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Jumat, 21 Desember 2012

Hiperemesis Gravidarum

Hyperemesis gravidarum

Hyperemesis gravidarum (HG) is a severe, debilitating nausea and vomiting in pregnancy that generally leads to more than 5 percent weight loss and may require fluid and nutritional supplement. It is different from the more common nausea and vomiting known as morning sickness.[citation needed] Dehydration, malnutrition, and other serious complications are the result of the "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids."[1] Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2%.[2]


Etymology

Hyperemesis gravidarum is from the Greek hyper-, meaning excessive, and emesis, meaning vomiting, and the Latin gravidarum, the feminine genitive plural form of an adjective, here used as a noun, meaning "pregnant [woman]". Therefore, hyperemesis gravidarum means "excessive vomiting of pregnant women".

Causes

While there are numerous theories regarding the etiology of HG, none is as yet conclusive. It is thought that the cause is most likely not due to one factor alone and may vary between women depending on such factors as genetics, body chemistry and overall health.[3] The disease is more frequently found with women pregnant with girls and twins.[4]
The most studied theories suggest that it is an adverse reaction to the hormonal changes of pregnancy. In particular, hyperemesis gravidarum may be due to elevated levels of beta HCG (Human chorionic gonadotropin),[5] as it is more common in multiple pregnancies and in gestational trophoblastic disease. This theory would also explain why hyperemesis gravidarum is most frequently encountered in the first trimester (often around 8 – 12 weeks of gestation), as HCG levels are highest at that time and decline afterward. It is thought that estrogen produces nausea and regurgitation of stomach acids in some women.[6] There is also evidence that leptin may play a role in HG.[7]
A recent study gives preliminary evidence that there may be a genetic component.[8]

Symptoms

When hyperemesis gravidarum is severe and/or inadequately treated, it may result in:
Symptoms can be aggravated by hunger, fatigue, prenatal vitamins (especially those containing iron), and diet.[6] Some women with hyperemesis gravidarum lose as much as 10% of their body weight.[9] Many sufferers of HG are extremely sensitive to odors in their environment; certain smells may exacerbate symptoms. This is known as hyperolfaction. Ptyalism, or hypersalivation, is another symptom experienced by some women suffering from HG.
As compared to morning sickness, hyperemesis gravidarum tends to begin somewhat earlier in the pregnancy and last significantly longer. While most women will experience near-complete relief of morning sickness symptoms near the beginning of their second trimester, some sufferers of HG will experience severe symptoms until they give birth to their baby, and sometimes even after giving birth.[10]

Complications

For the pregnant woman

If inadequately treated, HG can cause renal failure, central pontine myelinolysis, coagulopathy, atrophy, Mallory–Weiss syndrome, hypoglycemia, jaundice, malnutrition, Wernicke's encephalopathy, pneumomediastinum, rhabdomyolysis, deconditioning, deep vein thrombosis, pulmonary embolism, splenic avulsion, and vasospasms of cerebral arteries. Depression is a common secondary complication of HG.
Prior to the availability of intravenous therapy in the 1950s, hyperemesis gravidarum was sometimes fatal.[4]

For the infant

Infants of women with severe hyperemesis who gain less than 7 kg (15.4 lb) during pregnancy tend to be of lower birth weight, small for gestational age, and born before 37 weeks gestation. In contrast, infants of women with hyperemesis who have a pregnancy weight gain of more than 7 kg appear similar as infants from uncomplicated pregnancies.[11] No long-term follow-up studies have been conducted on children of hyperemetic women.

Diagnosis

HG is the most common cause of hospitalization in the first half of pregnancy and the second most common cause of hospitalization during pregnancy overall. It can be associated with serious maternal and fetal morbidity, such as Wernicke's encephalopathy, fetal growth restriction, and even maternal and fetal death.[12]
Women experiencing hyperemesis gravidarum often are dehydrated and lose weight despite efforts to eat. The nausea and vomiting begins in the first or second month of pregnancy. It is extreme and is not helped by normal measures.[13]
Fever, abdominal pain, or late onset of nausea and vomiting usually indicate another condition, such as appendicitis, gallbladder disorders, gastritis, hepatitis, or infection.[13]

Treatment

Because of the potential for severe dehydration and other complications, HG is in general treated as a medical emergency. Treatment of HG may include antiemetic medications and intravenous rehydration. If medication and IV hydration are insufficient, nutritional support may be required.
Management of HG can be complicated because not all women respond to treatment. In some instances, women with HG may be able to avoid hospitalization by eating a special diet of clear liquids and bland food rich in carbohydrates,[6] and eating before rising in the morning; while these may be of some assistance, they are unlikely to resolve the disorder on their own. Hypnosis has relieved symptoms in some cases, though the majority of women do not respond to this measure.[6] Wristbands used for motion sickness and seasickness have been shown by one study to be effective in treating some cases of HG, but not others; these are worn around the wrist at a traditional acupuncture point, 3 finger-widths from the joint, and are available at many pharmacies.[6] There is evidence that ginger may be effective in treating pregnancy-related nausea; however, in general this is ineffective in cases of HG.

