Profound Hypokalaemia Resulting in Maternal Cardiac Arrest: A Catastrophic Complication of Hyperemesis Gravidarum?

Multiple electrolyte derangements among perioperative women with obstructed labour in eastern Uganda: A cross-sectional study

There is a dearth of information on the patterns of electrolyte derangements among perioperative women with obstructed labour. We measured the levels and patterns of electrolyte derangements among women with obstructed labour in eastern Uganda. This was a secondary analysis of data for 389 patients with obstructed labour, diagnosed by either an obstetrician or medical officer on duty between July 2018 and June 2019. Five milliliters of venous blood was drawn from the antecubital fossa under an aseptic procedure for electrolytes and complete blood analyses. The primary outcome was the prevalence of electrolyte derangements, defined as values outside the normal ranges: Potassium 3.3-5.1 mmol/L, Sodium 130-148 mmol/L, Chloride 97-109 mmol/L, Magnesium 0.55-1.10 mmol/L, Calcium (Total) 2.05-2.42 mmol/L, and Bicarbonate 20-24 mmol/L. The most prevalent electrolyte derangement was hypobicarbonatemia [85.8% (334/389)], followed by hypocalcaemia [29.1% (113/389)], then hyponatremia [18% (70/389)]. Hyperchloraemia [4.1% (16/389)], hyperbicarbonatemia [3.1% (12/389)], hypercalcaemia [2.8% (11/389)] and hypermagnesemia [2.8% (11/389)] were seen in a minority of the study participants. A total of 209/389 (53.7%) of the participants had multiple electrolyte derangements. Women who used herbal medicines had 1.6 times the odds of having multiple electrolyte derangements as those who did not use herbal medicines [Adjusted Odds Ratio (AOR): 1.6; 95% Confidence Interval (CI): (1.0-2.5)]. Having multiple electrolyte derangements was associated with perinatal death although this estimate was not precise [AOR 2.1; 95% CI: (0.9-4.7)]. Women with obstructed labour in the perioperative period have multiple electrolyte derangements. Use of herbal medicines in labour was associated with having multiple electrolyte derangements. We recommend routine assessment of electrolytes prior to surgery in patients with obstructed labour.

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.

Hyperemesis gravidarum followed by refeeding syndrome causes electrolyte abnormalities induced rhabdomyolysis and diabetes insipidus

Although hyperemesis gravidarum (HG), an extreme form of morning sickness, is a common complication during pregnancy, HG associated simultaneous onset of rhabdomyolysis and diabetes insipidus due to electrolyte abnormalities are rare. A 34-year-old woman with severe HG at 17 weeks of gestation complicated with appetite loss, weight reduction by 17 kg, general fatigue, myalgia, weakness and polyuria was identified to have simultaneous hypophosphatemia (1.6 mg/dL) and hypokalemia (2.0 mEq/L). Appetite recovery and the improvement of the hypophosphatemia (3.2 mg/dL) were observed prior to the first visit to our department. At the admission, she presented polyuria around 7,000~8,000 mL/day with impaired concentrating activity (U-Osm 185 mOsm/L), and abnormal creatine kinase elevation (4,505 U/L). The electrolyte disturbances and physio-metabolic abnormalities in undernourished state due to HG let us diagnose this case as refeeding syndrome (RFS). In this case, abnormal loss by vomiting, insufficient intake and previous inappropriate fluid infusion as well as the development of RFS may accelerate the severity of hypokalemia due to HG. Thus, as her abnormalities were considered as results of rhabdomyolysis and diabetes insipidus due to severe HG associated hypokalemia based on RFS, oral supplementation of potassium chloride was initiated. After 6 days of potassium supplementation, her symptoms and biochemical abnormalities were completely resolved. Severe HG followed by RFS can be causes of electrolyte abnormalities and subsequent complications, including rhabdomyolysis and renal diabetes insipidus. Appropriate diagnosis and prompt interventions including adequate nutrition are necessary to prevent electrolyte imbalance induced cardiac, neuromuscular and/or renal complications.