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Nausea and Vomiting in Pregnancy

Nausea. Unpleasant sensation at back of throatAwareness of urge to vomitOften accompanied by cold sweatpallorsalivationdisinterest in surroundingsloss of gastric toneduodenal contractionsreflux of intestinal contents into stomach. Retching. Spasmodic, rhythmic contractions of respiratory m

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Nausea and Vomiting in Pregnancy

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    1. BY Prof. Dr. Mohammad Emam Prof. of Obstetrics and Gynecology Mansoura Faculty of Medicine Mansoura Integrated Fertility Center (MIFC) EGYPT Nausea and Vomiting in Pregnancy

    5. Epidemiology Up to 90% of pregnant women have nausea Up to 55% have vomiting Occurs between 4-16 weeks Usually mild, self-limited 5% are nauseated until delivery. Nausea and vomiting are worse in morning. May continue throughout the day. Not disturb the patient's health or her pregnancy. 2003 Monitoring the Future statistics 2003 Monitoring the Future statistics

    6. Epidemiology Primigravida Young women Obesity History of motion sickness Nausea/vomiting with oral contraceptives Psychiatric issues

    7. Pathophysiology Not fully understood Correlated with increasing hCG . Correlation with smooth muscle relaxation? Correlation with thyroid, progesterone, estrogen, adrenal hormones?

    8. I. During early pregnancy A. Obstetric causes Vesicular mole. Multiple pregnancy. Hydramnios. Retroverted gravid uterus. B. Non obstetric causes 1. Gastrointestinal causes Appendicitis. Cholecystitis. Peptic ulcers. Gastroenteritis. Intestinal obstruction. Hiatus hernia.

    9. Causes I. During early pregnancy B. Non obstetric causes ( continue) 2. Liver Viral hepatitis. 3. Pyelitis with pregnancy 4.Cerebral tumors. 5. Infectious fevers. 6. Red degeneration in a fibroid with pregnancy . 7. Torsion of ovarian cyst during pregnancy

    10. Causes II. Persistent vomiting late in pregnancy Pregnancy induced hypertension: severe preeclampsia, eminent eclampsia. Abruptio placenta. Other non obstetric causes of vomiting.

    11. Treatment-Mild Support and Reassurance Avoidance of triggering foods and odors. Frequent small meals Eating dry toast or crackers before rising. Drugs

    12. Prognosis Generally excellent Incidence of fetal demise is lower Birth weight, congenital FD unchanged. Untreated hyperemesis have high morbidity and mortality HG is associated with decreased gestational age.

    13. Hyperemesis Gravidarum

    14. Definition Protracted and severe vomiting before the 20th week of gestation that affects the general condition of patient and requires admission to hospital .

    15. Epidemiology Is the most severe manifestation of the spectrum of nausea and vomiting of pregnancy. It complicates 0.3 to 2% of all pregnancies. Typically occurs in first trimester. Vomiting with weight loss >5% of pre-pregnant weight.

    16. Epidemiology Dehydration, electrolyte imbalance and acid base disturbances . may lead to renal and hepatic injury . At risk for growth restriction and fetal anomalies .

    17. Risk Factors for HG Pgda Multiple pregnancy. Under the age of 24. PH of HG. Obesity. Female fetus.

    18. Causes of HG Theories: High levels of hCG (stim CRTZ, as in multiple molar). Increased estrogen levels & allergy. Psychological factors. High-fat diet. Thyroid gland activation in early pregnancy. Vitamin B6 deficiency. PG. Helicobacter pylori(HP) ???

    19. What is HP? Is a spiral-shaped gram negative rods found on gastric mucosa particularly the antrum .

    20. Prevalence of HP Very common all over the world 55% . 90% In peptic ulcer. 60% - 80% in gastritis without ulcer. Developing > developed. In Egypt very common at young age .

    21. Transmission HP Oral Oral. Faecal Oral. Vectorial. Iatrogenic.

    22. Biochemical changes Electrolytes disturbances (decreased Na+, decreased Cl-). Hypovolemia. Hemoconcentration (increased viscosity). Oliguria. Starvation. Ketoacidosis. ketone bodies accumulation (Ketonuria). Vitamin deficiency (B6, B1).

    23. Clinical Picture It starts as morning sickness that become aggravated gradually 1. Manifestations of dehydration as Sunken eyes. Dry tongue. Dry wrinkled skin. Oliguria.

    24. Clinical Picture 2. Manifestations of starvation as: Emaciation. Loss of weight. 3. General Examination: Vital signs :decreased blood pressure, tachycardia, and subnormal temperature. Jaundice in severe cases Urine: Oliguria in late cases

    25. Clinical Picture 4. Nervous manifestations in severe cases. Peripheral neuritis resulting in pain & tingling sensation. Wernicke's encephalopathy (nystagmus, optic neuritis & diplopia). Korsakoff's syndrome (confusion & loss of memory for recent events).

    26. Investigations 1. Sonar: to exclude multiple pregnancy & exclude vesicular mole. 2. Serum electrolytes (decreased of Na & Cl) 3. Renal function tests. 4. Liver function test. 5. Urine analysis. 6. Complete blood count. 7. Ophthalmic examination .

    27. Treatment Hospitalization IV hydration with electrolytes and vitamins Brief gut rest, then high carb, low fat diet Pharmacotherapy Enteral feeding if all other methods fail

    28. I. Treatment of Mild Cases 1. Reassurance and isolation from stressful home environment by hospitalization 2. Diet :small, frequent, semisolid, rich in carbohydrate, poor in fat and proteins. 3. Treatment of dehydration by ample fluids intake . 4. Drugs: Antiemetics: cortigen B6, metclopramide (primperan and plasil). Antihistaminic Corticosteroids in resistant cases. Vitamin B1 and B6

    29. II. Treatment of Severe cases Hospitalization & isolation of the patient in a single room, & no visitors are allowed. 2. IV fluids (glucose 5%, normal saline 3. Drugs Antiemetics (metclopramide, antihistaminic). Antacids. Vitamin B6 & B1. Sedatives. Hydrocortisone.

    30. II. Treatment of Severe cases 4. Follow up of maternal & fetal conditions: Maternal Vital signs twice /day: for hypotension and tachycardia. Urine analysis for acetone and chloride. Frequency, amount & characters of vomiting. Daily fluid chart for fluid input & output. Serum electrolytes daily (Na+, Cl-, K+). Examination of the fundus oculi/week. Liver function tests weekly . Renal function tests weekly. Fetal observation by serial sonography.

    31. II. Treatment of Severe cases 5. Termination of pregnancy : 1. Severe persistent vomiting unresponsive to all measures. 2. Jaundice. 3. High blood urea, oliguria or anuria. 4. Wernicke's encephalopathy. 5. Retinal hemorrhages.

    32. Complementary & Alternative Therapies Acupuncture/acupressure, at wrist . Nerve stimulation at wrist. Herbal remedies: Ginger, 1 gm powder daily (ACOG) Peppermint leaf Chamomile Vitamin supplements- B6. Hypnosis

    35. ACUPUNCTURE AND ACUPRESSURE Stimulation of the P6 (Neiguan) point, located three-fingers breadth proximal to the wrist, has been used for thousands of years by acupuncturists to treat nausea and vomiting from a variety of causes.

    36. ACOG Recommendations Level A Multivitamin use at conception reduces N/V B6 with or without doxylamine is 1st line therapy Level B Ginger appears to be beneficial Antihistamines, Phenothiazines, Benz amides Methylprednisolone may be a last resort

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