Management of Hyperemesis Gravidarum

Hyperemesis Gravidarum Case Study

Presenter : Vaisnvi MuthoovalooPembimbing : Dr. Achmad Djaenudin SpOG

Identitas Pasien

Nama Lengkap : Ny. C Jenis Kelamin : Wanita

Tempat / tanggal lahir : 24 Juli

1983/32 tahun

Suku Bangsa : Sunda

Status Perkawinan : Menikah Agama : Islam

Pekerjaan : Guru Pendidikan : S1

Alamat : Cengkareng, Jakarta RM 49-07-48

Identitas Suami

Nama Lengkap : Tn. E Jenis Kelamin : Laki – laki

Tempat / tanggal lahir : 35 tahun Suku Bangsa : Sunda

Status Perkawinan : Menikah Agama : Islam

Pekerjaan : Pekerja Swasta

Alamat : Cengkareng, Jakarta

Keluhan Utama

• Pasien mengeluh mual dan muntah sejak 2 minggu.

Mual yang hebat dan muntah sepanjang hari lebih dari 10 kali per hari, sehingga tidak bisa makan sama sekali sejak 2 minggu . Nafsu makan berkurang. Penurunan berat bedan ± 3 kg.

Merasa lemas dan haus. 1 minggu yang lalu muntah darah sebanyak 2 kali kira kira setengah aqua gelas Sudah berobat ke RS Bunda Suci 2 kali. 3 hari yang lalu, keluhan mual dan muntah muncul lagi.

Sangat lemas, pusing dan sesak sehingga menganggu aktivitas seharian. Juga mengeluh berkunang-kunang apabila bangun dari tempat tidur. Pasien mengaku kencingnya berwarna pekat seperti coca-cola dengan jumlah sedikit kira-kira seperempat gelas aqua, tidak disertai darah/nyeri dan sering merasa haus.

Keluhan demam, BAB hitam, nyeri perut, perdarahan per vaginanam disangkal. Keluhan mual dan pusing pada kehamilan sebelumnya disangkal. Riwayat penyakit seperti darah tinggi, penyakit gula darah dan alergi kepada obat- obatan serta makanan, asma dan sakit maag disangkal. Konsumsi minuman beralkohol disangkal.

Pasien mengaku hamil 8 minggu. HPHT tanggal 7 Januari 2016.

Riwayat kehamilan

Anak ke

Tahun Persalin

Jenis Kelamin Umur Kehamilan

Jenis Persalin

Penolong

Hidup / Mati

Berat bayi

Nifas Ibu

1 2012 Perempuan 39mgg normal bidan hidup 2900 gr

Baik

Rpd rpk

• -

RIWAYAT HAID

• Menarche : 12 tahun• Siklus : Teratur/ 28 hari

• Lama : 7 Hari• HPHT : 07/01/2016• Taksiran Persalinan : 14/10/2016

RIWAYAT OBSTETRI

• G2P1A0 hamil 8 minggu

Status Pernikahan

• Status : Menikah• Pernikahan ke : 1• Lama: 5 tahun

KB

• Pasien menggunakan kontrasepsi spiral namun sudah lepas ±1 tahun.

RIWAYAT ANTE NATAL CARE

• Pasien kontrol kehamilan pada bidan puskesmas 1 kali

• Keadaan umum : Tampak Sakit Sedang• Kesadaran : Compos Mentis• Tinggi badan : 165 cm• Berat badan : 50 kg• BMI : 18.35kg/m²

Status generalis Tanda vital• Tekanan Darah : 90/70 mmHg• Nadi : 90 kali/menit• Nafas : 26 kali/menit• Suhu : 36,4 0CMata : Cekung. Konjungtiva anemis -/- , Sklera ikterik -/-Mulut : Mukosa tampak kering.Leher : Pembesaran KGB -, Pembesaran kelenjar tiroid -Jantung : BJ I-II regular murni, Gallop - , Murmur -Paru-paru : Suara nafas vesikuler, Ronkhi -/- , Wheezing -/-Abdomen : Abdomen tampak merata, tampak linea albaEkstremitas : Varices -/-, edema --/--, akral dingin + +/+ +

STATUS OBSTETRI

Pemeriksaan Luar• Inspeksi : Abdomen mendatar, tampak

linea alba• Palpasi : TFU 3 jari di bawah

umbilicus, nyeri tekan negatif

Pemeriksaan lab

Pemeriksaan Hasil Nilai rujukan

Hematologi

Hb

Leukosit

Hematokrit

Tombosit

10,7 mg/dL

7.200 /uL

32,1 %

255.000 /uL

12,0-14,0

5000-10.000

36-42

150000-450000

USG

• Fetal heart monitoring : 156 kali/menit. • Fetal echo +• Gestational sac (+) 3.6 cm, usia gestasi : 8

minggu 2 hari• Taksiran partus :16 Oktober 2016

Resume

• Ny C, 32 tahun, G2P1A0 hamil 8 minggudengan keluhan nausea dan hyperemesis sejak 2 minggu lebih dari 10 x/ hari. Pasien anorexia, malaise, oliguria dan mengalami penurunan berat badan ≥5%(± 3 kg). Pasien juga mengalami hipotensi ortostatik dan tachypnea. 1 minggu yang lalu pasien hemetemesis 2 kali kira kira setengah aqua gelas. Sudah berobat ke RS Bunda Suci 2 kali. 3 hari yang lalu, pasien kembali nausea dan hyperemesis.

