Nausea and Vomiting of Pregnancy - PowerPoint by S7iOuiRJ

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									Nausea and Vomiting of
Pregnancy

        Sharon Phelan MD
Clinical Impact of NVP


 In ~ 40% of pregnant women, NVP
   interferes with family life, social
    interactions, and employment




     Clinically Significant NVP
         Daily Pattern of NVP
(%) of Total Episodes
    35
    30                                         Nausea        Vomiting

    25
    20
    15
    10
     5
     0
          6-8:59 9-11:59 12-2:59 3-5:59   6-8:59 9-11:59 12-2:59 3-5:59
           AM     AM      PM       PM      PM      PM      AM     AM

                               Time of Day
     Clinical Course of NVP

Early onset   Symptoms peak    Few women experience
 ~ 3 weeks         ~ 9 weeks   symptoms beyond 20 weeks




                         Gestational Age



  Mean onset       Symptoms generally
  ~ 5 to 6 weeks   cease ~ 10 to 16 weeks
 Characteristics of the Fundamental
 Stimulus for NVP
• Elaborated by placenta, not fetus
• Onset within 4 weeks of last menstrual period in
  some patients
• Fully manifest by 10 weeks gestation
• May persist until delivery of placenta
• Rapid improvement with removal of placenta
• More common with female fetus / placenta
• Diminished in older women and multiparas
• Diminished with smoking
                         Peak Symptoms of NVP and
                         hCG Levels
                    70                                                                     90
                                                                 NVP            hCG        80
                    60
Peak Symptoms (%)




                                                                                           70




                                                                                                hCG (IU/mL)
                    50
                                                                                           60
                    40                                                                     50

                    30                                                                     40
                                                                                           30
                    20
                                                                                           20
                    10
                                                                                           10
                     0                                                                     0
                         4   5   6   7   8    9   10   11   12   13   14   15    16   17

                                             Week of Pregnancy
   Fundamental Stimulus in NVP
               Fundamental Stimulus

   Modifiers                           Predisposition
 of Stimulus     Initial Response      to NV
or Response


                  Final Common
                Mechanisms of NVP

    Specific
   Modifiers   Secondary Response      Non-specific
     of NVP                            Modifiers


               Clinical Presentation
Impact of NVP

            Mother


  Family               Fetus

           Pregnancy
            Outcome
Differential Diagnosis of NVP

• Gastrointestinal disorders
• Genitourinary disorders
• Metabolic disorders
• Neurologic disorders
• Miscellaneous
• History of preexisting conditions
  associated with nausea and vomiting
• Pregnancy-related conditions
Evaluating the Pregnant Patient
with NV
• Physical findings suggestive of nausea
  and vomiting due to other causes
• Neurologic findings
• Laboratory tests
   •   Serum amylase level
   •   Serum liver enzyme levels
   •   Serum thyroid stimulating hormone (TSH) level

• Ultrasound results
   •   Multiple gestation
   •   Molar gestation
Patient-Centered Approach to
Treating NVP

• Assess emotional impact of NVP
  and effect on daily activities
• Acknowledge and validate
  patient’s concerns
• Dispel myths and misconceptions
  about NVP
   Management Considerations
   with NVP
       Mild to               Supportive measures
    Moderate NVP             (eg, dietary, lifestyle,
(not interfering with work   reassurance)
        or lifestyle)

    Moderate NVP             Consider pharmacologic
(interfering with work or    treatment options
         lifestyle)

     Severe NVP              Hospitalization
 (significant weight loss    (eg, fluid replacement,
     and dehydration)        nutritional supplementation,
                             IV medications)
Dietary Management of NVP
• Maintain a diary of food intake to determine
  offending agents
• Avoid foods, tastes, textures, or odors that
  trigger nausea and vomiting
• Eat frequent small meals and snacks, ingesting
  fluids between meals
• Eat carbohydrate-rich, low-fat foods
• Prevent an empty stomach; eating crackers
  before arising
• Eat protein-predominant meals
Complementary Therapies for
NVP
• Vitamin B6 (pyridoxine) supplementation
• Herbal remedies
  • Mint, ginger, orange
  • Powdered ginger supplement

• Acupressure
  • P6 (Neiguan) point on inner aspect of wrist

• Medical hypnosis, psychotherapy
    Safety and Efficacy of
    Nonpharmacologic Interventions

 Safe and effective    • Vitamin B6 10 – 25 mg PO TID


   Safe, clinically    • Dietary and lifestyle changes
   effective; little
evidence of efficacy

