OBSTETRICS د.اسراء المعيني HYPER EMESIS GRAVIDARUM

1. OBSTETRICSد.اسراء المعينيHYPER EMESIS GRAVIDARUM

2. Define as: persistent vomiting in pregnancy not due to other causes, an indicator of acute starvation (large ketonuria) ,loss of 5%of pre pregnancy weight

3. INCIDENCE • 0.5 -2% higher incidence in younger than in older women

4. AETIOLOGY • Related to a product of placental metabolism it occurs commonly with advanced molar gestation and multiple gestation . • There is correlation with, HCG, estradiol level ,pyridoxin deficiency ,psychological factors ,biochemical hyperthyroidism corelate with severity of nvp,an association between helicobacter pylori seropositive and hyperemesisgravidarum may exist.

5. RISK FACTORS • Worse nusea and vomiting • Younger age, hx of motion sickness, hx of contraception sickness, hx of migaine ,earlier in the day ,female gender of patient • Associations unique to n.v.of pregnancy • Family hx ,female gender of fetus, hx of migraine ,multiple gestation ,down syndrome ,molar gestation • Maternal metabolic disorder • Genetics of HG • In monozygotic twins • Siblings and mother of patients • Ethnic groups • PSYCHOPATHOLOGY • As a result of the mothers inability to respond to life stress

6. CLINICAL FEATURE • Nvp 60% symptomatic by 6weeks, 90% have no symptoms by 16weeks peak incidence between 8-12 weeks in HG can extended beyond 20, 30weeks of gestation • SIGN AND SYMPTOMS • N ,V, excess salivation (ptylism) 60% of patients, dehydration (dry and coated tongue ,skin turgordecrease,postural changes in blood pressure), significant weight loss ,jaundice ,various palsy , metabolic acidosis

7. LABROTORIES FINDING • 1-Hyper thyroidism transient and dose not require specific treatment TSH suppressed • 2-Liver enzymes increase transiently ,bilirubin concentration increase liver dysfunction resolve with termination of pregnancy • 3-s. amylase increase • 4-electroyte abn ,decrease Na, k, cl • 5-complete blood picture , increase PCV • 6- GUE ,for keton ,albumin, and specific gravity • 7-Renal function test increase blood urea and creatinine • 8- metabolic alkalosis • 9-US to cofirmation of pregnancy and rule out molar pregnancy

8. COMPLICATION • WERNICKES ENCEPHALOPATHY • CNS dysfunction is due to a deficiency in thiamine vitamin B1 present with apathy ,confusion ,ataxia, nystagmus ,blindness ,majority either died or end with permanent residual dysfunction • Cardiac dysfunction • prevented 3mg of B1 daily if vomiting sufficient to requireI.V hydration .100mg thiamine parenteraly daily for 3days if patient n hospital for HG • Pneumothorax , mallory weiss tears of esophagus , rupture ,splinic avulsion , acute tubular necrosis ,central pontine mylenolysis ,and acute peripheral neuropathy • If HG associated with weight loss more than5% associated with poor fetal out come ,low birth weight fetus,fetal death

9. DIFFRENTIAL DIAGNOSIS • GIT • Peptic ulcer • Pancreatitis • Gasroentteritis • GUT • Pyelonephritis • Uremia • Degenerative uterine fleiomyoma • Renal stone • METABO • DKA • Hyperthyroidism • NEUROLOGICAL • Tumors of CNS • MISCELLANEOUS • Drug intolerance • Psychological • PREGNANCYRELATED CONDITION • Acute faty liverof pregnancy

10. MANAGEMENT • Prevention there is evidence that women who taking multivitamins at the time of conception and in early pregnancy are less likely to require intervention for HG later in pregnancy • Diet and support • To at small portion of whatever seems palatable when ever symptoms allow ,less nusea associated with protein meals compared to CHO and fat and liquid meals are better tolerated than solid • Redesign the home environment to avoid sensory stimuli that provoke symptoms,

11. Indication for admission; • 1-severe dehydration and in ability to tolerate oral fluids • 2- sever electrolyte abno. • 3-.acidosis • 4- infection • 5- malnutrition • 6- wt loss

12. Pharmacological and alternative therapy • -Replace fluids (ringer solution is good choice glucose multivitamins Mg dextrose solution may stop fat break down • -Continue treatment until patient can tolerate oral fluid and until or no keton in the urine • Antiemetics- • 1-B6 10-30 mg per day safe if continue vomiting for 48 h so • 2-antihistamines B6+doxylamine (10+10mg) 3-4 times per day for 48 h

13. 3-Ginger tablets 250mg four times per day unsure safety • 4-Persistant symptoms with or with out dehydration - • Prochlorperazine • (stimetile) 25mg per 12 hour, safety for use during pregnancy has not been established. • Metaclopramide 5-10mg per 8hours po or IV • 5-Dehydrationor weight loss thaimine 100mg iv per day for 3days continue

14. 6-Meclizine 25-50 po/ 12-24 hours not exceed 100mg per day class B central acting. • 7-Methylpredinsolone up to 16 mg three time for three days taper over 2 weeks to lowest effective dose total duration 6 weeks ,if patient unable to mantain weight ,institute total entral or parentral nutrition.

