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MRCOG PART 2 SBAs and EMQs

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Essay 345

Bebo Posted by Bebo S.
Essay 345 Posted by PAUL A. Sat Feb 5, 2011 05:04 am A healthy 23 year old woman attends the early pregnancy clinic at 6 weeks gestation because of persistent nausea and vomiting. (a) Discuss your initial assessment [6 marks]. (b) Discuss and justify the management options for severe idiopathic vomiting in early pregnancy [14 marks]. History is taken if she is able to tolerate oral fluids or food. Information is obtained regarding symptoms such as fever with chills, urgency, frequency and flank pain which points to UTI. She should be asked if she suffers from pain abdomen, diarrhea which suggests gastrointestinal etiology. Examination includes recording of pulse, blood pressure and temperature. Dry mucous membranes, tachycardia and poetical hypotension show severe dehydration. Weight is recorded as base line to monitor weight loss. Abdominal examination is undertaken to identify any obvious intra bdominal pathology and to detect renal angle tenderness and right iliac fossa tenderness.  Investigations include Urine dipstix for the evidence of infection, MSU for culture, FBC, U&E, and liver function tests. Presence of ketonuria, electrolyte imbalance like hypokalemia indicate severity of vomiting. Thyroid function tests are done as abnormality is found in up to 66% of cases. Ultrasound scanning is valuable in identifying multiple pregnancy and molar pregnancy.  B) She is advised to take small and frequent meals. If she is unable to maintain adequate hydration and is ketotic, hospital admission is required. She is kept nil by mouth until her condition improves with medication which includes anti emetics, and IV fluids.  Daily monitoring is carried out by recording weight, urine ketones and measuring electrolytes to monitor the progress of hyperemesis and assess the effect of treatment. Anti emetics like promethazine, cyclizine, phenothiazines, metoclopramide can be used safely during pregnancy for control of vomitingw. Adverse effects include drowsiness, extra pyramidal effects and oculogyric crises.  IV normal saline or Hartman's solution with 20 - 40 mmol 8 hourly or as required to correct dehydration and electrolyte imbalance. Dextrose containing fluids should be avoided  as they precipitate Wernicke's encephalopathy. Thiamine should be supplemented at a dose of 25-50 mg tds orally as IV treatment is required to prevent Wernicke's encephalopathy.  Ondansetron, a seratonin inhibitor is effective in some women but safety data are still being collected.  H2 receptor blockers (rantidine, cimetidine ) and proton pump inhibitors ( omeprazole) can be used to relieve dyspeptic symptoms accompany the nausea and vomiting. Corticosteroids are shown to have dramatic and rapid improvement in refractory hyperemesis. If hyperemesis is very severe, total parenteral nutrition has shown to have a therapeutic effect in some cases. It is associated with the complication of phlebitis and thrombosis. Appropriate thromboprophylaxis is advised according to her risk profile as she may require prolonged hospitalization  She requires emotional support with frequent reassurance and encouragement from nursing staff and medical staff.  Termination of pregnancy is the last resort in extremely severe cases.
essay 345 by N Posted by Sherif N.

a) proper history taking from the patient about the number, colour and amount of vomitus, whether it is related to food, any special type of food, related to water, whether it is morning or all through the day, ask about any oliguria

examination of her weight, whether there is any weight loss during pregnancy, signs of dehydration as sunken eyes, dry skin, check her vital signs: BP, pulse

US to check the fetus, whether single or multiple, viability, whether it is normal or molar pregnancy, and confirm the dates

lab tests including FBC, liver functions, U&E, urine analysis whether there is ketones or chloride in urine, FBS

b) in severe idiopathic vomiting, hospitalisation is required, keep patient NPO, on IV fluids, avoid glucose solution for fear from werniche's encephalopathy

give her antiemetics injection as ondansetrone, metoclopramide, she can have rectal suppository too until she can start oral feeding gradually

cortigen B6 injections can also be given

follow up her response to oral feeding and tolerence to food, and start by ading carbohydrate rich food and avoid fat and water on empty stomach, this food will be introduced gradually and monitor the number of vomiting

if she can not tolerate oral feeding, if there is deterioration of her vital signs or labs, or appearance of complication, multidisciplinary team including an internist, nephrologist, psychologist , senipor obstetrician, senior midwife, anaesthesist, should be involved as termination of pregnancy may be needed to save life of the mother

proper documentation of the patient condition, management, and decision taken should be done, and follow up visit to discuss with her what happened and possibility of recurrence of this condition

Posted by miss T.

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(a)

I will take detailed history to identify the possible cause. Onset and duration of symptoms and their effect on her quality of life. Associated symptom like generalized abdominal pain, change in frequency and consistency of stools for GI cause, history of gall stones, and fever for cholecystitis, any upper abdominal pain for pancreatitits and hepatitis. Urinary symptoms like loin pain, suprapubic pressure, burning micturation, change in colour or smell of urine for acute cystitis or pyelonephritis. Symptom onset with pregnancy, inability to maintain oral intake, history in previous pregnancy and associated weight loss, dehydration will direct hyperemesis gravidarum. I will inquire about her LMP, parity, any drug intake and medical history.

I will then examine her thoroughly degree and signs of dehydration in skin turgor mucosu membranes, pallor, vital signs, postural hypotension, jaundice, body weight. Abdominal examination for tenderness, guarding or rigidity, any organomegally eghepatomegaly.

Investigation include FBC for Hb and hematocirt (raised in dehydration). Biochemistry for urea and electrolytes, (hypokalemia expected with excessive vomiting) liver function tests, (may be abnormal in hyperemesis gravidarum and raise many fold will indicate hepatitis), amylase (to rule out pancreatitis) urine dipstick for ketones (dehydration) proteins, leucocytes and nitrites (UTI), thyroid function tests, (biochemical hyperthyroidism with hyperemesis gravidarum rarely need treatment) and pelvic USS to confirm intrauterine pregnancy and to exclude molar or multiple pregnancy.

 

(b)

Management depends on the degree of dehydration and her ability to maintain oral intake.

Patient with severe vomiting will be admitted to the hospital and a senior obstetrician will be involved in her care, may need opinion of physician/gastroenterologist later.

She will be given IV fluids replacement. Crystalloids Lactated ringer and normal saline are first line options. Fluids will be given as bolus doses over 1-2 hour and further regimen will be directed by clinical assessment of dehydration and ketonuria. If she has persistent vomiting with severe dehydration she may need total parenteral nutrition with intensive monitoring. IV fluids can later be reduced if patient start tolerating oral.

If she has hypokalemia, she is at risk of arrythmias, I will correct it by giving her potassium replacement as 20 or 40mEq KCL in each drip of fluids. Dose will be adjusted, increased, reduced according to lab result. If patient has hyponatremia, rapid sodium replacement should be avoided as it is associated with central pontine mylenosis.

Anti emetics will be given and she will be informed that they are safe in pregnancy. Options are metoclopramide 10mg TDS, chlorphenaramine 25 mg TDS IV/IM. Ondansetron 8mg IV TDS, in severe cases. Her diet will be divided in to six small meals, as per her tolerance. Antacid will be considered to reduce the vicious circle of acidity inducing more vomiting and causing further heartburn.

Daily monitoring of vital signs, dehydration, ketonuria, input/output chart, urea and electrolytes.

Thromboprophylaxis as being pregnant and dehydrated she is at increase risk of venous thromoembolism. Aims are to maintain hydration, mobilization, if possible, and SC low molecular weight heparin.

In refractory cases to anti-emetics there is a role of steroids, IV prednisolone 40mg TDS. Decision should be made by the consultant obstetrician.

Patient needs emotional support. She and her partner/family needs to be informed all the time of her condition and involved in decision making. She will be told about the safety of drugs with pregnancy. Further in pregnancy she is at risk of low birth weight fetus and needs monitoring of fetal growth.

Posted by Leila R.
  1. History of any other associated symptoms like dysuria , frequency of micturition, and  bowel movement, any history of diarrhoea, palpitation, sweating or weight loss despite increase appetite before pregnancy, any medical illness like hyperthyroidism, kidney and liver disease. Any medications taken.

 Then physical examination including general appearance for dry mucosa, and washed out looking. Blood pressure and pulse rate should be taken. Abdominal palpation for size of the uterus, any signs of abdominal distension, and any presence of suprapubic tenderness and costovertebral angle tenderness.

Investigations including urine dipstix, and MSSU, full blood count, liver function test, urea and electrolytes, and thyroid function test. These tests help to assess the severity of vomiting, such as presence of ketonuria, elevated liver function and thyroxine levels with depressed TSH, and presence of electrolyte imbalance implies hyperemesis gravidarum. Also urine dipstix and MSSU help to rule out UTI. Ultrasound to diagnose multiple pregnancy and to rule out molar pregnancy should be performed.

 

  1. Treatment includes hospital admission if the patient doesnot tolerate anything by mouth or if there is ketonuria.

 During treatment daily monitoring of vital signs, blood test and ketonuria is important to monitor any improvement or teterioration.

