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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 


Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland
drlakshayem@gmail.com

Monday, September 4, 2017

Hyperemesis Gravidarum

Nausea and vomiting of pregnancy is generally seen in the first trimester. EM Mindset always starts with the "ruling out the life threats first", therefore we need to think of other life-threatening pathologies as well before labelling someone as "Simple Nausea and Vomiting of Pregnancy". 

Severe nausea and vomiting of pregnancy is known as hyperemesis gravidarum and is defined as intractable vomiting with weight loss >5%, volume depletion, and laboratory values showing hypokalemia or ketonemia. Findings on physical examination in nausea and vomiting of pregnancy are usually normal except for signs of volume depletion. 



Physical exam is often normal in Nausea and Vomiting of pregnancy

The presence of abdominal pain in nausea and vomiting of pregnancy or hyperemesis gravidarum is very atypical and should prompt further work up.   


Etiology
The exact mechanism remains unknown. One theory is that nausea and vomiting are protective in pregnancy as it reduces exposures to teratogenic materials while others believe that elevated human chorionic gonadotropin (hCG) or estradiol levels could be the cause.


Potential mimics
  • Ectopic Pregnancy, Molar Pregnancy
  • Appendicitis
  • Cholecystitis/Hepatitis
  • UTI (Pyelonephritis)
  • DKA
  • Pancreatitis
  • Ovarian Torsion
  • Pre-eclampsia
  • Gastroenteritis
  • Bowel Obstruction
  • HELLP Syndrome

Management
  • IV fluids containing 5% dextrose to replete volume and reverse ketonuria
  • Antiemetic drugs 
  • Thiamine 100 mg (to avoid Wernicke’s encephalopathy)
  • Oral fluids as and when possible


Serial measurements of urinary ketones can be used to determine success of therapy. With resolving ketonuria, correction of dyselectrolytemia and able to keep up with oral fluids, patients can usually be discharged with oral anti-emetics.There is no clear drug of choice. Options include Diphenhydramine, Ondansetron, Prochlorperazine, Phenothiazines, Doxylamine and pyridoxine, Metocloperamide. 

Steroids are used as last resort in patients who require parenteral nutrition due to weight loss. However, corticosteroids should be used with caution or possibly avoided before 10 weeks gestation as recent studies have linked oral clefts with methylprednisolone use in the first trimester.


Complications
  • Wernicke’s encephalopathy
  • Acute Renal Failure 
  • Central pontine myelinolysis
  • Mallory-Weiss tear
  • Pneumomediastinum


Admission Criteria

  • Uncertain Diagnosis
  • Any complications 
  • Unable to tolerate orally
  • Persistent ketonuria or dyselectrolytemia
  • Weight loss >10% prepregnancy weight. 

References:
  1. Current Diagnosis and Treatment Emergency Medicine 7e, Chapter 38. Obstetric and Gynecological Emergencies and Rape. Ryan Tucker, MD; Melissa Platt, MD
  2. Goodwin TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am 2008;35(3):401–417 [PubMed: 18760227].


Posted by:

              
     Lakshay Chanana
     
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine
     England

     @EMDidactic




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