TOPIC DISCUSSION
HIPEREMESIS GRAVIDARUM Nanda Lucky Prasetya, S.Ked Yasser Jayawinata, S.Ked Wahyu Permatasari, S.Ked Wulan Ayu Lestari, S.Ked Selviana Octavianti, S.Ked
Department Obstetrics and Gynecology FMUI-CMNH Professional Education of Medical Doctor Faculty of Medicine, University of Indonesia (C) March 2014
Nausea and vomiting in pregnancy is extremely common. Severe hyperemesis requiring hospital admission occurs in 0.3-2% of pregnancies. Hyperemesis gravidarum (HEG) is the most severe form of nausea and vomiting in pregnancy.
Kementerian Kesehatan RI. Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan. Jakarta: 2013
May also cause
{ } volume depletion, electrolytes and
HEG =
acid-base
PERSISTENT NAUSEA AND VOMITING >5 episodes per day
+
associated with
Ketosis manifested as ketonuria
Weight loss more than 5% of prepregnancy weight
imbalances
(hypokalemia), nutritional
deficiencies,
alkalosis from HCl depletion
acidosis from
partial starvation (Chihara, et.al 2003)
Depression
1. Juekstock JK, Kaestner R, Mylonas I. Managing hyperemesis gravidarum : a multimodal challenge. BMC Medicine. 2010. 8:46.p.1741-7015 2. J Inndon Med Assoc volum 61 nomor 11, november 2011
Morningsickness
Excessive vomiting
HG
less severe
more severe
NVP
HG
Tidak mengganggu aktivitas sehari-hari, < 5x/hari
Mual dan muntah mengganggu aktivitas sehari-hari, > 5x/hari
Mual dan muntah tidak menimbulkan komplikasi (ketonuria, dehidrasi, hipokalemia, penurunan BB)
Mual dan muntah dikeluhkan terus melewati 20 minggu pertama kehamilan
Tidak menimbulkan komplikasi patologis Juekstock JK, Kaestner R, Mylonas I. Managing hyperemesis gravidarum : a multimodal challenge. BMC Medicine. 2010. 8:46.p. 1741-7015 J Inndon Med Assoc volum 61 nomor 11, november 2011
Studies estimate that nausea and vomiting occurs in 50-90% of pregnancies. begins by 9-10 weeks of gestation, Lacroix and co-workers (2000) found that it is lasted an average of 35 days. peaks at 11-13 weeks, resolves in most cases by 12-14 weeks. In 1-10% of pregnancies, symptoms may continue beyond 20-22 weeks.
Cunningham FG, et.al. 23rd edition Williams Obstetrics. McGraw Hill: New York; 2010.
Normal nausea and vomiting may be an evolutionary protective mechanism it may protect the pregnant woman and her embryo from harmful substances in food, such as pathogenic microorganisms in meat products and toxins in plants, with the effect being maximal during embryogenesis (the most vulnerable period of pregnancy). Studies shows that women who had nausea and vomiting were less likely to have miscarriages and stillbirth.
