00:01 So now let's discuss Hyperemesis Gravidarum. 00:05 Let's start with a case. 00:08 A 25 year old Gravida 1 Para 0 female at 8 weeks gestation presents to the emergency room with complaint of nausea vomiting. 00:17 She says she is unable to keep anything down. 00:20 She reports a 10 pound weight loss throughout the pregnancy. 00:24 On physical exam she appears dehydrated. 00:27 Vital signs are stable and she is afebrile. 00:30 Her basic metabolism panel shows a potassium of 2.9 and a sodium of 131. 00:36 What is her diagnosis? Let's explore the lecture to find out. 00:41 So hyperemesis gravidarum, what are the signs and symptoms? First, intractable nausea and vomiting. Now it's very common in pregnancy to have nausea and vomiting in the 1st trimester. 00:51 And this usually resolves by 13 weeks. 00:54 However, with hyperemesis gravidarum this is intractable and it usually can continue into the 2nd trimester. 01:01 Patients with hyperemesis gravidarum usually have weight loss that can be anywhere from 5 to 10 pounds all the way up to 15 to 20 pounds. 01:10 They also experience electrolyte disturbance. 01:13 This is usually manifest in a low potassium. 01:15 Sometimes low sodium as well. 01:19 Another symptoms is a hypokalemic, hypochloremic metabolic alkalosis. 01:24 So how do we treat hyperemesis gravidarum? Well the first thing we want to do is IV hydration. 01:30 Now it's very important that this hydration be first with normal saline. 01:35 Why is that? Well, pregnancy is a state that can make you thyamine deficient. 01:40 If you begin to hydrate with something that contains D-5 or some type of a glucose solution, that can worsen the thyamine deficiency. 01:49 And actually lead to something called Wernicke's Encephalopathy. 01:52 The other thing about hydration is you need to make sure it is slow. 01:56 If you hydrate too quickly, you can cause central pontine myelinolysis. 02:00 We want to avoid that. 02:02 So electrolyte disturbances. 02:05 You want to correct those. 02:06 Again pregnancy is a time when thyamine is low. 02:10 It's going to be worse by hyperemesis gravidarum. 02:13 So we want to correct that. 02:15 We also want to correct the other electrolyte disturbances such as a low sodium or low potassium. 02:20 Next we want to treat the nausea vomiting. 02:24 And this is a clinical pearl. 02:26 So we have a lots of options for treating nausea vomiting in pregnancy as well as hyperemesis gravidarum. 02:32 Our first line treatment is vitamin B6 and doxylamine. 02:36 They work synergistically together to help with the nausea vomiting that we see with pregnancy. 02:40 If that's not effective we can move on to our other anti-emetic. 02:44 Let's discuss a few. 02:46 One is ondansetron. 02:48 Ondansetron is a medication that works very well for nausea vomiting. 02:52 However, the side effect is constipation. 02:55 You want to make sure your patients are aware of this, because constipation can be a common problem in pregnancy. 03:01 The next medication is Metoclopramide. 03:04 This medication has a side effect of extrapyramidal movements. 03:08 So you want to make patients aware of that if they start to feel very anxious or weird or start making movements that they feel that they can't control. 03:17 They want to stop taking the medicine. 03:19 Another clinical pearl are those extrapyramidal side effects can be reverse by Benadryl. 03:25 The next medication is Phenergan. 03:27 Phenergan also works very well for nausea vomiting. 03:30 But it has a side effect of sleepiness. 03:33 I should mention that the most recent guidelines recommend avoiding Zofran prior to ten weeks if possible, primarily because of the increased risk of oral clefts and VSD. 03:47 Let's go back to our case. 03:48 Again this is a 25 year old Gravida 1 Para 0 female at 8 weeks gestation that presents to the emergency room complaining of nausea vomiting. 03:58 She states she is unable to keep anything down. 04:00 She has a 10 pound weight loss throughout the pregnancy. 04:04 And on physical exam she appears dehydrated. 04:07 Her vital signs are stable. 04:08 She doesn't have a fever. 04:09 Her basic metabolism panel shows a potassium of 2.9 and a sodium of 131. 04:16 What is her diagnosis? Is it A. Anorexia. 04:20 B. Bulimia C. Hyperemesis Gravidarum or D. Morning sickness. 04:27 Let's think about all the answer choices. 04:30 Anorexia. 04:31 Anorexia manifests a little differently. 04:34 These are patients that are not eating. 04:35 And it really has nothing to do with pregnancy. 04:38 Bulimia, these people with bend eat and then induce vomiting. 04:42 Again unrelated to pregnancy. 04:44 Is Hyperemesis Gravidarum our answer here. 04:48 Let's check out the stem again. 04:50 The patient had a 10 pound weight loss and she has some electrolyte disturbance. 04:55 Her potassium is low as well as her sodium. 04:58 In this case hyperemesis gravidarum is the answer.
The lecture Hyperemesis Gravidarum by Veronica Gillispie, MD, MAS, FACOG is from the course Antenatal Care. It contains the following chapters:
A patient with hyperemesis gravidarum presents to the hospital showing signs of dehydration, a potassium level of 3.1, and a sodium level of 132. What is the best immediate treatment for this patient?
Which of the following is the first-line treatment for hyperemesis gravidarum?
Which of the following can be a complication when using D5 IV hydration to replete a patient with hyperemesis gravidarum?
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I love her, she's great at explaining. The use of case scenarios make the classes more interesting too.
She is really amazing! I have been learning a lot. Thanks Dra. Veronica Gillispie.