 The most important part of management is to ensure adequate hydration. This should be achieved with IV normal saline to correct hyponatremia which could lead to central pontine myelinosis. Fluids should be given enough to correct maternal tachycardia, hypotension and ketonuria.

 20-40mmol KCL should be added in the 1lt of fluid 8 hourly to correct hypokalemia associated with hyperemesis.

Thiamine 25-50mg TDS orally or 100mg in 100mls normal saline weekly should be given to prevent wernickes encephalopathy.

Dextrose solution should be avoided except in diabetic patients. Use of dextrose containing fluids especially high concentration ones may precipitate wernicke’s encephalopathy.

Antiemetics should be given liberally to prevent vomiting. Regular parenteral antiemetics such as Cyclizine, promethazine, metoclorpramid, chlorpromazine, domperidone and ondansetrone can be used safely during pregnancy.

In severe refractory cases with no improvement with despite convetional antiemetics and IV fluids and electrolyte a trial of corticosteroids may be considered.

Thromboprophylaxis with low molecular weight heparin and TEDS should be given as this patient has high risk for VTE due to dehydration and immobilization.

 Psychological support is important in this patients.

 

 

 

  

ALI NAVEED HAQ Posted by Ali Naveed Haq H.

A healthy 23 year old woman attends the early pregnancy clinic at 6 weeks gestation because of persistent nausea and vomiting. (a) Discuss your initial assessment [6 marks]. (b) Discuss and justify the management options for severe idiopathic vomiting in early pregnancy [14 marks].

Persistent nausea and vomiting in early pregnancy can develop into hyperemesis gravidarum which is a condition that is seen in 0.1 -1% of pregnancies . In the initial assessment it is important to ask for the history of vomiting its association with meals, presence of blood in the vomitus, history of hyperthyroidism, assisted reproduction, asociated abdominal pain , acid peptic disease and pancreatitis. History of urinary tract infection, history of regular use of medication that may be causing persistant vomiting. 

Clinically it is improtant to assess the level of dehydration, assessing the tongue  and skin turgor, hypotension by measuring blood pressure and tachycardia which may be an associated feature , other signs like abdominal tenderness. Evaluation of the degree of electrolyte imbalance by requesting for an urgent full blood count to look for hemoconcentration, liver function tests for wernikes encephlopathy, electrolytes and urea  for hyponatremia, hypokalemia, hypocholinemia, uraemia, urine analysis for infection thyroid function tests if indicated by history or elicited by signs like exophthalamos, lid lag. Ultrasound for the evidence of gestational trophoblastic disease which may appear as snow storm appearance and multiple pregnancy.

b) It is important to admit this lady and and correct the electrolyte imbalance by giving I/V fluids like Ringers lactate and normal saline , it is important to not to prescribe dextrose solutions as they preceiptate Wernikes encephlopathy if present. the fluids can be monitored by repeating electrolytes as required. Addition of pottasium may be required in case of hypokalemia. Addition of thiamine prevents wernike encephalopathy ,in addition addition of other vitamins B6 prevents peripheral neuritis.

Severe and persistant vomiting  can give rise to Wernikes encephlopathy , weight loss, dehydration leading to acute tubular necrosis, mallory wies syndrome, muscle wasting, and even death. The pharmocological treatment has to be given in most cases and comprises of cyclazine , promethazine, domperidone , metoclopromide. these are not teratogenic and have been extensively used safely in pregnancy. Metoclopromide can cause cerebeller ataxia therefor should be used with caution. Their continual use may have to be prescribed till vomiting stops and later to prevent recurrence. Most patients respond to this treatment along with correction of electrolyte imbalance.

In some women with abdominal pain omeprazole and rinitadine may have to be added. This provides relief if there is associated acid peptic disease and pancreatitis. Ondansteron is a drug that is usually prescribed in oncology units for control of vomiting is recommended in some cases of severe persistant hyperemesis gravidarum. It is not known to be teratogenic, but limited data is there to support its use.

If the vomiting is still persistent corticosteroids may be prescribed with caution, and in highly selected cases where there is intractable vomiting. They are useful agents and can be give orally and intravenously in twice daily dosage. In some patients who have food related vomiting oral naso gastric feeding may be required and is found to be helpful. Very ocassionally total parenteral nutrition may be required through a central line, thiamine should be added and cvp should be checked for infection in prolonged use. 

Low molecular weight heparin should be added to the treatment as persistant vomiting can cause venous thombosis.A daily dose of LMWH prevents this. 

In summary persistant vomiting needs careful attention as it can cause severe morbidity and mortality in pregnant ladies and coexistant illnesses must be looked for in the diagnosis.

 

H H Posted by H H.

Will take history regarding the frequency of vomiting ,effect on quality of life and if she can take and retain oral fluids or food. Will ask if vomiting is associated with urinary symptoms as loin pain ,frequency ,dysuria and fever(pyelonephritis). Will ask of associated abdominal pain and diarrhea which  can point to a bowel problem as gastro enteritis, acute appendicitis or acute cholecystitis. Will ask of associated fever  which denotes infection. Will ask of associated weght loss which can point to severity of the condition. Will ask of her LMP and if she is sure of it.

I will feel the pulse,tachycardia and dry mucous membranes point to dehydration. Will measure temp (fever in infection),BP and BMI. Weight loss of >5% indicate a severe condition. Abdominal examination ,loin tenderness , abdominal tenderness,rigidity,rebound tenderness ,distension and bowel sounds. Hyperemisis gravidarum associated with absence of abdominal signs or fever.

Will test for the severity of the condition by doing FBC for increase in hematocrite and to exclude infective cause by doing CRP and WBC which are increased in infection. Will do serum urea and electrolytes for renal function and exclude hypokalemia, , LFT and serum amylase(pancrititis). Will test urine for ketonuria ,nitritis,glucose,protein by dipstix.Ketonuria denote a severe condition. Urine C/S if nitritis positive.Will ask for obstetric ultrasound to exclude molar pregnancy ot multiple pregnancy.

 

Will follow local guidelines for management of severe idiopathic vomiting of early pregnancy. Will admit her to hospital .Nothing given by mouth and will correct her dehydration with IV fluids. Will use Heartman solution and avoid the use of glucose 5% which can lead to Wernicks encephalopathy. Will avoid use of hypertonic saline which can lead to pontine demylinosis. Will monitor correction of fluids with use of hematocrite ,electrolyte measurement(to correct hypokalemia and hyponatremia) , and response to treatment . Will give antiemetics as metochloropromide, antihistminics as cyclizine and if vomiting is resistant to treatment will try ondansteron or steroids.

Will supply thiamine IM to prevent Wernicks encephalopathy.As the condition improves will start oral fluids gradually.  Some cases will need emotional and psychological support to improve. Ginger can be used and gives good response.

Women who do not improve with previous procedures can be put on total parentral nutrition, this will need multidisciplinary approach ,including dietician,anaesthetist and nutritionist. Cases which are resistant to treatment and can endanger maternal life can be offered a termination. Patient should be given written information of her condition and her wishes respected. Support group and websites are provided.

  

345 answer by hbadran Posted by HAnaa B.

Assessment of 6 weeks pregnancy complaining of severe nausea and vomiting include history taking to assess the severity of the condition in case she is not tolerating anything per mouth  and the other symptoms that may accompany her condition that can lead to certain diagnosis like frequency , dysuria and lion pain in case of UtI .diarrhea and abdominal pain in cases related to gastroenteritis  and gallbladder disease, bleeding  and epigastric pain in case of oesphgeal varicosities  and pancreatitis ,recent thyroid disorders or family history of such diseases.

Symptoms of wernickes encephalopathy ( thaiamin defieciency) include diplopia , ataxia, confusion and abnormal ocular movement.

Recent Loss of weight more than 3 kg.

The history also include how is her condition affecting QOL and work related issues.

Examinations include pulse, BP, skin, and mucous membrane condition to assess the state of dehydration .presence or absence of jaundice and abdominal tenderness and masses and weight.

Investigation include urine dipstick for ketones ,nitrates and leukocytes ,FBC,LFT,RFT,U&E,TFT,US to diagnosis multiple pregnancy and molar pregnancy.

Management of idiopathic nausea and vomiting in early pregnancy principles ,include admission and  hydration preferably by saline to maintain extra cellar volume  ,  correct electrolyte imbalance  and wash out ketones till nil in urine .fluids with dextrose may predispose to wernickes encephalopathy and worsen the condition if we start with. 

Antiemetic ,1stline cyclizine  meteclopromide,domperidone    and promethazine  either oral , injection or rectal suppository.ondansetron can be used as 2ndline .non pharmacological like ginger, P6 and acupuncture should be offered in mild to moderate cases.

Diet management, patiet should be kept NPO  in severe cases  then start clear fluids .

Avoid spicy food and eat small meals, avoid drugs that has GIT side effect like ferrous sulphate ,Thaimin can be used to prevent wernickes encephalopathy.

Entral or parentral nutrition for cases not tolerating any diet.

Steroid can be used as oral prednisolone or iv hydrocortisone in sever cases should be used under specialist  supervision.