XV . DIAGNOSIS

• Ibu: G2 P1 A0 hamil 8 minggu dengan hyperemesis gravidarum

PENATALAKSANAANRencana Diagnostik:• Pemasangan kateter, urinalisis, elektrolit serum, kalsium, fungsi tiroid dan

fungsi hati

Rencana pengelolaan : • Puasa 24 jam• Terapi cairan : Hartmann/NaCl 2000ml dalam 3-5 jam lanjut dengan

maintenance 25-30ml/kgBB/24 jam diatur sesuai dengan jumlah output urine (minimal 100ml/jam)

• Ondansetron IM/ slow IV 4-8mg seterusnya PO 4-8mg 2kali/hari.• Ranitidine IV 50mg 3kali/sehari. Seterusnya PO 150mg 2kali/sehari.• Multivitamin IV• Folic Acid 5mg sekali/hari

EDUKASI PASIEN

• Edukasi pasien tentang penyakitnya.• Makan makanan kesukaan ketika rasa lapar

muncul, terlepas dari jadwal makan yang biasanya

• Makannya sering tapi dalam jumlah porsi kecil• Hindari makan yang berbau dan yang

berlemak dan pedas.

PROGNOSIS

Ibu: • Ad vitam : Dubia ad bonam• Ad fungsionam : Dubia ad bonam• Ad sanationam : Dubia ad bonamJanin: • Ad vitam : Dubia ad bonam• Ad fungsionam : Dubia ad bonam• Ad sanationam : Dubia ad bonam

HYPEREMESIS GRAVIDARUM

Definition • Persistent and excessive vomiting starting before the end

of the 22nd week of gestation being associated with metabolic disturbances such as carbohydrate depletion, dehydration, or electrolyte imbalance.

• HG is a diagnosis of exclusion, characterized by prolonged and severe nausea and vomiting, dehydration, large ketonuria, and more than 5% body weight loss.

• Pada pemeriksaan fisik didapatkan keadaan umum tampak sakit sedang, kesadaran compos mentis. Tekanan darah 9070 mmHg, nadi 98x/menit, pernafasan 28x/menit, suhu 36,4oC. Ditemukan mata cekung, mukosa mulut tampak kering dan akral dingin.

Pathophysiology – multifactorial• HCG– increased levels in patients with HG as HCG

stimulates secretions in upper GIT• Estrogen- positive assoc between NVP and maternal

serum estrogen level. Increased estrogen causes a decrease in GI motility and gastric emptying altering GI pH and encourages subclinical H pylori infection

• Thyroid hormone- physiological gestational transient thyrotoxicosis. Raised FT3 & low TSH found in 66% HG

Risk factors

• Elevated HCG level– Molar/trisomy pregnancy

• Psychological factors• Female fetus• Low maternal age• Use of vitamins in early pregnancy• Nausea associated with contraception


• Symptoms

– Nausea– Vomiting– Ptyalism– Enhanced olfactory senses– Food and/or fluid intolerance– Lethargy


• Signs – Dehydration– Weight loss– Ketonuria– Anaemia– Tachycardia

• Initial Investigations– Urea and Electrolytes– LFT– CBC– Urinalysis– USG-multiple/molar pregnancies

• Additional investigations– Calcium– Blood sugar– TSH


COMPLICATIONS MaternalHypokalemiaHyponatremia and central pontine myelinosisWernickie’s encephalopathyMalnutritionMallory- Weiss esophageal tears

FetalGrowth restrictionWernicke’s encephalopathy is associated with 40% fetal

death

COMPLICATIONS

• Hyponatremia (Na<120 mmol/l) - anorexia, headache, nausea, vomiting and lethargy

• Severe hyponatremia may lead to central pontine myelinolysis (osmotic demyeliniation) – Pyramidal tract signs– Spastic quadriparesis– Pseudobulbar palsy – Altered sensorium– Ataxia and convulsion

• Vitamin B1 deficiency precipitated by IV fluid containing high concentration of dextrose – Ophthalmoplegia (typically sixth nerve palsy, diploia), – Ataxia – Altered sensorium

