Percutaneous Endoscopic Jejunostomy Tube Placement for Treatment of Severe Hyperemesis Gravidarum in Pregnancy

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].

Investigating gastrointestinal disorders in pregnancy

This article reviews anatomical and physiological changes and alterations in reference intervals for laboratory tests in healthy pregnancy, pertinent to investigation of the gastrointestinal system. The safety of procedures and radiological investigations relevant to the investigation of gastrointestinal disorders in pregnancy are also reviewed.

Safety of Percutaneous Endoscopic Gastrostomy Placement in Pregnancy: A Case Report and Literature Review

Gastrostomy tube placement in pregnancy is historically contraindicated due to risk of injury to the developing fetus and exposure to anesthetic agents. However, in cases where oral nutritional access is severely jeopardized, percutaneous endoscopic gastrostomy (PEG) tube placement can be a life-saving measure. In this case report and literature review, we present a case of successful PEG placement in a pregnant woman, followed by a discussion of the existing literature regarding PEG placement during pregnancy.