Patient who is  pregnant and  bed ridden are at increase  risk of VTE so TEDs and LMWH should be discussed.

Emotional support and reassurance of the patient that the condition will be resolved by 16-20 weeks ,  and it is not related to pregnancy outcome.

TOP can be recommended in severe cases. 

Patient should be monitored   for improvement daily by measuring BP and pulse  4-6 hrs  ,daily U&E if vomiting persist, fluid balance chart, urine dip stick, her acceptance to food  and patient weight 2 times a week   . 

 

 

sofia Posted by sofia  S.

 A healthy 23 year old woman attends the early pregnancy clinic at 6 weeks gestation because of persistent nausea and vomiting. (a) Discuss your initial assessment [6 marks]. (b) Discuss and justify the management options for severe idiopathic vomiting in early pregnancy [14 marks].

Ans a;Initial assessment would include taking history of onset duration severity of vomiting and it affect on quality of life .associated symptoms like flank pain and dysuria would indicate UTI, colicky abdominal pain         with h/o gall stone would indicate cholecystitis,headach and confusion will indicate  CNS involvement .history of ovulation inducing drugs will indicate possibility ovarian hyperstimulation syndrome or multiple pregnancy .LMP and history of hyperemesis  in previous pregnancy and surgical history to rule out possible intestinal obstruction.

Examination  would include assessment of hydration  pulse BP and weight.Look for jaundice pallor .abdominal exam for tenderness, distension ,organomegaly and bowel sound.

Investigation would include FBC  and hematocrit.  Urea& Serum electrolyte as it can lead to hyponatremia and hypokalemia .liver fuction test and serum amylase and thyroid function test. Urine dipstix for ketone bodies and MSU for culture. Ultrasound for confirmation of pregnancy and to rule out multiple and molar pregnancy.

Ans b; Reassure  the patient ,as no organic pathology found and vomiting in pregnancy is self limiting and would improve with time. Due to severity of vomiting she would require admission .indications for admission would be inability to maintain hydration and nutrition characterised by tachycardia and hypotension with weight loss(>10%) or electrolyte disturbance and abnormal liver function test.

IV hydration with ringer lactate and normal saline. Avoid dextrose as it can precipitate wernike  encephalopathy .orally to be allowed as tolerated preferably dry bland food. Total parental nutrition  may be required in patient  if no  symptomatic improvement after hydration and patient continues to lose weight . hypokalemia to be corrected by adding 20-40 meq KCL 8 hrly in iv fluids. this would correct tachycardia and hypotension and electrolyte disturbance.

Antiemetic to be started . would initially require iv or im therapy followed by oral. Regimens include cyclizine 50 mg 8 hrly,promethazine 25 mg,metoclopromide   10 mg 8hrly,domperidone 10mg p.o tds or 30-60 mg per rectal tds. Safety of ondancetron in pregnancy is not proven.

If no improvement despite conventional treatment corticosteroids may be required

Thiamine orally 25-50 mg tds or thiamine iv 100mg in 100ml normal saline weekly in order to prevent wernicke`s encephalopathy.

Assessment should be made for thromboprophylaxi as dehydration increases her risk of thrombosis. Maintain hydration and mobility. Heparin if additional risk factors.

 

Monitor patient for  symptomatic and biochemical improvement.

Severe refractory cases termination of pregnancy can be an option but it usually very rare.

Fetal growth monitoring during present pregnancy as risk of growth restriction.

Offer psychological support. Provide written information.expain high risk of reccurence in subsequent pregnancy.

Essay # 345 Posted by Gulshan K.

(a) I will take her history about details of her complaints like duration of her ailment, color of vomitus, any associated symptoms, any aggravating or relieving factors and her ability to tolerate oral fluids or foods. Any other symptoms like abdominal pain, constipation or diarrhea suggest gastrointestinal cause. Ask about urinary symptoms like dysuria frequency and burning micturation suggest urinary infection. Fever suggests infection. I will ask about complaints related to involvement of nervous system such as confusion, ataxia or headache. I will perform her clinical examination including her pulse, blood pressure, temperature, respiration and will look for her hydration status by checking her mucous membrane, sunken eyes, skin turger and her weight. Pulse will show tachycardia. Blood pressure and a spiking temperature will suggest infection. Abdominal examination will reveal specific site of tenderness or any abdominal mass. Renal angle tenderness suggests renal focus. Investigation should include FBC, WBC, CRP, Urea electrolytes, LFT AND Thyroid function tests. Urine analysis for ketonuria, pus cells, bacteria and nitrates. Urine culture in case of infection. Ultrasound for number of fetuses and their viability, gestational age and to rule out molar pregnancy. It will also help to find out any apparent pathology in pelvis including ovaries and also will help to find out any urinary tract abnormality.  

(b) Management includes admission and rehydration. Advice to eat small frequent meals and take protein meal instead of carbohydrate. Liquid diet will be more tolerable than solids. Electrolyte imbalance should be corrected by intravenous fluids with normal saline or hartmanns. Potassium should be added with each bag of intra venous fluid. Avoid dextrose solution and double strength saline to prevent wernike encephalopathy and pontine myelonysis respectively. Titrate treatment based on fluid balance and weight charts and also by checking daily urea and electrolytes. Advice to stop iron supplementation if any taking. Antiemetic to start Cyclizine, promethazine metoclopramide or ondensetron all are safe in first trimester. Thiamine orally if tolerating 25 to 50mg three times a day otherwise intravenously 100mg in 100ml normal saline over 30 to 60 mins weekly. Prolonged dehydration and bed rest predispose to thromboembolism so she needs thromboprophylactics and TED stockings. In refractory cases, daily prednisolon can be given in divided doses.  In case of unable to maintain weight, parental nutrition should be considered. Fetus is at risk of low birth weight, so needs fetal surveillance.  In severe cases, termination of pregnancy should be offered. Psychological support is critical in her management. Reassure her that there will not be any long term consequences.  

ans to essay 345 Posted by SARO K.

 

Ans to essay 345:

I will ask about severity of vomiting and its effect on her daily life.I will ask whether she is able to tolerate orally ,ptyalism,constipation,urine output which will give a clue about her effect of vomiting.I will ask about fever,dysuria,loin pain,freq/urgency of urine pointing towards urinary tract infection.I will ask about epigastricpain due to gastritis,cholecystitisand pancretitis.I will ask about vaginal discharge with lower abdominal  pain,Right iliac fossa pain ponting towards PID  and appendicitis respectively.I will enquire about drugs like iron preparation ,NSAIDS WHICH AGGRAVATES VOMITING.I will ask abt family history of Twins/Spont/stimulated conceptins point towards multiple pregnancy .I will get details about psychological stress in the family,occupation and domestic violence which plays role  in the persistant vomiting.I will find out abt her medical condition like DM,hypertension and Thyrotoxicsis which might need modification &caution abt IVfluids.I will check her pulse, BP ,weight (baseline)icterus(hepatitis)and anemia .I will look for mucous membrane,sunken eyes for dehydration.I will examine her abdomen to look for any mass, Right illica fossatenderness,adnexal tenderness,rigidity.I will send blood for CBC,urea and electrolytes,liverenzymes,thyroid function test ,urine for ketones,andmidstream specimen for culture and sensitivity.

I will admit her if unable to tolerate orally with dehydration, inability to manage her routine activity with wt loss .I will rehydrate her with starting IV fluids -1liter normal saline with 20 to 30 mmol of KCl q8h(If DIABETIC dextrose containing fliud) Dextrose will precipitate wernickes encephalopathy.I will  keep her nil by mouth .Add Thiamine 100 mg iv in 100ml NS weekly with antimetics round o clock  without any harm to the pregnancy.Antiemetics  -cyclizine 50mg im.iv tds(Or)metoclopramide 10mg im/iv tds(OR)Domperidone 30-60mg pr(OR)chlorperazine 10 -2 mg im tds.caution about Extrapyramidal side effects.I will monitor I/O chart with repeat blood test to normalisation of enzymes and ketonuria.If thyroid tests are abnormal without tremor ,tachycardia,eyesigns.no need to treat as it settle with treatment of vomiting.If Not responding we can give ONdensetron 8mg iv tds  with good response.Concern  is catB drug with little data on human effects in first trimester.IF still resistant,we can give corticosteroids as RCT has proved its response.I will assess her risk of VTE and start prophylaxis if necessary.I will give psychological support ,if  needed psychiatry opinion . I will ask her to start oral sips then to plenty of oral fluids followed by bland low residue diet as freq small meals. I will suggest her to take toasted bread with icecream and avoid oily spicy diet ,caffeine and alcohol.I will inform her about effect on fetus is Low birth weight and need for serial monitoring.I will inform  her that vomiting usually settles by 14 weeks and about the recurrence in subsequent pregnancy.I will add on family support. 

 

 

Posted by Muthu M.