 Safe, preliminary     • Ginger root 250 mg PO QID
evidence of efficacy   • P6 stimulation 5–10 min q 4–6 h
                         to continuous application
  Pharmacologic Treatment of NVP

H1-receptor            • Dimenhydrinate (Dramamine® Oral)
antagonists            • Doxylamine (Unisom® Sleep Tabs)
                       • Hydroxyzine
                       • Meclizine
                       • Cyclizine

Dopamine antagonists   • Phenothiazines (Phenergan®)
                       • Metoclopramide (Reglan®)


5-HT3 antagonists      • Ondansetron (Zofran®)


Corticosteroids        • Methylprednisolone (Solu-Medrol®)
    Drug of Choice for NVP
Hospitalizations/1000 births                                  Prescriptions in 1000s

20                                                                             150

                Bendectin
18

                                    Hospitalizations
16                                     for EVP                                 100

14


12                                                                              50
                                                        Diclectin
10


8                                                                                0
       80       82     84      86   88     90      92    94         96
                                      Years

     EVP=excessive vomiting in pregnancy
  Safety of Pharmacologic Agents
  for NVP
• Swedish registry of promethazine or meclizine
  use in first trimester
   • No increase in congenital defects

• Meta-analysis of epidemiologic studies of
  Bendectin®
   • No difference in risk of birth defects in exposed infants

• Antinauseant medication in first 8 weeks
   • Fewer congenital heart defects

• Meta-analysis of antihistamine use and major
  malformations
   • Protective effect
Safety of Pharmacologic Agents
for NVP
• Ondansetron
  • Manufacturer’s assigned category B
  • No teratogenicity in 18 cases of first
    trimester exposure
• Corticosteroids
  • 6 cohort and 1 case-control study
    concluded not teratogenic
  • Meta-analysis  may increase risk for oral
    clefts in first 10 weeks gestation
  NVP Treatment Algorithm
                        Monotherapy                 If no improvement,
            Vitamin B6 10 mg – 25 mg, TID or QID       proceed to the
                                                          next step

                             Add
               Doxylamine 12.5 mg, TID or QID
           Adjust schedule and dose according to
               severity of patient's symptoms


                               Add
     Promethazine (Phenergan®) 12.5 – 25 mg q4h PO/PR
                                or
Dimenhydrinate (Dramamine® Oral) 50 – 100 mg q4 – 6h PO/PR
(not to exceed 400 mg per day; not to exceed 200 mg per day
             if patient is also taking doxylamine)

      No Dehydration                Dehydration               continued
NVP Treatment Algorithm
(continued)
                 No Dehydration
              Add any of the following:
                 (in alphabetical order)
    Metoclopramide (Reglan®) 5 – 10 mg q8h IM/PO
                          or
        Ondansetron (Zofran®) 8 mg q12h IM/PO
                          or
            Prochlorperazine (Compazine®)
        5 – 10 mg q3 – 4h IM/PO; 25 mg BID PR
                          or
 Promethazine (Phenergan®) 12.5 – 25 mg q4h IM/PO/PR

                                                       continued
     NVP Treatment Algorithm
     (continued)
                              Dehydration
                          IV fluid replacement
                   IV multivitamin supplementation
                 Dimenhydrinate (Dramilin® Injection)
             50 mg (in 50 mL saline, over 20 min) q4 – 6h IV

             Add any of the following: (in alphabetical order)
              Metoclopramide (Reglan®) 5 – 10 mg q8h IV
                                 or
         Prochlorperazine (Compazine®) 2.5 – 10 mg q3 – 4h IV
                                 or
            Promethazine (Phenergan®) 12.5 – 25 mg q4h IV

                                      Add
                   Methylprednisolone (Solu-Medrol®)
16 mg q8h IV/PO for 3 days. Taper over 2 weeks to lowest effective dose.
           If beneficial, limit total duration of use to 6 weeks.
                                       or
Ondansetron (Zofran  ®) 8 mg, over 15 min q12h IV, or 8 mg q12h IM or PO
Initial Treatment of Severe NVP

• Hospitalization
• Intravenous fluids, electrolytes,
  and multivitamins
• Intravenous antiemetics /
  antinauseants
• Enteral or parenteral nutrition for
  severe cases
Management of Severe NVP

• Continued drug therapy to counter
  NV (PO, PR, or IM)
• Parenteral or enteral nutrition,
  if necessary
• Gradual reintroduction of PO fluids
  and solid foods
• Psychological support

								
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