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Management
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The standard recommendation to take prenatal vitamins for 3 months before conception may reduce the incidence and severity of nausea and vomiting in pregnancy.
Many women with mild NVP do not consult a physician, because the general condition is quite satisfactory, and a mild NVP is considered a manifestation of normal pregnancy. As a rule, management of pregnant women with mild NVP is outpatient.
Dietary and lifestyle changes should be liberally encouraged, and women should be counselled to eat whatever appeals to them.
Diet Modifications are:
- more frequent meals, smaller portions
- Avoid fatty, creamy foods, which slow down gastric emptying.
- Eat mainly carbohydrates, which are bland such as potatoes, pasta, rice, or soups including these.
- Receiving any beverage, including broth in small sips for a total of 1- 1. 5 L/ day to prevent dehydration. In this case, it does not cause vomiting.
Baked or boiled chicken or fish can be taken in small quantities, as it is more easily digestible.
Sleep requirements increase in early pregnancy. Because fatigue seems to exacerbate NVP, women should be encouraged to increase their rest, especially while they are symptomatic.
Ginger (Zingiber officinale) is used as non-pharmacologic remedy to reduced the severity of NVP symptoms in women with mild form of the disease. It is present as a spice in foods and beverages. It can also be taken in the form of tea or tablet extracts, as well as a candied root or piece of natural root under the tongue. Acupuncture and acupressure may be beneficial too.
Medication
When conservative measures have not been effective, pharmacological intervention is warranted. First-line pharmacotherapy for mild NVP is vitamin, or doxylamine, orvitamin B6 plus doxylamine, which are safe and effective.
Any of these could be first choices:
– Vit. B6- 10-25 mg by mouth TID
– Ginger- 250 mg by mouth QID
– Doxylamine (Unisom OTC)- 25mg by mouth QD
Moderate vomiting. The main clinical feature is nausea and vomiting, which may occur at any time of the day, 5-10 times a day, more often after meal. Loss of appetite, perversion of taste and olfaction, loss of body weight are characteristic of this type of vomiting. Metabolic derangements are of great significance; hypersalivation is very frequent and may lead to dehydration of the pregnant. Pulse rate is about 100-120 per minute; a subfebrile condition, hypotension, xeroderma and disturbances of carbohydrate, fat, water, mineral and other types of metabolism take place in a moderate form of vomiting.
Management
Admission to hospital is necessary.
Medication unclude following groups:
• Pyridoxine (Vit. B6). 10-25 mg TID.
• Ginger root. 250 mg QID.
• Antihistamines – more sedating.
Doxylamine (Unisom) 25 mg by mouth QD. Doxylamine is an antihistamine with anti-allergic, hypnotic, sedative effect. In April 2013, the US Food and Drug Administration (FDA) approved doxylamine succinate 10 mg and pyridoxine hydrochloride 10 mg as a delayed-release combination pill called Diclegis (Diclectin®) for the treatment of NVP (as a 1st line therapy). The standard dose of Diclectin® is 4 tablets/day and is recommended to be taken as 2 tablets at bedtime, 1 in the morning and 1 in the afternoon. It may take several days to experience the full effect of the medication, and women should not discontinue therapy or be discouraged if they don’t find immediate relief. The standard dosage can be adjusted based on severity of NVP and maternal weight. The safety of higher doses of up to 12 tablets per day has been demonstrated without increasing adverse effects, or fetal risk; side effects of tiredness, drowsiness and sleepiness, as well as birth defects and birth weight, were not increased with supra doses of Diclectin®.
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• Other antihistamines:
- Diphenhydramine(Benadryl) 25-50 mg by mouth every 4-8 hrs.
- Meclizine (Antivert) 25 mg by mouth every 4-6 hrs.
- Dimenhydrinate (Dramamine) 50-100 mg by mouth every 4-6 hrs.
• Metoclopramide (Reglan) 5-10 mg po TID. Reglan (metoclopramide) increases muscle contractions in the upper digestive tract. This speeds up the rate at which the stomach empties into the intestines. Other anti-emetics are:
- Chlorpromazine (Thorazine): 10-25 mg by mouth BID to TID.
- Prochlorperazine (Compazine): 5-10 mg by mouth TID to QID.
- Promethazine (Phenergan): 12. 5 to 25 mg by mouth every 4-6 hrs.
- Trimethobenzamide (Tigan): 250 mg by mouth TID to QID.
- Ondansetron (Zofran): 8 mg p by mouth BID to TID.
• Transfusion therapy.
When dehydration is demonstrated at any time in the course of evaluation and treatment of NVP, intravenous rehydration is warranted. Aims of infusional therapy: restoration of electrolyte balances, improvement of microcirculation and blood supply of vital organs and systems, correction of main types of metabolism, deintoxication.
Serum albumins 200. 0 a day intravenously (or frozen plasma, protein) 2-3 times in total. A 5% glucose solution in combination with insulin, sodium chloride solution, Ringer’s solution may be administered for detoxication.
Totally about 1, 500-2, 000 ml of solution may be taken intravenously during a day.
In order to prevent dangerous complications, diurnal urine excretion should be checked up.
Hyperemesis gravidarum (a severe form). Hyperemesis gravidarum (HG) is a condition of severe nausea and vomiting during pregnancy leading to fluid, electrolyte and acid-base imbalance, nutritional deficiency and weight loss. In this case the patient has vomiting more than 10 times a day. A severe intoxication is characterized by high temperature, tachycardia (more than 120 per minute), hypotension, paleness and yellowness of skin, xeroderma, and dermatosis. A sharp smell of acetone is marked. More over, acetonemia, proteinuria, cylindruria and oliguria are revealed on laboratory investigation. All kinds of metabolism are disturbed. A weight loss of more than 3 kg or 5% of body weight is typical. In addition to severe nausea and vomiting, 60% of women with HG also have excess salivation or ptyalism.