I would start with history to classify whether she is high risk, so I will assess her height, weight, and BMI, smoking habit, any previous obstetrics history and the outcome, any previous termination due to excessive vomiting.  I will check whether she had vomiting history before pregnancy was confirmed and tried to rule out any associated medical disorders (renal problems, thyroid problems, bariatric surgery) or regular medications which could be the reason for her persistent vomiting.  Whether she had scans in this pregnancy, number of fetus.  I would explore more about her eating habits to make sure she is eating healthy foods at regular intervals as small to medium portions and talk to her about folic acid intake in 1st trimester.  On examination, rule out wasting of muscles and tissues, dehydration signs such as dry skin, loss of skin elasticity, slow capillary filling.  I will do urine analysis to check for signs of infection, if so I will send mid stream urine specimen for MSU. I will also look for ketones, then she needs Intravenous rehydration.  I will also do FBC, U&E, TFT and CRP to look for anaemia, infection sign, increase haematocrit value and electrolytes disturbances for dehydration sign; if I will be admitting the patient. 

I would like to reassure the patient that no cause was found for her vomiting, generally it will resolve around 12-14 weeks gestation.  Until then, she will have symptomatic & supportive management and diet modification to help with her persistent vomiting.  If there is signs of severe dehydration present in the form of ketones, I will admit her in view of giving her intravenous fluids and to maintain the normal metabolism.  I will make sure she will have Thiamine tablets to avoid having wernicke’s encephalopathy due to excessive vomiting.  Give her folic acid 400mcg, as she is still in 1st trimester.  If necessary, arrange for dietician to see her and help with her diet and modify to see whether her symptoms will improve.  In addition to intravenous fluids, she needs regular parental antiemetics such as metaclopropamide or cyclizine for her symptoms.  I will advise her to avoid hunger and should have at least dry biscuits or some thing frequently.  While she is being in-patient, I will make sure she has TEDstockings and will have regular low molecular weight heparin to avoid having thrombosis due to severe dehydration and decrease mobility.  Once her metabolism is better, and no ketones in her urine, I will encourage to eat and change antiemetics into oral.  If she could tolerate, she could go home and have regular antenatal and screening as per national guidelines.  While in-patient, she needs regular U&E’s to check for K levels and may need to be supplemented.  She will have a scan to rule out multiple pregnancy or molar pregnancy.  In spite of regular intravenous fluids and other symptomatic management, if her condition does not improve, to avoid long term consequences she could be offered to terminate the pregnancy if she wishes.  However, this is very rare scenario and a highly sensitive issue, hardly ever happens.  She needs proper psychological assessment to rule any other underlying issue and also needs counseling.  I will make sure my consultant is aware and we have a management plan for her care.

Posted by Ghida R.

i will first enquire about onset of nausea and vomiting, the frequency, content whether food content, blood ( to rule out Mallory Weiss), bilious, associated fever, headache and abdominal pain especially site and radiation. I need to ask about associated change in bowel habits eg diarrhea to check for gastroentritis, also change in colour of urine and stool as these point out to gallstones, I need also to check if patient has history of previous attacks of recurrent vomiting especially prior to pregnancy as this might point out to a prior medical condition as cholecystitis, pancreatitis Other urinary symptoms as dysurea, hematuria, flank pain can point out to a urinary tract infection eg cystitis, pyelonephritis, renal colic . 

I will need to perform a  general examination including vital signs to check for signs of hypovolemia rapid pulse, low blood pressure, and for fever. oher signs of dehydration include dry mucous membranes, decreased skin turgor, I will check also for presence of icterus, which will point out for liver disease, for palpable cervical lymph nodes as in viral illness. I will need to check for epigastric and right upper quadrant tenderness to check for cholecystitis, pancreatis. also check for suprapubic tenderness , costovertebral angle tenderness to check for  urinary tract infections.

As regard investigations it will include a full blood count, urea and nitrogen, creatinine, electrolytes, transaminases, amylase lipase, urine analysis and urine culture. An ultrasound of abdomen will infom about presence of gallstones, pancreas.

in severe cases of idiopathic nausea and vomiting especially those associate with weight loss and metabolic disturbances, the patient is best admitted to hospital for iv hydration with daily weighing. patient is also supplemented with KCL to correct hypokalaemia,. once patient is able to tolerate food she should be allowed high sugary food, avoid fatty food. she should eat in small frequent meals. Non pharmocological measures should be offered as for wrist band that act as acupuncture, these are effectiv for mild cases of hyperemesis gravidarum, as well as ginger gums. As for the pharmacological  measures, several medications can be used, metoclopramide, diphenhydramine, domperidone. and for severe refractory cases we can used dexamethasone and ondansetron.In the absence of medical or surgical condition that is causing recurrent vomiting, pregnant patient must be reassured that this will go away beyond the 14th week of gestation, and that a small percentage might still vomit  until their 20th week of gestation.. ,     ,

ANSWER TO ESSAY 345 Posted by DHARSHITHA J.

(a)Assessment  includes assessing the level of dehydration and exclusion of pathalogical causes of vomiting.

Detailed history including frequency of vomiting, period and presence of fever and jaundice,features of hyperthyroidism and previous pregnancies complicated with hyperemesis and history of h.mole.

Examination includes measurement of BP, pulse, weight/ BMI,urine out put,level of dehydratin,and exclusion of jaundice and features of hyperthyroidism.

Abdominal and vaginal examination toasseess the size of the uterus may help to exclude multiple pregnancy or h.mole.

Investigations includes urinalysis, to assess amount of ketone bodies, and to exclude urinary infection. Blood investigations includes FBC, toassess PCV and Hb to assess level of dehydration and liver function tests to exclude liver pathalogy, Serum TSH and free T3 and T4 to exclude hyperthyroidism and hepatitis screen to exclude exclude viral hepatitis and hepatitis B and C.

Serum electrolytes and blood urea to assess renal function and to exclude electrolyte imbalance.

Also serum beta HCG if history suggestive of H. mole.

U/Sscan to exclude multiple pregnancy and h.mole and any liver pathalogy such as gall stones.

(b) First step is determination the place of management, either outpatient or inpatient.

Inpatient management is desired if severe dehydration or if the patient cannot tolerate oral feeds.

Main aim of the management is rehydration either with Hartmans or normal saline. IV access is gained , blood taken at the same time for investigations. IV dextrose not appropriate as can cause wernicke's encephalopathy.

Symtom controll with antiemetics- first line drugs include cyclazine and metaclopropamide oral or IV. Ondanstron can be used if these not responding. Steroids-dexamethazone and ginger also shown to be effective in  treatment of hyperemesis.

H2 receptor blockers such as ranitidine used to reduce gastric acid secretion.

Close monitoring of BP,pulse, level of dehydration, urine out put,and urine for presence of ketone bodies and serum electrolytes and FBC are important.

Vitamin B supplementation, oral or IV, to prevent wernicke,s encephalopathy and Korsacoff's psychosis

Rapid rehydration not desired as it can cause cerrabeller pontine demyelination.

Thrombopropylaxis considered as dehydration and immobilization are 2 factors for thromboembolism.

Psychological support and counselling are also important aspects.

Nutritional support and dietary advice referring to a dietician, and total parenteral nutrition in extreme cases.

Close followup after discharge, in ANC in regard to weight gain and fetal growth.

Termination of pregnancy considered in extreme cases not responding to treatment.

Posted by BHAWANA  P.

My initial assessment will include enquiry about duration of vomiting, how many times is she vomiting, content of vomitous9 food/bile/blood- Mallory Weiss tears) and projectile or not ( brain pathology). I will ask about any signs of systemic disease- fever, suprapubic tenderness, dysuria( UTI),Pain in abdomen( ectopic, surgical causes), PV bleed ( molar, ectopic).


Any past medical history of brain disease, diabetes( more prone for infection), any medication she is on- folic acid ( if not may need to be on it), anti-emetics  need to be elicited. Also psychological causes need to be explored- inplanned pregnancy, single mother, support from partner and family.


On examination- I will assess for signs of dehydration- dry mucous membranes, sunken eyes. Abdominal examination will be done to rule out any ectopic, UTi or surgical causes of pain. Pulse, B.P. should be to assess degree of dehydration and temp for systemic illness.


Investigations will include- full blood count( anaemia, Wbc- infection), U&Es- electrolyte imbalance, thyroid functions tests( biochemical Hypo/hyperthyroidism).Urine dipstick for dehydration and UTi. MSU should be sent if leucocytes/nitrites positive.
Ultrasound will be done to rule out molar/multiple pregnancy.


b)The management will include Iv access and Iv fluids. Hartman’s /normal saline 6-8 hourly can be given to correct dehydration. If patient is not able to tolerate orally Parenteral metrochlopramide, prochorperazine and cyclizine can be given.If vomiting still refractory odansetron can be given but it is not licensed in pregnancy. Patient should be informed that there are no known side-effects with odansetron. In severe refractory cases steroids has been used successfully in hyperemesis. Patient need to be counselled that short courses of steroids do not have side- effects but prolonged courses has been associated with cleftlip/palate and PPROM and maternal infection.


Termination of pregnancy can be offered in severe refractory cases according to maternal wishes. Counselling  and reassurance that most of the vomiting settle down after first trimester and exploration of family support can play a role in hyper-emesis.
Anta- acids like ranitidine should be given to reduce gastric irritation. Thiamine replacement should be done to prevent Wenicke’s encephalopathy.