15. THYROID DISORDER • During pregnancy ,the production of thyroid binding globulin by the liver doubles as a result of estrogenic stimulation ,as consequence, there is an increased amount of total thyroxin T4 and tri-iodothyronine T3,no significant change in the amount of circulating free thyroid hormoneFT3,FT4 renal clearance of iodine increase in pregnancy

16. MATERNAL HYPERTYROIDISM • Occur in 1:500 pregnancy 90%of cases are secondary to graves disease this autoimmune disorder is associated with the presence of circulating thyroid-stimulating antibodies other causes • Toxic nodule- • Hashimotos thyroiditis- • Multinodular goiter -

17. CLINICALY • The diagnosis may be difficult to make in pregnancy because mild maternal tachycardia ,weight loss, heart mumurs and heat intolerance are all symptoms in early pregnancy ,thyroid function test

18. Hyperthyroidism is confirmed by high levels of FT3, FT4 with reduce level of TSH • Uncontrolled maternal hyperthyroidism is associated with maternal cardiac arrhythmias ,including atrrial fibrillation, dairrhoea ,vomiting, abdominal pains ,psychosis(thyrotoxic crisis) ,gestational hypertension ,PE, if thyroid stimulating antibodies present may cross the placenta and cause fetal thyrotoxicosis and goiter . • Fetal complication include :miscarriage , fetal growth restriction ,still birth ,fetal tachycardia and prematurity.

19. Treatment • Treatment should start during pregnancy to maintain maternal FT3 FT4 levels in the high/normal rang. • Radioactive iodine is contraindicated because it completely obliterates the fetal thyroid gland .

20. Treatment is usually medical with carbimazole or propylthiouracil both cross placenta fetal hypothyroidism rarely seen ,beta blokers may be indicated initially before the anti thyroid drugs take effect .women should not discouraged from breast feeding but to feed before taking the medication, and to take it in divided doses. • Surgical treatment may be necessary in rare circumstances when no response to medical treatment , • the lowest dose of drug must be used because high doses cross the placenta and may cause fetal hypothyroidism

21. MATERNAL HYPOTHYROIDISM • 1% of pregnant lady , • with adequate thyroxin replacement no adverse pregnancy out come • Hypothyroidism associated with • congenital abnormality • HT ,PTL ,IUGR ,PPH, • subfertility with autoantibodies even mother euthyroid state at increase risk of miscarriage, if hypothyroid not treated adequately can result in neurodevelopmental delay at 7_9years

22. -The commonest cause is iodine deficiency , maternal iodine deficiency associated with development of cretinism in the newborn as a result of congenital hypothyroidism . • -Autoimmune hashimotos thyroiditis, if treated can result in hypothyroidism , T4 supplement is required , dose should check early in pregnancy, should continue on full thyroid replacement through out of pregnancy serial TFT performed each trimester, to maintain FT4 at upper end of normal rang for each trimester,.

23. Pituitary disorders: • Hyperprolactinaemia: is an important cause of amenorrhea and infertility in pregnancy it is most often • Due to microadenoma, treated with bromocriptine and cabergoline (dopamine agonist) in 80% of cases tumor decrease in size. • or caused by macro adenoma , drugs or dissconnecting tumor • which might need surgery or radiotherapy which is best undertaken befor pregnancy.

24. Drugs usually stopped in pregnancy,pituitary enlarge during pregnancy but rare for microadenoma to cause problem. • Visual fields during pregnancy should be monitor if evidence of tumor growth during pregnancy drugs should be recommended, if macroadenoma(>1 cm )it is best to continue with dopamine agonist because risk of the tumor enlargement • There is no evidence that drugs are teratogenic.

25. Adrenal disorders: • Cushing s syndrom: • All adrenal disease rare in pregnancy • It characterized by increase glucocorticoid production ,due to hypersecretion of adrenocorticotriphic hormone from piuitarytumor,in pregnancy adrenal cause is more common. • Most female are infertile few cases of pregnancy a high incidence of preterm delivery and still birth

26. Dx: is dificult because symptoms mimic norma pregnancy changes such as striae ,weight gain, weakness,hypertension, glucose intolerance • If suspected plasma cortisol level should be assayed (level in pregnancy increased),CT ,US ,MRI should be used .

27. Addison s disease • Adrenal insufficiency is usually an autoimmune process . • c.f: • exhaustion ,nusea, hypotension ,hypoglycemia and weight loss- • dx: • difficult in pregnancy because the cortisol levels may be low-normal range due to the physiological increase in cortisol –binding globulin in pregnancy.

28. Occasionally ,the disease may present as a crisis and treatment consists of glucocorticoid and fluid replacement. • -in adequatly treated patients , the pregnancy usually continue normally. • Treatment: • Replacement with steroids should be continued in pregnancy and parenteral use at time of stress such as delivery and hyper emesis gravidarum.

29. Phaeochromocytoma: • Is a rare catecholamine producing tumour. • 90% arise in adrenal medulla,in pregnancy present as hyper tensive crisis like PE,a characteristic feature is paraxysmalHT,other features like headache blurring of vision ,anxiety, convulsion

30. DIAGNOSIS: • 24 hours urine collection and measurement the level of catechol amine • If elevated measure in plasma • Treatment: • Alpha-blocked with phentolamine • C.S is the preffered mode of delivery,to avoid the sudden increase in catecholamine associated wih delivery