IV hydration

IV hydration often includes supplementation of electrolytes as persistent vomiting frequently leads to a deficiency. Likewise, supplementation for lost thiamine (Vitamin B1) must be considered to reduce the risk of Wernicke's encephalopathy.[14] A and B vitamins are depleted within two weeks, so extended malnutrition indicates a need for evaluation and supplementation. In addition, mineral levels should be monitored and supplemented; of particular concern are sodium and potassium.
After IV rehydration is completed, patients in general progress to frequent small liquid or bland meals. After rehydration, treatment focuses on managing symptoms to allow normal intake of food. However, cycles of hydration and dehydration can occur, making continuing care necessary. Home care is available in the form of a PICC line for hydration and nutrition (called total parenteral nutrition). Home treatment is often less expensive than long-term and/or repeated hospital stays.

Medications

While no medication is considered completely risk-free for use during pregnancy, there are several that are commonly used to treat HG and are believed to be safe.
The standard treatment in most of the world is pyridoxine/doxylamine, (known as Bendectin, or Debendox in the UK and Diclectin in Canada), a combination of doxylamine succinate and pyridoxine (vitamin B6). However, due to a series of birth-defect lawsuits in the United States against its maker, Merrell Dow, Bendectin is not currently on the market in the U.S. (None of the lawsuits were successful, and numerous independent studies and the Food and Drug Administration (FDA) have concluded that Bendectin does not cause birth defects.) Its component ingredients are available over-the-counter (doxylamine succinate is the active ingredient in many sleep medications), and some doctors will recommend this treatment to their patients.
Antiemetic drugs, especially ondansetron (Zofran), are effective in many women. The major drawback of ondansetron has been its cost. In severe cases of HG, the Zofran pump may be more effective than tablets. Zofran is also available in orally disintegrating tablet (ODT) form, which can be easier for women who have trouble swallowing due to the nausea. Promethazine (Phenergan) has been shown to be safe, at least in rats and may be used during pregnancy with minimal/no side-effects. Metoclopramide is sometimes used in conjunction with antiemetic drugs; however, it has a somewhat higher incidence of side-effects. Other medications less commonly used to treat HG include corticosteroids, and antihistamines.
Other less commonly used treatments are tetrahydrocannabinol (THC) and medical cannabis. THC is the principal psychoactive constituent of the cannabis plant and is available by prescription in the U.S. and Canada under the brand name Marinol. Marijuana, specifically cannabis sativa, was found in a 2006 study to have been "extremely effective" and "effective" in the treatment of symptoms of HG, which is similar to its effects for people suffering from similar symptoms for other reasons like chemotherapy.[15] Queen Victoria of the United Kingdom of Great Britain and Ireland, who is known by many as the first medical marijuana pharmacologist, used marijuana to treat her worst symptoms associated with her pregnancies.[16][17] Prenatal maternal use of marijuana is allegedly child abuse in some jurisdictions,[18] and not in others.[19] A peer-reviewed published study, albeit with a small sample size and not reproduced, found no significant differences in developmental testing outcomes between children of marijuana-using and non-using mothers except at 30 days of age when the babies of users had more favourable scores on two clusters of the Brazelton Scales: autonomic stability and reflexes.[20]

Nutritional support

Women not responding to IV rehydration and medication may require nutritional support. Patients might receive parenteral nutrition (intravenous feeding via a PICC line) or enteral nutrition (via a nasogastric tube or a nasojejunum tube).

Support

It is important that women get early and aggressive care during pregnancy. This can help limit the complications of HG. Also, because depression can be a secondary condition of HG, emotional support, and sometimes even counseling, can be of benefit. It is important, however, that women not be stigmatized by the suggestion that the disease is being caused by psychological issues. The more pregancies the worse the sickness gets and the earlier the signs show.
Because the recurrence risk in a subsequent pregnancy is on the order of 80%, many survivors avoid getting pregnant a second time.[4]

Notable cases

It is commonly assumed that the author Charlotte Brontë suffered from hyperemesis gravidarum. She died in 1855 while four months' pregnant, having been afflicted by incessant nausea and vomiting since the start of her pregnancy, and was unable to stomach food or even water.[21]
In December 2012, it was reported that Catherine, Duchess of Cambridge, had been hospitalised with the condition.[22]