TEDs and appropriate thromboprophylaxis need to be considered.If prolonged hospitalisation weight measurement and regular U&Es need to be done for correction of electrolytes. If patient responds then outpatient management with oral anti-emetics, thiamine, folic acid, ranitidine should be carried out. Appropriate advice regarding diet as avoiding spicy/oily food, regular intake of small amounts of food, sips of fluids throughout the day can help to maintain daily intake. Ginger has some evidence in prevention of vomiting in mild cases.

 

yk Posted by rabhia B.

Hyperemisis is nausea and vomiting of pregnancy which leads to biochemical changes in the body. Detail history should be taken regarding duration of symptoms and severity like decreased urine output, thirst, feeling dry, drowsy, weak and unable to keep solid and liquid down. It is a diagnosis of exclusion, so history of urinary tract infection, gastroenteritis, hepatitis, hypocalcaemia, thyroid disorders, pancreatitis and viral infection should be asked. Molar pregnancy can cause similar symptoms that needs to be rule out with further investigation. History of other medical conditions like Addison disease and previous abdominal surgery should be asked. Past history of hyperemisis and psychiatric history is relevant, Drugs intake like Iron ,antibiotics and over the counter medication should be asked, What treatment she has tried already so to plan further management.

Examination of patient includes checking for general appreance looks well oriented or unwell which indicates severity of condition.

Signs of dehydration includes sunken eyes, dry lips and mucous membranes, tachycardia, hypotension, muscle weakness and decreased urine output, Thyroid examination to rule out underling thyroid disorder. Abdominal examination to rule out acute surgical abdomen, hepatomegaly for hepatitis, pain and tenderness in epigestrium for pancreatitis and suprapubic and loin tenderness for urinary tract infection. Lower limb examination for muscle weakness due to electrolyte disturbance and CNS involvement in severe Hyperemisis. Legs redness and tenderness for DVT.

Investigation includes FBC for raised haematocrit, polycythemia and thrombocytosis which indicated dehydration. Urea and electrolytes for low sodium, low potaseium, low or high calcium, low magnesium, raised urea and creatinine. LFT for raised enzymes , indicates hyperemisis Gravidarium or underling liver cause. Thyroid function raised T4 could be due to severity of Hyperemisis as HSG mimics TSH or due to underling Thyroid disease. Urine analysis for dehydration and for infection screen. Msu for culture and sensitivity if urine analysis positive for infection. TVS to rule out molar pregnancy and multiple pregnancies which can cause this condition. Weigh the patient for baseline reading and to monitor the progress of disease.

Management includes reassurance, as hyperemisis mostly resolves with increasing gestation . Dietary advice like small frequent meals and ginger stuff might help for prevention. In acute cases rehydration with crystalloid fluids. Avoid fast rehydration  and dextrose solution as risk of central pontine demylenolsis. Potassium and other electrolytes replacement according to blood results. Antiemetic like stemetil, cyclazine, metochlopramide intravenous, per rectal and oral can be given on regular and as required basis. Ondensetron can be given if first line antiemetic does not work. Side effects like extraparamydia with metochlopramidel should be informed. Steroids can be given for unresponsive cases. If steroids used for long time fetal growth defects, risk of gestational diabetes and hypertension should be watched.  Prevent complications like DVT by TEDS and by Heparin along with rehydration and mobilisation. Vitamin B1 (thiamine) replacement daily to prevent wernicks encephalopathy. This has high maternal and fetal loss rate, Acute renal failure can be prevented be careful fluid balance charting and replacement of fluids. Daily urine  dipstix for dehydration and daily repeat blood tests in severe disease. Haematemisis( Malloy Weiss tear) treat with Ranitidine or Lansoperazole. If persist Medical team input, might need endoscopy.  In  severe cases Multidisciplinary care with anesthest, dietation and ITU physian and psychiatric team. In advance cases TPN and parenteral vitamins may be needed to prevent nutritional deficiency.

 

 

essay 345 Posted by vaneeza K.

A . I will assess  the severity of disease and effect on quality of life ,whether she is able to retain anything.History of associated diarrhea  and abdominal pain indicate gastroenteritis,fever,dysuria ,frequency of urine and pain in lumbar region should be asked to exclude genitourinary cause of vomiting.I will ask about dark colour urine ,clay colour stool to exclude hepatitis .Pain in epigastric region radiating to back is due to pancretitis.Check BP and pulse as tachycardia and hypotension is due to dehydration.Assess the degree of  dehydration by checking mucous membrane and skin turgor.Check weight for monitoring.abdomen will be examined for any tenderness and organomegaly like hepatomegaly.Investigate FBC for hb and raised haematocrit,urea and electrolytes to test for hypokalaemia,hyponatraemia and low serum urea.LFTs, for transaminases and bilirubin,calcium to exclude hypocalcaemia .TFT ,raised freeT4 and supressed TSH,Urine for dipstix ,protein and ketones.PELVIC USS to confirm gestational age,rule out molar or multiple pregnancy.

B.Patient will admitted to hospital if she is unable to maintain adequate hydration for fluid replacement and electrolytes correction.0.9% NS or hartmann soln will be started while keeping NPO along with KCL 40meq in each drip (or as needed). Dextrose should be avoided as it precipitate wernicke,s encephalopathy. Double strength saline should be avoided as rapid correction of hyponatraemia may result in central pontine mylinolysis. Antiemetics metoclopramide(10mg im ,iv tds) cyclizine(50mg im,iv ,orall,tds) ondansetron 8mg po bd) , all are effective and safe in pregnancy.Thiamine 100  mg in 100 ml of NS over 30 -60 min weekly can be given to prevent wernickes encephalopathy,Monitor BP 4-6 hourly, intake,output, urine dipstix for ketone, urea and electrolytes daily. weigh the patient twice weekly.Titrate treatment based on fluid balance ,weight charts and daily urea ,electrolytes.If refractory to treatment,Prednisolone 40-50 mg daily in divided doses or hydrocortisone 100 mg bd may rapidly resolve the symptoms .Following response to treatment doses should be gradually taper off

Dehydration and bed rest increases the risk of VTE so TED stocking LMWH can be given.Biochemical hyperthyroidism should not be treated as it resolves with treatment.

Once patient is stable restart oral food.Advise to take more small meals and avoid spicy food, stop iron, pyridoxine 50-100mg or powdered ginger are treatment option for nausea with fewer side effect. P6(wrist ) accupuncture should be offered.

In more sever cases parenteral nutrition and enteral feeding should be given .or as a last  resort TOP should be discussed.           

Patient needs emotional support and counselling.She should be informed that nausea and vomiting will resolve by 16-20wks of pregnancy.  Most of pregnancies have good outcome and  there is no increase risk of congenital anomalies but hyperemesis is associated with low birth weight .

 

 

 

 

Essay 345 Posted by Samira  K.

a-Initially patient should be enquired about severity of vomiting.Any history of Wt.loss more than 3kg,history of peptic ulcer or gastritis.Others sympoms like gastroenterology (diarrhea,constipation,abdominal pain,)symptoms.Urinary symptoms like dysurea,frequency.Symptoms of hyperthroidism like tremors ,palpitation .Social circumstances like any stress and impact of condition on quality of life.Examination should include BP,pulse and sign of dehydration like skin turgor,mucous membranes will be dry.look for postural hypotension.Scan to exclude twins although at 6 wks it is difficult to exclude molar pregnancy ,bhcg levels can be performed to exclude molar changes.Urine dipstix for ketones,leukocytes,proteins.Serum electrolytes ,TFT,LFT,U&E,SERUM amylase should be sent(to exclude pancreatitis)

b-Management options for severe hyperemesis requires admission to hospital and rehydration to correct fluid loss ,protect from hypotension and to correct electrolyte imbalance particularly hypokalemia and metabolic alkalosis.Add potassium to fluids and infuse until potassium becomes normal.Fluids containing dextrose should be avoided as they worsen hypokalemia and predispose to Wernicks encephopathy.0.9% Nacl is preferred.

If severe vomiting patient should be kept NPO and later on to start clear fluids followed by small amount of regular meals.Severe cases not responding to therapy might require Parenteral nutrition.

consider starting I/V ondanestron rgularly  as first line antiemetic as it is very effective and other drugs like metoclopramide,domperidone can be added.Metoclopramide is having extrapyrimidal side effects but not ondanestron.

Thiamine therapy to prevent Wernicks encaphalopathy.Pyridoxine supplement as its deficiency is associated with hyperemesis 

TED+LMVH to avoid VTE as pregnancy+immobility+dehydration increases risk of VTE.If all other treatment fails then IV hydrocortisone can be tried.In intractable cases patient can be given choice for TOP.

While inpatient monitor pulse/BP 4 times a Wk to check if fluids in her body are adequate and to avoid postural hypotension.monitor fluid balance chart to check for +ve or -ve balance.Excessive fluid repacement can lead to pulmonary edema.and insufficient fluids can lead to VTE.Urine dipstix daily for ketones.as excessive ketones is a sign of starvation.If vomiting persist daily U&E.Weigh patient twice Wkly.

