Nausea and Vomiting

Question 1

Recurrence

Answer 1

Wide range: 15-80%

Question 2

Hyperemesis Diagnostic Criteria

Answer 2

No definitive diagnostic criteria, diagnosis of exclusion

Most commonly cited: persistent vomiting not related to other causes…measure of acute starvation (large ketonuria)…at least 5% prepregnancy weight loss

Question 3

When in pregnancy does N/V occur in most women?

Answer 3

BEFORE 9 weeks.

Question 4

DDx of N/V in pregnancy

Answer 4

GI causes (gastroenteritis, gastroparesis, hepatitis, biliary tract disease, peptic ulcer disease, intestinal obstruction)

GU causes (degenerating fibroid/uremia/stones/ovarian torsion)

Metabolic (Addison’s Disease, porphyria, DKA, Hyperthyroid/hyperparathyroidism)

Neurologic (lymphocytic hypophysitis, tumors, vestibular tumor, migraines, pseudotumor cerebri)

Pregnancy Related (PreE, Acute Fatty Liver)

Drugs toxicity/intolerance
Psych

Question 5

When should you treat hyperthyroidism when present with hyperemesis?

Answer 5

Proof of primary thyroid disorder: Goiter present or presence of thyroid autoantibodies

Question 6

hCG stimulates what organ?

Answer 6

THYROID (so increase levels of Thyroid Hormone which neg feedback TSH, so TSH gets low)

Question 7

What produces hCG?

Answer 7

Placenta

Question 8

Another hormone responsible for N/V in pregnancy?

Answer 8

Estrogen

Question 9

Smokers have less risk for hyperemesis, why?

Answer 9

Lower levels of hcg and estrogen

Question 10

Risk factors for hyperemesis

Answer 10

Mother/sisters had it
Large placental mass (molar preg/multiple gestations)
Previous hyperemesis

Question 11

Significant morbidity from hyperemesis?

Answer 11

Wernicke’s Encephalopathy (Vitamin B1 deficiency/Thiamine)–> death/neurologic disability

Esophageal rupture

PTX

Splenic avulsion

Acute tubular necrosis

Question 12

Hyperemesis–most common fetal effect? other effects?

Answer 12

Low birthweight (LBW)/SGA

Death rare
Less miscarriage (placenta is healthy, producing hcg!)
Long term effects unknown
Generally good outcome with N/V in pregnancy

Question 13

Why important to treat first stages of N/V in pregnancy?

Answer 13

Reduce hospital admissions

Question 14

Nonmedical options for tx N/V

Answer 14

Ginger (reduces nausea, but not vomiting)
Protein (reduces sx more than fat/carbs)
Avoid inciting stimuli
Small frequent meals

Question 15

Prenatal vitamins can prevent or lessen N/V in pregnancy. How long to take prior to conception?

Answer 15

3 months

Question 16

Acupuncture pressure point? Does it work?

Answer 16

P6 (Neiguan, inside wrist) with acupuncuture, acupressure, accustimulation, wrist bands
Conflicting studies, 2 of the largest studies showed no different than placebo

Question 17

First line therapy to treat N/V pregnancy? Dosing?

Answer 17

Vitamin B6 (Pyridoxine) + Doxylamine (antihistamine/H1 blocker) = Diclegis (10mg/10mg) –> FDA approved for those who don’t respond to diet/lifestyle changes: 2 tabs at bedtime, if persistent take 2 tabs at bedtime and 1 tab morning of day 3. Max dose four tabs daily (can move to eventual 1 tab morn, afternoon, 2 at bedtime.

Vit B6 10-25mg/8hrs (some studies show good effect with severe, but not mild N/V!)

Question 18

Odansetron common side effects

Answer 18

drowsiness, headache, fatigue, constipation

Question 19

Dangerous side effect odansetron, how do you prevent it? Dose iv?

