drug management of each of these conditions, with the exception of HELLP syndrome and acute fatty liver. The preferred drug treatment and the known complications associated with their use in pregnancy are also described. Where possible, studies relating to the safety of different therapeutic options are discussed.
Collapse
Affiliation(s)
- C Williamson
- Wellcome Advanced Clinical Fellow, Imperial College School of Medicine, London, UK
| |
Collapse
|