Vomiting is not connected with taking meals, it may occur at any time of the day, up to 10-24 times a day. The organism does not assimilate any food and liquid (even water). And those are the reasons of metabolic disturbances. The symptoms of the central nervous system disturbances develop and the death of pregnant may occur as a result of multifunctional insufficiency. The diagnosis is based on determination of bilirubin, ketosis, and electrolyte level in blood, acetone, and biliary pigments in urine, control of body weight, diuresis and clinical findings. Hyperemesis gravidarum is a clinical condition with generally agreed upon symptoms. Laboratory abnormalities in women with HG may include increased serum blood urea nitrogen, creatinine, and hematocrit, as well as ketonuria and increased urine specific gravity. In addition, electrolyte disturbances supporting a diagnosis of either hypochloremic metabolic alkalosis or metabolic acidosis with severe volume contraction may be found. Pre-albumin (plasma transthyretin) levels may be low, reflecting poor protein nutrition status in the mother and possibly predicting lower fetal birth weights. Vitamin and mineral deficiencies such as vitamin B1 (thiamine), iron, calcium, and folate are also possible.
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Treatment should be intensive, urgent and complex.
The main principles are:
· Treatment-and-protective regimen.
· Antiemetics.
· Transfusion therapy: albumin, plasma, protein, 5% and 10% solution of glucose, rheopolygluckinum, Ringer solution, 40 ml of molar solution of sodium lactate (40 ml of this solution contains 4 ml of 85% lactic acid in the form of sodium lactate; 40 ml of this solution is diluted with 200 ml of sterile distilled water, and isotonic solution yields). Daily volume of infusion is about 30 ml/kg of body weight (or about 2500. 0 ml).
· Desensitizing therapy, vitamins and symptomatic medicines.
· Parenteral nutrition- women with hyperemesis gravidarum should be supported with enteral (tube feedings) or parenteral nutrition and intravenous fluids.
The prognosis is unfavorable in the event of signs of a threatening condition that determine the indications for an emergency termination of pregnancy. These signs are the following: progressive weakness, euphoria, and delirium, tachycardia (up to 110-120 beats / min), hypotension (up to 90 -80 mmHg), jaundice, pain in the right upper quadrant, decreased diuresis (up to 300- 400 ml per day), hyperbilirubinemia (within 100 μ mol / l), increased levels of residual nitrogen, urea, proteinuria, cylindruria. If a complex urgent therapy is not effective during 24 -48 hours, emergency termination of pregnancy is indicated.
Self Test
1. Which of the following is not a risk factor for NVP?
A. Smoking
B. Increased placental mass
C. NVP in a previous pregnancy
D. Having a family member who experienced HG
E. Carrying a female fetus
2. NVP is associated with which of the following fetal effects?
A. Deafness
B. Increased risk for fetal malformation
C. Lower rates of miscarriage
D. Higher birthweights
E. None of the above
3. Taking prenatal vitamins to reduce the incidence and severity of NVP is best initiated:
A During the first 3 months of gestation
B. Three months before conception
C. At the onset of symptoms
D. Taking prenatal vitamins has no significant effect on NVP
4. Which statement reflects a current recommendation for pharmacologic treatment of NVP?
A. The combination of doxylamine and vitamin B6 is unsafe for use during pregnancy
B. Doxylamine and vitamin B6 taken together is a safe and effective first-line pharmacotherapy during pregnancy
C. Pregnant women can safely take hydroxyzine with ondansetron
D. Methylprednisolone is considered safe during the first trimester
5. Which statement accords with the 2015 ACOG guidelines?
A. Treatment with ginger capsules reduces nausea and vomiting
B. Acupressure reduces NVP symptoms
C. Prompt treatment of NVP will not prevent progression to HG
D Treatment with turmeric capsules reduces vomiting
6. True or false? Hyperthyroidism in patients with HG is confirmed by measurement of free thyroxine and free triiodothyronine concentrations.
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A. True
B. False
C. subjective symptoms
D. quantity of protein in urine
E. quantity of protein in blood
7. Which statement about methylprednisolone for severe NVP or HG is true?
A. Methylprednisolone is used in the first trimester as first-line pharmacotherapy
B. Intravenous use of methylprednisolone, followed by an oral tapering regimen, reduces rehospitalization
C. No relationship exists between cleft lip or cleft palate, and methylprednisolone
D. For severe vomiting during pregnancy, methylprednisolone use is considered safe for 12 weeks
E. Methylprednisolone can be used when first-line treatments have not reduced severe vomiting
8. What is recommended as first-line management of severe NVP in a woman who is unable to tolerate food or liquids?
A. Medical hypnosis
B. Enteral feeding with a nasogastric or nasoduodenal tube
C. Parenteral therapy with dextrose, vitamins, and thiamine
D. Total parenteral nutrition using a central venous catheter (CVC)
E. Total parenteral nutrition using a percutaneously inserted central catheter (PICC)
Chapter 23. Hypertension in pregnancy
Hypertensive disorders of pregnancy remain leading causes of maternal and perinatal morbidity and mortality. Synonyms are: pregnancy hypertension, pregnancy induced hypertension, preeclampsia, eclampsia, pregnancy induced hypertension.
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