• Thiamine replacement may improve the symptoms of Wernicke’s encephalopathy

Condition Disease

Gastrointestinal

disorders

Pancreatitis

Appendicitis

Peptic ulcer disease

Biliary tract disease

Neurological

disorders

Benign intracranial;

hypertension

Tumour

Severe migraine

Vestibular disease

Others Drugs induced

Condition Disease

Infections Acute pyelonephritis

Acute gastroenteritis

Viral fever

Encephalitis

Viral hepatitis

Malaria

Metabolic

disorders

Diabetic ketoacidosis

Hyperthyroidism

Hyperparathyroidism

Hypercalcemia

Uraemia

Addison’s disease

• Correction of dehydration and electrolyte imbalance

• Prophylaxis against recognized complications• Provision of symptomatic relief

• Admit if :– Symptom are severe despite 24 hrs of medication– Evidence of dehydration and ketosis– Admit earlier if coexisting conditions eg diabetes

• IV fluid- NS and Hartmann’s solution preferrable if ketotic or fluid intolerant.

*Avoid dextrose

• Antiemetics are safe and recommended liberally in HG

• Patients on antiemetic -better pregnancy outcome due to better nutrition

Anti-emetics Drug Recommended

dose

Route

1st line Promethazine

Cyclizine

25 mg t.d.s

And/or

50 mg t.d.s

PO/IM

PO/IM/IV

2nd line Prochlorperazine

Metoclopramide

12.5mg t.d.s.

10mg t.d.s.

3-6 mg b.d.

And/or

10mg t.d.s.

IM

PO

Buccal

PO/IM/IV

3rd line Ondansetron 4-8mg then

4-8mg b.d.

IM/ slow IV

PO

• Steroids should be used for intractable hyperemesis which is not responding to above management

• IV Hydrocortisone 100 mg BD for 48 hrs

• Oral prednisolone 30 – 40 mg/day -1 week then tapered gradually 5mg reduction every week

Prolonged nausea & vomiting Intolerable to fluid and/or food Clinical dehydration Ketouria Weight loss

Nausea & vomiting History of other medical condition e.g diabetes,

Summary for Management of Hyperemesis Gravidarum-NHS 2013

Admission

Admission

Initial assessment Temp, Pulse, Resp, BP, Body weight U&E LFT Urinalysis/ MSU USS

Additional investigations FBC (full blood count) Blood glucose TFT (thyroid function test) Calcium

Diagnosis

Treatment

Subsequent assessment Fluid intake output chart

U&E (urea and electrolytes), LFT (liver function test

Alternate day if initial results were normal, daily if the results were abnormal

Fluid & electrolyte replacement

Normal saline/ Hartmann’s

KCl (potassium/ about 100 mmol/24 hr)

All hyperemesis Pabrinex 250 mg thiamine

per pair weekly if oral thiamine is not tolerated.

Antiemetics (1st group) 1st line: Cyclizine 50 mg t.d.s. PO, IM or IV2nd line: Prochlorperazine 12.5mg t.d.s. IM

Buccastem 3-6mg bd sublingually Third line: Metoclopramide 10 mg t.d.s. PO IM

or IV

Intractable vomiting

Antiemetics (2nd group) Promethazine (phenergan) 25 mg

a day IM/oral Chlorpromazine 10-25 mg t.d.s.

PO 25 mg t.d.s. IM

Domperidone 10 mg q.d.s PO 30-60 mg b.d PR

With consultant decision Ondansetron 4-8 mg b.d. PO, IM or

IV Hydrocortisone 100 mg b.d. IV for

48 hr followed by: Prednisolone 30-40 mg o.d. PO for one week then reduce the dose by

5 mg/week

Other supportive treatment

• Diet & lifestyle (small frequent dry meal, learn to avoid certain scents which make the patient intolerable)

• Ginger • Acupressure/acupuncture

The options for severe hyperemesis who failed to response to above measures

• Enteral nutrition• Parenteral nutrition (TPN)• Termination of pregnancy

A doxylamine/pyridoxine combination should be the standard of care, since it has the greatest evidence to support its efficacy and safety. (I-A)

H1 receptor antagonists should be considered in the management of acute or breakthrough episodes of NVP. (I-A)

Pyridoxine monotherapy supplementation may be considered as an adjuvant measure. (I-A)

Phenothiazines are safe and effective for severe NVP. (I-A)SOGC 2002, ACOG 2010

Hyperemesis guidelines

• Metoclopramide is safe to be used for management of NVP, although evidence for efficacy is more limited. (II-2D)

• Corticosteroids should be avoided during the first trimester because of possible increased risk of oral clefting and should be restricted to refractory cases. (I-B)

• When NVP is refractory to initial pharmacotherapy, investigation of other potential causes should be undertaken. (III-A)

SOGC 2002, ACOG 2010

Documents

Management of Hyperemesis Gravidarum