GIT disorders Flashcards
What are the causes of hyperemesis gravidarum?
- high HCG
- estrogen & thyroid hormone may be involved
associated with
- multiple pregnancy
- molar pregnancy
- clinical hyperthyroidism
What is the clinical picture of hyperemesis gravidarum?
- > 5% pre pregnancy weight loss
- dehydration: pallor, hypotension, tachycardia
- electrolyte imbalance: metabolic alkalosis
What are the effects of hyperemesis gravidarum on pregnancy?
on MOTHER
- Mallory Weiss tear
- VTE
- Wernicke’s enecephalopathy + Korsakoff psychosis
on BABY
- low birth weight
- fetal death
What is the cause of Wernicke’s encephalopathy?
Vitamin B1 thiamin deficiency
What are the sign & symptoms of Wernicke’s encephalopathy?
Symptoms
- blurred vision
- confusion
- unsteadiness
- memory problem
Signs
- nystagmus
- opthalmoplegia
- hyporeflexia
How is Wernicke’s encephalopathy diagnosed?
Clinically but can be confirmed by MRI
What are the investigations done for hyperemesis gravidarum?
Blood test
- CBC: leucocytosis, hemoconcentration
- electrolytes: hyponatremia, hypokalemia, metabolic alkalosis
- Liver Function Tests: abnormal in 50%
- Thyroid Function Tests: abnormal in 66%
Ultrasound
- gestational age
- number of fetuses
- exclude molar pregnancy
Urine
- ketonuria
How is hyperemesis gravidarum managed?
1- Emotional support & reassurance that it resolves by 20 weeks
2- Rehydration: IV normal saline solution with potassium chloride
3- Anti-emetics: H1 receptor antagonist, phenothiazine’s, dopamine antagonist (Metoclopramide), seretonin inhibitors (Odansetron
4- Steroids incase of vomiting refractory for treatment
5- thromboprophylaxis with LMWH
6- termination of pregnancy if not treated with anything
all women admitted with prolonged vomiting should be on thiamine supplementation
What is the management of hyperemesis gravidarum according to classification?
Mild
- small frequent meals
- ginger extract
- B6 (pyridoxine)
Moderate
- promethazine
- metoclopramide
- ondansetron
- prochlorperazine
Severe
- IV hydration with thiamine
- Parenteral: metoclopramide, ondasetron, promethazine
Intractable
- Chlorpromazine
- Methylprednisolone
- Enternal nutrition
LAST RESORT
- termination of pregnancy
What are the symptoms of intrahepatic cholestasis?
In second half of pregnancy
- pruritus without rash
- jaundice
- anorexia
- malaise
What is the mechanism of intrahepatic cholestasis?
increase in cholestatic effect of estrogen in genetically predisposed patients
- positive family history is found in 35%
What investigations should be done for intrahepatic cholestasis?
- LFT: increased serum bile acids > 10 fold, increased AST, ALT, increased direct bilirubin
- Coagulation profile: PT, APTT, INR
- Liver ultrasound: exclude other causes (stones)
- Viral serology: exclude HCV, HBV, CMV, HEV
- Liver autoantibodies: exclude antimitochondrial, antismooth muscle antibodies
exclude all other causes of jaundice first
How is intrahepatic cholestasis managed?
- for pruritis -> ursodeoxyxholic acid (UDCA)
- enterohepatic circulation -> cholestyramine to decrease it
- weekly LFT
- Vitamin K for women with prolonged PT
- fetal wellbeing monitoring
- induce labor at 37 weeks
- intensive monitoring during labor
- neonate should receive vitamin K
fully reversible postpartum within 1-2 weeks
What are the effects of intrahepatic cholestasis on pregnancy?
- fetal growth restriction
- fetal death
- preterm birth
- fetal intracranial hemorrhage
- postpartum hemorrhage
- recurrence risk is 90%
What is the pathophysiology & prognosis of acute fatty liver in pregnancy?
dysfunction of fatty acid oxidation
- more in primigravida’s & male fetuses
life threatening third trimester complication
- 20% maternal mortality