Answer 19

Prolonged QT interval –> Torsades

Avoid use in arrhythmias, hypokalemia, hypomagnesiemia

No greater than 16mg iv dose

Question 20

What other antiemetic can cause this dangerous side effect that zofran does?

Answer 20

droperidol

Question 21

Do Zofran or Reglan pumps work?

Answer 21

Limited data on efficacy; up to 30% have complications

Question 22

Safety of Zofran questionable in which trimester, causing what malformation in the fetus?

Answer 22

First Trimester
Cleft palate
Cardiac defects, esp. septum (studies are conflicting)–overall risk is LOW

Question 23

Is Zofran better than other drugs?

Answer 23

IV zofran vs. metoclopramide (Reglan) less xerostomia/drowsiness/persistent ketonuria in 24 hrs…similar efficacy

Zofran comp to diclegis more effective

Question 24

Meds CI in pts taking Zofran

Answer 24

Flagyl (BV)
Macrolides (Azithromycin/Erythromycin) (Chlamydia/PPROM)
Analgesics/Sedatives (Methadone)--heroin recovery
Fluoxetine (SSRI)
HIV protease inhibitors
TCA
Diuretics
Antihistamines (hydroxyzine)
Trazadone
Antipsychotics
Antimalarials
Antiarrhythmics

Question 25

Methylprednisolone fetal effects? How common is it? Dose? Does it work?

Answer 25

Cleft palate in first trimester use 1-2/1000 -- rare 48mg daily x3 days then 2 wk taper Some studies show reduced readmission, others not really

Question 26

Should we use methylprednisolone routinely? What gest age is safer for use?

Answer 26

It is not a first line agent; only use in REFRACTORY cases! | Avoid before 10 wks

Question 27

How long should we use methylprednisolone to observe response?

Answer 27

No response in 3 days, d/c use...then taper over 2 wks oral prednisone

Question 28

How do we avoid maternal adverse effects from prolonged steroid use?

Answer 28

Do not cont effective dose/tx hyperemesis for longer than 6 wks

Question 29

Presence of ketonuria indicate severity of hyperemesis?

Answer 29

No

Question 30

Labs that may be abnormal in hyperemisis

Answer 30

``` elevated amylase elevated ast/alt (300s highest) tsh low, elevated free thyroxine (T4) electrolytes elevated bili (less than 4mg/dL) ```

Question 31

What dx should we consider if hyperemesis persistent and resistant to standard therapies and how do we test for it? Tx?

Answer 31

Gastric Ulcer H. pylori H2-receptor antagonist + abx

Question 32

What kind of acidosis/alkalosis present with hyperemesis?

Answer 32

hypchloremic metabolic alkalosis

Question 33

What percentage of hyperemesis pts have abnormal thyroid labs?

Answer 33

70%

Question 34

When should hyperthyroidism resolve in hyperemesis without treatment?

Answer 34

20wks

Question 35

Do you need to routinely order thyroid studies on hyperemesis pts?

Answer 35

Not unless there is goiter present. Hyperthyroid rarely presents with N/V.

Question 36

What do we need to replenish in hyperemesis pts?

Answer 36

Thiamine first Dextrose Correct vitamin deficiencies Correct ketosis

Question 37

First line therapy in hyperemesis who cannot maintain weight/not responsive to medical therapy to maintain nutrition?

Answer 37

Enteral feedings (NGT or nasoduodenal tube)

Question 38

What about TPN?

Answer 38

Potentially life threatening: thromboembolism/sepsis | Adverse neonatal outcomes

Question 39

Why use a PICC line?

Answer 39

Peripherally inserted central catheters--to avoid central access, but still significant morbidity...only use when enteral feeding is not possible! LAST RESORT!

Question 40

Complications with PICC lines?

Answer 40

``` superficial thrombophlebitis cellulitis Line infections Mechanical line failure pain necessitating d/c line sepsis thromboembolism bacteremia most frequent major comp ```

Question 41

Hypnosis?

Answer 41

Some studies have shown effective