.

Srabani Posted by SRABANI M.

a.In history, I would assess the severity of vomiting which may include a scoring system. I will also ask about other associated symptoms like diarrhoea, constipation, abdominal pain, urinary frequency, dysuria.History of weight loss should be taken. I will also assess impact of vomiting on her quality of life.Past obstetric history of similar problem should be asked.

Examination will include degree of dehydration by checking mucous membrane &  skin turgor,pulse, BP, temperature, ptyalism.Also signs of hypovolumia and electrolyte imbalance should be examined.heamatemesis may be present for Mallory-weiss tear.On abdominal examination, tenderness or a mass may be present.Tenderness in the loin can be present

Initial investigation will include FBC, U&E, LFT, serum amylase.Urine should be tested for ketone & MSU  to exclude UTI.thyroid function test should be done to exclude hyperthyroidism.Ultrasound scan should be done to exclude molar pregnancy and multiple pregnancy

b. She needs admission if she can not tolerate oral fluid. Rehydration with correction of electrolyte imbalance should be done .IV fluid , either normal saline or Hartman’s  should be given but not dextrose solution as it may worsen hyponatraemia and may cause Wernicke’s encephalopathy.U&e should be checked daily and if needed potassium  should be replaced.She should be kept nil by mouth for 24 hrs and then introduce light diet as tolerated.If no response to IV fluide and electrolyte replacement , antiemetics can be given such as cyclizine, proclorperazine , metoclorpromide or domperidone as regular basis or as when required.Cyclizine can be given as 50mg/ 8 hrs PO/IM/IV.Ondansetron can be used as second line therapy .Thiamine can be given as 25-50 mg PO TDS to prevent Wernicke’s encephalopathy.Spicy food should be avoided and small regular meal should be given to her.If vomiting is protracted and unresponsive to fluid and antiemetics, a trial of corticosteroid ( Prednisolone 40 mg PO per day in divided doses or hydrocortisone 100mg IV twice daily) can be given.VTE risk should be assessed and if needed TED stocking and low molecular weight heparin can be given. Monitoring the patient by 4-6 hourly Pulse, BP check, U&E if vomiting persists, maintaining fluid balance chart, daily urine dipstix for ketone and also weigh the patient twice weekly.Emotional support is very important and reassurance that in most cases nausea and vomiting will be resolved spontaneously  by 16 to 20 weeks and also it is not associated with poor pregnancy outcome.Some patient may request Termination of pregnancy and also in severe cases  termination of pregnancy may be recommended by the clinical team.

 

Answer to SAQ 345 Posted by C M.

A healthy 23 year old woman attends the early pregnancy clinic at 6 weeks gestation because of persistent nausea and vomiting. (a) Discuss your initial assessment [6 marks]. (b) Discuss and justify the management options for severe idiopathic vomiting in early pregnancy [14 marks].

A ) Discuss your initial assessment [6 marks].

A full history about the nausea and vomitting (when it started, duration, how many times a day is she vomitting, any evidence of haematemesis) is asked and its relation to any recent food intake ie gastroenteritis and whether other family members are affected should be sought. I would confirm her gestation from LMP and find out her past obstetric history - ?multiparous/primiparous and has this happened before in previous preganancies. I would enquire anout any symptoms of a UTI (dysuira, frequency) or any other infections. I would also enquire about any medication use eg metronidazole that can cause her symptoms. I would then inspect her for pallor and signs of clinical dehydration such as dry mucous membranes. I would palpate her abdomen for tenderness and any palpable masses . I would also feel her pulse for irregularity, volume of the pulse (?thready which shows compromise) and also asses her jugular venouse pressure. I would then attain a blood pressure, heart rate and temperature looking for hypovolemia, infection as potential causes and then I would perform a urinalysis (looking for ketones, leukocytes, protein and nitrates and if this is positive I would then arrange for a microscpy and culture to exclude infection. I would also run a FBC, U&E, CRP and Thyrod function test to exclude infection, renal failure, anaemia and hyperthyroidism. An ultrasound is also useful to assess chorionicity.

B) Discuss and justify the management options for severe idiopathic vomiting in early pregnancy [14 marks].

This lady is best managed in the acute instance in the hospital as she will require intensive rehydration. She will require intravenous access with a FBC, U&E, CRP & thyroid function sent of to exclude infections, anaemia, renal failure and infection. She will require adequate rehydration with IV Normal saline/ hartmanns solution with accurate fluid input/output chart. She will need regular urinalysis to ensure the ketonuria improves and asses response to current management. If an infection is picked up in the assessment this should be trated at the same time. Regular pulse and blood pressure monitoring is useful as if she were hypovolemic and hypotensive before you can assess response rates. Antiemetics should be given in the form of either Prochlorperazine, Cyclizine, Metoclorpromided and IV or IM initially as she may vomit the medication if given orally.  Onve the vomitting has settled she can then be transfered to oral preparations. The use of Ondansetron can also be made but under the guidance of a consultant because of its potential risks in pregnancy and that little is known about its use in pregnancy. Analagesia for pain reliek from all the retching may be given and this may be IV paracetamol or rectal. I would put her in Thiamine as she runs the risk of Wernekes Encephalopathy idue to persistent vomitiing. I would also ensure she is on folic acid as well as she is still in the organogenesis stage of pregnancy and if she has been unable to consume folic acid this may contribute to spinal defects as well. There is a role for steriod cover if the vomitting is intractable and this would should be considered.

In the long term I would ensure I give her advice about fluid managment and when to report to us for fluid resucitation. I would ensure she carries on with Folica acid and that she has a 12 week scan to asses for chorionicity.

 

Essay 345 Posted by zaitouni L.

a) Initial assessment of the patient :

I will asses the severity of vomiting ,its effict on her  QOL .

I will ask about diarrhea ,abdominal pain to exclude gastroenterities. Iwill ask about urinary frequency or dysuria to exclude urinary tract infection.I will ask about dark urine or pale stool to exclude hepatities.

       Examination of the patient:       To asses the degree of dehydration

blood pressure ,pulse,temperature, should be taken. Examination of mucous membranes )jaundice) and skin turger.

Abdominal examination : for abdominal tenderness,masses or loin tenderness

Investigations:FBC,urine examination for ketones,protienes ,leucocytes,and nitrities.

b)  managment optiions:

Most probable diagnosis is hyperemesis gravidarum.

hyperemesis gravidarum have  maternal riskes including dehydration electrolyte imbalance ,abnormal liver ezy.mes.  Also may lead to rupture oesophagus ,or wernickes enchephalopathy.

FBC shoud be done to exclude haemoconcentration. U&E to exclude electrolyte imbalance. LFT should be done .

    Abdominal ultrasound to  exclude vesicular,mole.or multiple pregnancy.TFT .to exclude hyperthyroidism.

Rehydration of the patient :by IV fluides containing NA to avoid wernickes enchephalopathy.

Correction of electrolyte imbalance which is uaually hypokalaemia

Anteemetices should be given as metoclopramide ,or domperidone.

Nothing per mouth ,then oral fluides should be given.Avoid spicy food.Avoid druges which sause gastric irritation asferrouse .

Entral or total parentral nutrition  may be requered.

TEDs &LMWH should be given to avoid throboembolism

. If the patient is not improving corticosteroides can be given.some patientes canbe offered TOP

Monitoring of patient : by measuring blood presure & pulse.Fluid balance chart ,dailyU&E,if vomiting persist. Daily urine

dipstick,Wiegh patient  twice weekly

The patient should be  offered emotional support,reassurance  . The patient should be informed thet   most patients resolve by 16 ws.-20ws  that vomiting is not associated with poor pregnancy outcome. . ., ,  ,

Posted by Bee Fong C.

 

(A)             Sinister causes such as molar pregnancy, infection, liver causes need to be excluded. However it can also be a idiopathic vomiting. The severity of the vomiting need to be assessed to see if she is keeping anything down. She can be feeling unwell with fever and rigors pointing to infection. Any jaundice with pale stool and dark urine suggest of obstructive hepatitis or pancreatitis especially with symptoms of pain. She can also be complaining of vaginal bleeding pointing towards molar pregnancy.

            The general appearance of the patient need to be assessed for malnutrition, jaundice and anaemia. She can also have features of anaemia, jaundice or hyperthyroidism on her eyes. Thyroid nodules or goitre can be palpated. Abnormal heart rate, blood pressure will show severe dehydration. Raised temperature will point to infection. Abdominal right upper quadrant and epigatric tenderness will suggest pancreatitis, gallstones or refractory vomiting.

            Bloods will reveal anaemia, abnormal liver or thyroid function. Renal function is assessed. If pancreatitis is suggested, amylase need to be performed with calcium. Inflammatory markers will be raised in infection. Urine is tested for ketones, nitrites and leucocytes. Ultrasound may reveal twin or molar pregnancy.

