Welcome to this month’s edition of Staten Island Corner. The inspiration for this month’s entry was a “disagreement” that I was involved with on a pediatric shift. We had an 18 year old patient with presumed hyperemesis gravidarum. After the initial NS IVF bolus, I asked the nurse to switch the fluids to D5 NS. I was then told that they were only comfortable giving D5NS at maintenance rates. In our patient, who was dehydrated, it was obvious that this patient would require more than maintenance therapy so I had to continue to give NS and hold off on the D5NS. The pediatric EM attending was also more comfortable with the NS. I had stated that on the adult side, giving D5NS is standard practice when treating hyperemesis, but I realized that once again, I was not aware of the literature supporting this practice and therefore I really did not have an argument. I hope this helps because I am sure that some if not all of you have been in similar situations.
What exactly is Hyperemesis Gravidarum?
Hyperemesis gravidarum is a severe form of nausea and vomiting of pregnancy that causes starvation metabolism, weight loss, dehydration, and prolonged ketosis. The Fairweather criteria define hyperemesis gravidarum as vomiting more than three times a day, weight loss, ketonaemia, electrolyte imbalance and volume depletion, with typical onset at 4–8 weeks of pregnancy and continuing through to weeks 14–16 of pregnancy. It has an incidence of approximately 0.5-2%. It is believed to be associated with increasing levels of beta HCG, thyroid hormone, and estrogen as well as possible H. Pylori infection. This is usually a diagnosis in women less than 9 weeks and if a patient is further along than 9 weeks, alternative diagnoses should be highly considered. Clinical findings include dehydration, acidosis due to inadequate nutrition, and alkalosis due to loss of HCl and hypokalemia.
What is the management of Hyperemesis Gravidarum?
The initial management is fluid hydration. In a patient that is tolerating PO, oral hydration is recommended. However, in a dehydrated patient who is vomiting, IV hydration is needed. The initial fluid in a dehydrated patient should be isotonic crystalloid solution (NS) bolus. If a patient is severely dehydrated, they will often present with starvation metabolism and ketonuria. In these cases, it is recommended by the American College of Obstetrics and Gynecology Practice Bulletin to add glucose to the solution to reverse ketotic metabolism. Although this has never been studied, it is our common and standard practice in the Emergency Department. A multiple vitamin and thiamine should be considered in patients with prolonged vomiting (more than three weeks) or more than a five pound weight loss to prevent the rare cases of Wenicke-Korsakoff Syndrome that have been reported in the literature. In this respect, it is a similar approach to how we approach management of chronic alcoholism. It is also important to note that thiamine requirement increases during pregnancy.
In addition to rehydration, the other main goal in the management of these patients in the ED is symptomatic relief with antiemetics. Medications such as zofran, metoclopramide, promethazine, etc have been used successfully. Two medications that we do not use frequently, pyroxidine and doxylamine, have been shown to improve the nausea and vomiting in pregnancy and have no significant teratogenic risk. There is debate in the literature regarding the use of steroids in hyperemisis gravidarum. A short course of oral methylprednisolone has been reported to have benefits in patients with intractable hyperemesis, but has been associated with increased risk of craniofacial abnormalities when used in early pregnancy. Diazepam in combination with antiemetic therapy has also been shown to improve patient’s symptoms.
Diposition?
Discharge criteria from the ED include: signs and symptoms of volume depletion have resolved, tolerating oral fluids, urine ketones have cleared, and close follow up with OBGYN in 1-2 days. Hyperemesis Gravidarum is the most common indication for admission during the first part of pregnancy and is the second most common (first being preterm labor) during all of pregnancy.
So what is the take home point?
The management of hyperemesis gravidarum is fluid hydration and antiemetics. Although the risk of Wernike-Korasakoff Syndrome is low, it is recommended to play it safe and administer thiamine to the patients with persistent vomiting prior to giving dextrose. That being said, the standard of care is dextrose containing fluids after the initial bolus of NS. So the next time one of you is in this situation, you can state that the reason you are giving dextrose is not only because “it is what we do on the adult side,” but also to reverse the ketoneogensis as well as follow the recommendations given by the American College of Obstetrics and Gynecology.
References:
American College of Obstetrics and Gynecology Practice Bulletin: nausea and vomiting of pregnancy. Obstetrics & Gynecology. Apr 2004;103(4):803-14.
Jueckstock JK, Kaestner R, Mylonas I. Managing hyperemesis gravidarum: a multimodal challenge. BMC Med. 2010 Jul 15; 8:46.
Houry D, Keadey M. Complications in pregnancy part I: Early pregnancy. Emergency Medicine Practice. 2007 June; 9 (6): 1-26.
Ismail SK, Kenny L. Review on hyperemesis gravidarum. Best Pract Res Clin Gastroenterology. 2007; 21 (5): 755-69.
basile
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I think that was a great summary Joe. I agree with what you said and you make a really good point that it is a multiproblem disease. I would guess people get apprehensive because they feel like you are giving them too much sugar in a short amount of time. Anything with dextrose in it seems to scare people if the patient isn’t hypoglycemic or hyperkalemic. So it may help if you can tell the other staff actually how much dextrose you are giving the patient. When calculating the amount of dextrose in the fluid you are giving it is a simple fraction. It is the grams of dextrose divided by the grams of water where 1g of water equals 1mL of water. So, an amp of D50 is 50mL of a 50% dextrose solution which is often given. It is 50mL of water or 50g so 50% dextrose would be 25g mixed into it (25g/50mL). D5W or D5NS contains 5% dextrose which is the percentage in 1000g of water. This means that there is 50g of sugar which is equivalent to 2 amps of D50. This amount is often given for people that are hypoglycemic. Hopefully this will also add to your ammunition for feeling confident giving these patient d5NS.
Nice summary. I appreciate the mention of treating with Thiamine as well. This is often overlooked and has all benefit and no risk. We should do it every time.
I also think that Pyridoxine is only helpful if given before the hyperemesis starts and is not as useful after the patient is already sick.
D50 has VERY little sugar, as Michael pointed out. A can of Coke has about 40 grams, An entire liter of D5 has 50 grams. Not a lot of sugar in D50.
Nice job fellas.