References

 This article uses bare URLs for citations. Please consider adding full citations so that the article remains verifiable. Several templates and the Reflinks tool are available to assist in formatting. (Reflinks documentation) (December 2012)
  1. ^ Hyperemesis Education & Research Foundation Understanding Hyperemesis: Overview
  2. ^ Eliakim, R., Abulafia, O., & Sherer, D. M. (2000). "Hyperemesis gravidarum: A current review". American Journal of Perinatology 17 (4): 207–218. doi:10.1055/s-2000-9424. PMID 11041443.
  3. ^ http://www.helpher.org/hyperemesis-gravidarum/theories-research/index.php
  4. ^ a b c Laura Geggel (3 December 2012), A Royal Spotlight on a Rare Condition The New York Times
  5. ^ Hershman JM (June 2004). "Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid". Best Pract. Res. Clin. Endocrinol. Metab. 18 (2): 249–65. doi:10.1016/j.beem.2004.03.010. PMID 15157839.
  6. ^ a b c d e Carlson, Karen J., MD; Eisenstat, Stephanie J., MD; Ziporyn, Terra, PhD (2004). The New Harvard Guide to Women's Health. Harvard University Press. pp. 392–3. ISBN 0-674-01343-3.
  7. ^ Aka N, Atalay S, Sayharman S, Kiliç D, Köse G, Küçüközkan T (2006). "Leptin and leptin receptor levels in pregnant women with hyperemesis gravidarum". The Australian & New Zealand journal of obstetrics & gynaecology 46 (4): 274–7. doi:10.1111/j.1479-828X.2006.00590.x. PMID 16866785.
  8. ^ Fejzo MS, Ingles SA, Wilson M, et al. (August 2008). "High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals". European journal of obstetrics, gynecology, and reproductive biology 141 (1): 13. doi:10.1016/j.ejogrb.2008.07.003. PMC 2660884. PMID 18752885.
  9. ^ "Extreme Weight Loss and Extended Duration of Symptoms Common in Hyperemesis Gravidarum" (pdf). Retrieved 26 July 2012.
  10. ^ "Do I Have Morning Sickness or HG?". H.E.R. Foundation. Retrieved 6 December 2012.
  11. ^ Dodds L, Fell DB, Joseph KS, Allen VM, Butler B. (2006). "Outcomes of pregnancies complicated by hyperemesis gravidarum.". Obstet Gynecol. 107 (2 Pt 1): 285–92. doi:10.1097/01.AOG.0000195060.22832.cd. PMID 16449113.
  12. ^ http://www.helpher.org/PressCenter/presskit/poster-extreme-weightloss.pdf
  13. ^ a b "eMedicine – Pregnancy, Hyperemesis Gravidarum – Diagnosis and Differentials : Article by Susan Renee Wilcox, MD". Archived from the original on 2008-02-08. Retrieved 2008-02-02.
  14. ^ British National Formulary (March 2003). "4.6 Drugs used in nausea and vertigo – Vomiting of pregnancy". BNF (45 ed.).
  15. ^ Westfall, R. E.; Janssen, P. A.; Lucas, P.; Capler, R. (2006). "Survey of medicinal cannabis use among childbearing women: Patterns of its use in pregnancy and retroactive self-assessment of its efficacy against 'morning sickness'". Complementary Therapies in Clinical Practice 12 (1): 27–33. doi:10.1016/j.ctcp.2005.09.006. PMID 16401527.
  16. ^ Hartley-Parkinson, Richard; Brown, Larisa; Nolan, Steve (3 December 2012). "Bulimia, cannabis and a minister in the next room for the birth: Trials and traditions of Royal mothers-to-be from Diana to Victoria". Daily Mail. Retrieved 6 December 2012.
  17. ^ King, Bonnie; Leveque, Phil (29 March 2009). "Medical Marijuana Questions & Answers with Dr. Phil Leveque". The Salem News. Retrieved 6 December 2012.
  18. ^ In re P.T., 9th Dist. 6293 (Ohio App. 2007).
  19. ^ Matter of Jones v. Jones, 50257 (NY: Family Court 2012).
  20. ^ Hayes, J. S.; Lampart, R.; Dreher, M. C.; Morgan, L. (1991). "Five-year follow-up of rural Jamaican children whose mothers used marijuana during pregnancy". The West Indian medical journal 40 (3): 120–123. PMID 1957518.
  21. ^ McSweeny, Linda (2010-06-03). "What is acute morning sickness?". The Age. Retrieved 2012-12-04.
  22. ^ Melanie Haiken (December 3, 2012). "Pregnant Kate Middleton Hospitalized for Hyperemesis Gravidarum - Which Is What?". forbes.com. Retrieved December 3, 2012

 

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