 

(B)             Patient with severe hyperemesis need to be admitted and supported as it can be distressing. Conservative measures should be given such as advice on diet can be given from dietician.

            Antiemetic such as prochlorperazine, metaclopramide and cyclizine can used parentarally. Ranitidine will help to prevent heartburn and gastritis. Thiamine is given to prevent encephalopathy. Pyridoxine is given if necessary. Steroids can be given if other simple measures fail. Local protocol and national guidelines need to be followed.

            Dehydration is treated with intravenous fluids. Any hypokalaemia is corrected. It is tailored with renal function. Urine analysis should be measured daily to look for ketosis.

            Any pyrexia and pain should be given analgesia and antipyretic. Acupuncture can also be recommended although the evidence is limited. If it is too severe, termination of pregnancy can be offered after discussion with the patient and informed consent is taken.

            Thromboembolism deterrent stockings and low molecular weight heparin should be given as prophylaxis to prevent venous thromboembolism in the state of dehydration.

            Most patient will recover uneventfully and need to be reassured. However, some patient may continue to repeated episode and support needs to be given.

Answer 345 DCR Posted by DCR R.

A) I would take a detailed history of the symptoms of the lady, severity of vomiting, whether she is able to keep  in fluids, how it affects her quality of life, fatigue, dizziness any associated abdomial pain and diarrhoea and history suggestive of food poisoning. I will also ask a past medical history, any medications that she is on, r/o symptoms of hyperthyroidism. I will do a general examination, assess pulse, BP, BMI, degree of dehydration, jaundice &  examine her abdomen look for tenderness. I will do a urine dipstick to look for ketones, any leucocytes or nitrites send an MSU if positive. I will also do FBC, U&E, LFT, TFT and organise for a USS pelvis to rule out multiple pregnancy and gestational trophoblastic disease.

B) If she has severe vomiting and is dehydrated I would admit her, put an IV cannula and draw blood for FBC, U&E, LFT, TFT and organise an USS pelvis. Mainstay of treatment is fluid resuscitation with crystalloids and potassium relacement as they develop hypokalemia due to severe vomiting. First line anti-emetics known to be safe in pregnancy are cyclizine 50mg TDS, phergan 25mg nocte and stemetil 5mg tds. If she is not able to tolerate it orally they can be given as injectables. If she fals to respond to these, metoclopomide 10mg tds, domperidone oral or suppositories and ondansetron can be given. She should be prescribed thiamine supplements 25-50mg tds to prevent a serious complication of wernicke's encephalopathy and started on thromboprophylaxis and TED stockings to prevent VTE. Advice should be given on small and frequent meals and reassurance regarding the use of antiemetics. Hyperthyroidism  associated with hyperemesis usually resolves after the first trimester and does not require treatment. In cases of GTD, suction and evacuation is performed. UTI must be treated with antibiotics as per culture and sensitivity.  Advice should be given on small and frequent meals and reassurance regarding the use of antiemetics. In most cases vomiting is controlled and she can be discharged on oral antiemetics. In refractory cases treatment with corticosteroids may be considered.

Posted by BHAWANA  P.

 

My initial assessment will include enquiry about duration of vomiting, how many times is she vomiting, content of vomitous(food/bile/blood- Mallory Weiss tears) and projectile or not ( brain pathology). I will ask about any signs of systemic disease- fever, suprapubic tenderness, dysuria( UTI),Pain in abdomen( ectopic, surgical causes), PV bleed ( miscarriage,molar, ectopic).

Any past medical history of brain disease, diabetes( more prone for infection), any medication she is on- folic acid ( if not may need to be on it), anti-emetics  need to be elicited. Also psychological causes need to be explored- inplanned pregnancy, single mother, support from partner and family.

On examination- I will assess for signs of dehydration- dry mucous membranes, sunken eyes. Abdominal examination will be done to rule out any ectopic, UTi or surgical causes of pain. Pulse, B.P. should be to assess degree of dehydration and temp for systemic illness.

Investigations will include- full blood count( anaemia, Wbc- infection), U&Es- electrolyte imbalance, thyroid functions tests( biochemicalHypo/hyperthyroidism).Urine dipstick for dehydration and UTi. MSU should be sent if leucocytes/nitrites positive.

Ultrasound will be done to rule out molar/multiple pregnancy.

b)The management will include Iv access and Iv fluids.Hartman’s /normal saline 6-8 hourly can be given to correct dehydration. If patient is not able to tolerate orally Parenteral metrochlopramide, prochorperazine and cyclizine can be given.If vomiting still refractory odansetron can be given but it is not licensed in pregnancy. Patient should be informed that there are no known side-effects with odansetron. In severe refractory cases steroids has been used successfully in hyperemesis. Patient
need to be counselled that short courses of steroids do not have side- effects but prolonged courses has been associated with cleftlip/palate and PPROM and maternal infection.

Termination of pregnancy can be offered in severe refractory cases according to maternal wishes. Counselling  and reassurance that most of the vomiting settle down after first trimester and exploration of family support can play a role in hyper-emesis.

Anta- acids like ranitidine should be given to reducegastric irritation. Thiamine replacement should be done to prevent Wenicke’s encephalopathy.

TEDs and appropriate thromboprophylaxis need to beconsidered.If prolonged hospitalisation weight measurement and regular U&Es
need to be done for correction of electrolytes. If patient responds then outpatient management with oral anti-emetics, thiamine, folic acid, ranitidine should be carried out.
 

 



 

 


 
 

Posted by Yingjian C.

a) My initial assessment would include taking a history to assess the severity of the vomiting and to rule out other causes of vomiting which may not be related to pregnancy. In particular, history of duration of the vomiting, ability to retain fluids or solids, any giddiness related to changes in posture, weakness or lethargy would be sought. Enquiry regarding symptoms suggestive of other causes of vomiting would be made, example urinary tract symptoms such as frequency, dysuria, or neurological symptoms such as headache, blurred vision, any weakness or sensory loss, or suggestions of infective gastrointestinal causes such as diarrhea, a positive travel or contact history.

I would also examine her and find out how much weight she has lost as a result of the vomiting, and assess her hydration status by checking her vital signs, looking out for tachycardia, postural hypotension, looking at the tongue and assessing her mental state. An abdominal examination would be done to look for any signs of abdominal tenderness and organomegaly. I would also look for signs that may point to other causes of vomiting in pregnancy for example jaundice, neurological signs, signs of thyrotoxicosis. I would complete the examination by doing a urine dipstick for leukocytes and ketones, as well as an electrolyte panel to assess sodium, potassium, urea and creatinine levels. A thyroid function test would be ordered if clinically indicated.

b) Management options for severe idiopathic vomiting in early pregnancy includes administration of regular doses of antiemetics usually in intravenous/ rectal form, together with intravenous fluids. Antiemetic agents that can be used include antihistamines such as promethazine, cyclizine, phenothiazines- chlorpromazine, prochlorperazine and dopamine antagonists such as metoclopramide and domperidone. These drugs are known to be safe in pregnancy without increased risks of teratogenicity. However one must bear in mind side effects such as drowsiness with phenothiazines and extrapyramidal effects and oculogyric crises especially with metoclopramide and phenothiazines. In cases of intractable vomiting, ondansetron can be considered. There is no known teratogenicity with this drug and it appears safe; however there is limited evidence on its use in pregnancy.

Normal saline or Hartmann’s solution can be given as fluid replacement therapy, and electrolytes replaced accordingly, for example hypokalemia replaced with slow infusion of potassium and hyponatremia replaced with normal saline and not hypertonic saline as there would be a risk of central pontine myelinolysis. Intravenous thiamine should be considered in cases where the vomiting had been persistent for more than a week. Fluids containing dextrose should be avoided as they do not provide enough calories for the patient, and they may precipitate Wernicke’s encephalopathy in patients with thiamine deficiency, and may worsen any hyponatremia.

In severe cases refractory to the above forms of treatment, corticosteroids can be considered. These are given at high dosages and must be tailed down gradually to avoid precipitating an Addisonian crises.

Enteral feeding can be considered in severe cases. Nasogastric tubes can be used but are usually poorly tolerated and easily displaced. Nasojejunal feeding tubes can be used but require radiological guidance for placement. Alternatives such as gastrostomy tubes can be considered. In very severe cases, total parenteral nutrition can be employed however there are risks of infectious and metabolic complications, as well as high cost. As a last resort, termination of pregnancy can be discussed.

The risks of thrombosis must also be born in mind in such cases and thromboprophylaxis administered. Psychiatry referrals may be required for certain cases as there are psychological problems associated with severe vomiting in pregnancy. 

Essay 345 by NA Posted by naila A.