PUQE
Pregnancy-Unique Quantification of Emesis/ Nausea (PUQE) index. Total score is sum of replies to each of the three questions. Nausea Score: Mild NVP = ≤6; Moderate NVP = 7–12; Severe NVP = ≥13. Reprinted with permission from Lacasse A et al.[27]
Modified Pregnancy-Unique Quantification of Emesis/Nausea (PUQE) index. Total score is sum of replies to each of the three questions. Nausea Score: Mild NVP = ≤6; Moderate NVP = 7–12; Severe NVP = ≥13. Reprinted with permission from Lacasse A et al.[27]
PATOPHYSIOLOGY
FACTOR CONTRIBUTING Hormonal
hCG levels increasing or normal different-isotypes-hCG level > transient hyperthyroid (assc. with severity)
GI
estrogen and progesterone level increasing > abnormal gastric pacemaker > tachy/bradygastria
Hepatic dysfunction
impaired fatty acids oxidation, increase fatty acids production
Lipid alteration
hepatic related
Infection
H. pylori (assc. with >2nd trimester persistent vomiting)
Vestibulo-olfaktorius
Hyperacuity of olfactory system
Genetic Biochemical
Increasing fetal DNA in mother's circulation, increasing TNF level
Psychological
Stress, emotionq
Ogunyemi DA, et. al. Hyperemesis gravidarum. Medscape:2014
FACTOR CONTRIBUTING Hormonal
hCG levels increasing or normal different-isotypes-hCG level > transient hyperthyroid (assc. with severity)
GI
estrogen and progesterone level increasing > abnormal gastric pacemaker > tachy/bradygastria
Hepatic dysfunction
impaired fatty acids oxidation, increase fatty acids production
Lipid alteration
hepatic related
Infection
H. pylori (assc. with >2nd trimester persistent vomiting)
Vestibulo-olfaktorius
Hyperacuity of olfactory system
Genetic Biochemical
Increasing fetal DNA in mother's circulation, increasing TNF level
Psychological
Stress, emotionq
Ogunyemi DA, et. al. Hyperemesis gravidarum. Medscape:2014
TREATMENT
Seldom is the treatment of nausea and vomiting of pregnancy so successful that the affected expectant mother is afforded complete relief. Fortunately, the unpleasantness and discomfort usually can be minimized. Eating small meals at more frequent intervals but stopping short of satiation is valuable. Borrelli and colleagues (2005) did a systematic literature search and reported that the herbal remedy, ginger, was likely effective. Mild symptoms usually respond to vitamin B6 given along with doxylamine, but some women require phenothiazine or H1receptor blocker antiemetics (American College of Obstetricians and Gynecologists, 2004b). In some women, vomiting may be so severe that dehydration, electrolyte and acid–base disturbances, and starvation ketosis become serious problems.
Cunningham FG, et.al. 23rd edition Williams Obstetrics. McGraw Hill: New York; 2010.
Kementerian Kesehatan RI. Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan. Jakarta: 2013
Kementerian Kesehatan RI. Buku Saku Pelayanan Kesehatan Ibu di Fasilitas Kesehatan Dasar dan Rujukan. Jakarta: 2013
• Deteksi komplikasi HG
Dehidrasi > syok, hambat tumbang janin Gangguan keseimbangan elektrolit > alkalosis metabolik hipokloremik, hiponatremia, hipokalemia Ketosis > intake sulit, lemak dioksidasi > penumpukan aseton: bau napas aseton Pada lab : peningkatan relatif Hb, Ht, hiponatremia, hipokalemia, keton dalam darah Ruptur esofagus ringan, pneumothorax HG dengan kenaikan BB hamil < 7 kg > BBLR, KMK, prematur, apgar menit ke-5 < 7 Wernicke encephalopathy > trias: Oftalmoplegia, ataksia, confusion
Evaluasi keberhasilan terapi Tujuan > mencegah komplikasi Klinis: penurunan frekuensi muntah, mual, perbaikan TTV, status hidrasi baik, Lab: perbaikan asam basa dan elektrolit
Other keypoints •
Pemeriksaan lab yg penting saat awal penemuan HEG adalah cek keton pada urin
•
Tentukan usia kehamilan, muntah brp kali, deteksi tanda komplikasi, ada dehidrasi/syok, perbaiki tanda-tanda umum, periksa DPL
•
Cek urin saat pasang kateter, keton (+) artinya ada metabolisme anaerob > metabolisme CHO tdk berjalan > puasakan
•
Kateter > hitung balans cairan (>1ml/kgBB/jam)
•
Cari underlying cause > gastritis? mola hidatosa? gemelli?
•
Ondansetron dapat diberikan
•
HEG yg utama elektrolit > puasakan > diet parenteral
Thank you.