 

  1. I’ll take history to exclude other causes of vomiting. I’ll take history of dysurea frequency of micturation and supra pubic or loin pain to exclude UTI. I will ask about abdominal pain to exclude other causes such as appendicitis or hepatitis. History of diarrhea or constipation suggests GIT causes. I’ll check her BP, pulse and weight. Check the state of hydration by noting skin turger, sunken eyes and mucous membranes. I’ll palpate abdomen for any tenderness or abdominal mass. I’ll send blood for FBC, liver function test, electrolytes and urinalysis for ketones, proteins, glucose, nitrites and bacteria. I’ll request USG for fetal viability, gestational age, and exclude molar pregnancy.
  2. I’ll admit her to correct her fluid and electrolyte imbalance. Hypertonic saline should be avoided to correct hyponatremia due to risk of pontine mylinolysis. Dextrose containing solution should be avoided due to risk of precipitation of Wernikes encephalopathy. Ringer lactate or normal saline with potassium should be started. Thiamine should be started to correct thiamine deficiency. Antiemetic should be started such as cyclizine, promethazine or metochlopramide. Initially she should be kept nil by mouth, once vomiting is stopped oral intake can be started as frequent small meals. Electrolytes are checked daily. Corticosteroids can be given in resistant cases. Ondensterone can be used in intractable cases.Total parantral nutrition may be considered in intractable cases. Termination of pregnancy is an option in extreme cases. Psychological support and reassurance is the key to treatment. Once she is stable she can be discharged with follow up appointment as the condition is likely to recur and she needs continuation of treatment in 1st trimester.
anuradha n Posted by anuradha N.

a) Her initial assessment includes history examination, investigations

She should be asked about the severity of vomiting, number of episodes, whether able to tolerate oral liquids or not, whether she is able to carryout her routine activities.She should be enquired whether vomiting is associated with pain abdomen, fever, diarrhea (to exclude other causes such as UTI, appendicitis diarrhea)

examination- to assess the severity of dehydration by sunken eyes, dry tongue,pulse, blood pressure(postural hypotension)

Abdomen-tenderness, palpable masses, loin tenderness,

Investigations-FBC,hematocrit raised in severe dehydration,urea and electrolytes - for the evidence of hyponatremia, hypokelemia, metabolicalkalosis , thyroid function test- raised t4, depressed TSH, urine dipstick-for leucocytes, protien, nitrites and ketones, ultrasound scan abdomen/pelvis- to exclude multiple pregnancy, molar pregnancy

b)Woman who is dehydrated,ketotic needs admission for adequate fluid and electrolyte replacement.

Fluids- such as normal saline(sodium chloride 0.9%.contains 150 mmol/l sodium,hartman's solution-NaCl 0.6%-131mmol/l)are appropriate.Dextrose normal saline(contains Na+ 30 mmol/l),5% dextrose contains no sodium should be avoided as it can worsen hyponatremia and precipitate wernicke's encephalopathy.Potassium chloride 40 mmol/l can be added to the normal saline drip so as to correct hypokelemia.Fluid and electrolytes are titrated by daily serum sodium,potassium and fluid balance chart.Thiamine(100 mg in 100 ml normal saline) should be given to prevent wernick's encephalopathy.

To control vomiting,drugs such as promethazine,cyclizine,metachlopramide,chlorpromazine can be safely used in 1 trimester.If vomitting persists, these can be given on regular basis.Odensetron is used as 2nd line drugs as reports on safety of drug in pregnancy are lacking.

In hospital,she should be kept nil by mouth till vomiting subsides,then start oral clear liquids.She should avoid spicy food.Start small frequent meals such as dry toast and then gradually increased as tolerated.Gastric irritants -ferrous sulphate are avoided.

She is daily  monitered with 6th hourly pulse,BP,serum urea and electrolytes,fluid balance chart,urine dipsticks for ketones.She is weighed twice weekly so as to assess the adequacy of hydration.Steroids (oral prednisalone in divided doses ,hydrocortisone 100mg IV) are reserved when there is no response to the above treatment,vomiting persists.If there is response to steroid therapy it must be tapered slowly.If there is no response it should be discontinued.

Enteral feeding with nasogastric tube is considered to prevent malnutrition.It may be poorly tolerated if vomiting persist and frequent need of tube replacement.Naso gastric tube can be bypassed by gastrostomy feeding tube.Enteral feeding is more cost effective than total parenteral nutrition.(TPN)

TPN may become supportive therapy in cases of prolonged vomiting with malnutrition.It has some therapeutic effect.Metabolic and thrombotic complications are known.Stirct monitering protocols are mandatory.The central  line must be inspected regularly.TPN is considered when optimal rehydration,antiemetics,steroids have failed to result in improvement.

As dehydration,immobilisation,pregnancy increase the risk of thromboembolism,elastic stockings,LMWH in prophylactic doses to be given. 

Patient and relatives are reassured,emotional support given.Women should be informed that most cases resolve spontaneously by 16-20 weeks.In severe prolonged vomiying,termination of pregnancy is considered at woman's request.

Essay 345 Posted by Reena G.

A)First I will assess her severity of vomiting by scoring and will ask whether she is not able to tolerate water and what is the impact of it  on her  quality of life like unable to carry her routine work and feels tired. I will ask about associated symptoms like loose stool , frequency , dysuria, abdominal pain, fever, dyspepsia to rule out causes like diarrhoea, UTI, appendicitis , pancreatitis, peptic ulcer, viral hepatitis.I will assess her dehydration by looking at her tongue, ketotic smell, skin turgidity, pulse and blood pressure, will palpate her abdomen for any abdominal tenderness , any mass .I will do some blood test like FBC, U&E, LFT,( her LFT may be raised, rule out hepatitis, serum amylase  to be done to rule out acute pancreatitis), TFT-hyperthyroidism also can cause vomiting but TSH is suppressed in 1st trimester, will do urine dipstix for proteins leucocytes, nitrites, ketones, ultrasound to rule out multiple or molar pregnancy

B) I will admit her in the ward and will hydrate her with I.V. fluids, normal saline and ringer and will avoid dextrose as it can exacerbate wernickes encephalopathy , correct her hypokalemia by KCl drip 20-40mmol/litrex 8 hourly. Start on I.V.antiemetics  like metoclopramide/ prochlorperazine, /promethazine all are safe in 1st trimester, can give ondansteron as second line, non pharmacological  antiemetics measure like ginger and wrist p6 acupressure to be consideredI will make her nil by mouth then will allow her clear fluids, will consider thiamine injection 100mg in 100 ml normal saline , can continue weekly.She should be told to avoid spicy food and take small regular meals, severe case needs total parenteral nutrition even..As pregnancy with vomiting and immobilization can further add the riks for venous thromboembolism so LMW heparin And TED stockings to be considered. Ther is role of steroid in refractory vomiting but needs specialist supervision .She needs daily monitoring of pulse and B.Px 4 hourly, daily her U&E and urine dipstix for ketones should be checked, Fluid balance should be done daily and weight to measured twice weekly. Patient to be counseled  and encourage support by telling her that her symptoms will improve as her pregnancy advances and ther will no adverse effect on baby due to this condition, some patient might request for termination of pregnancy  and should be considered in rare cases

Dr.Mohanad Posted by vanosch M.

 

a)

In initial assessment of this woman, a detailed history should be taken, this should include when she has this problem, how frequent she vomited and any association symptoms such as abdominal pain, diarrhea or urinary symptoms. Any chronic medical history should be inquired as uncontrolled DM may be associated with nausea and vomiting. Any drug  is used should also inquired and documented. Past surgical, obstetric and menstrual history may be beneficial in her subsequent management.

After that clinical assessment should follow including BMI vital signs, ABP-Pulse-temperature. Neck should be examined for thyroid's goiter or nodule. Abdominal examination is crucial to rule out any acute surgical abdomen, such as guarding or rebound tenderness. At 6 weeks gestation the uterus will not palpable unless she is unsure of her LMP or she has multiple or molar pregnancy.

Investigation should include FBC and WBC and differentiation, usually she will have high level of WBC if she has an acute abdomen such as appendicitis. Urea and creatinine also required with urinalysis to rule out UTI. Electrolytes may be disturbed with severe vomiting. Ultrasound scan is recommended to assess the viability of the fetous and to rule out multiple or molar pregnancy as this is well known to be associated with nausea and vomiting. If there is a clinical suspicion of hyperthyroidism, thyroid function test should be requested and thyroid US may be required.

 

   (b)

If patient has severe vomiting, she should managed as in patient.

Iv access should secured with replacement of fluid and electrolytes as appropriate.

She may be kept NPO for a while as this may have benefit to let her has a chance to get benefit of medical treatment and to reduce irritability and inflammation of GIT.

Patient counselling and reassurance play an important role in patient management.

Multi-disciplinary approach should be undertaken with good liaison with internal medicine or renal physicians if needed   

Anti-emetic drugs in general safe in pregnancy (category B).

                                                                                                                         

As this patient has severe vomiting medications should be given IV. Metoclopramide 10 mg iv every 8 h regularly or anti-histamine such as phenergan 25 mg Im/Iv. Vitamin B6 also has beneficial effect alone or as Navidoxin.

Input-output chart is important to avoid fluids overload, with regular clinical assessment of vital signs and chest auscultation.

Corticosteroids may considered in severe cases which not respond to other treatment.

In rare cases where patient is not responding to medical treatment, termination of pregnancy may be undertaken as last resort where there is life-threatening after informed consent from the patient and with informing her partner.