Hyperemesis

3)                     Say NO DNS: Say NO to 5% Dextrose àNo PLEASE. Such types of fluids may kill her à may yield Wernicke’s encephalopathy.

4)                      No double strength saline please-even if document hyponatraemia.4) supplement Vit B1 by parental route:-if available-otherwise oral tab (in our country Vit B1 is available as BENALGIS – (Tab form 25-50 mg TDS) -U may keep it at your own stalk-because at Kolkata there is limited supply. It is -for best interest of your pts.) . I V dose will be thiamine 100mmg diluted in NS again –over 30-60 mts.  If not available one can administer Inj Multivitamin as we commonly use in P.ileus.

 Firstly simply Hyperemesis is not to be confused with Hyperemesis which is a serious condition decussating hospitalization.

In cases simple nausea chewing ginger, give chewable chocolates, ginger.,  honey & some dry foods before leaving bed and taking small foods at a time will help. Only few women with progress to Hyperemesis who will warrant antiemetic Ry. If one antiemetic is not sufficed then one can quickly add another one or even two more antiemetic to relive her as all antiemetic are safe and nonteratogenic. This dictum should be in the mind of practioners .To added other types of antiemetic: - at least 3 agents concurrently to combat incessant vomiting-. No hesitation / No apprehension about teratogens :-My preferences are 1)  Tab B6 -10 mg QDS-preceded by Ondansteron  4/ 8 mg or phenergan sublingual(MD is now available) each time sublingually  30 mts prior to B6 tab ,2) liberal Chewing ginger pieces --.& 3) Doxyalamine &  4) promethazine-MD antihistamincs ( Extra Pyramidal effects can appear with promethazine ( Phenothiazines) can cause drowsiness / Extrapyramidal sump –with Reglan are rare possibilities)à  then switch over to some other agents. My experience is that one may have to combine as many as four kinds of antiemetic for initial 3-4 days if this is real Hyperemesis and nothing can be taken by mouth (simple nausea vomiting is not be confused with Hyperemesis-which warrant hospital admission) à may have to be prescribed à gradually taper off. Antiemetic should not be stopped too early.  Not to discharge home from Hosp/N Home too early. Corticosteroids I V very rarely prescribed. Hydrocortisone 100 mg I V BD basis. All IV drips slowly –too rapid Na replacement May harm her. If persistent vomiting then to rule out other pathology may try benefited with single shot of injection phenergan  ,failing which hydrocortisone 100mg iv bd

. What are the other causes of Hyperemesis in Preg? To think of any Surgical causes?  If vomiting is not controlled by 72 hrs with above quoted regime:-One should explore other causes of vomiting (GB Stone, UTI, Subacute App  hyperthyroidism.. Hiatus hernia.

 Deworm the patient if recent H/O passage of R worm.

What investigations? How best to gauze metabolic changes but rpt vomiting?? 1) Urine for acetone Urine alb, ketones, pus cells etc,  Sp Gr may be high, & blood biochemistry right on admissionàlater USG.-not Obstet but whole abd as GB may be cause of vomiting. Also to .rule out twin & rarely molar pregnancy.   2) Blood biochemistry:-serum electrolytes,  & vary rarely when her condition is very critical on admission àone may rarely opt for ABG( arterial blood gas-which will by 2 minutes time yield information on 10-32 characteristics of blood ,Resp & metab component mainly including serum lactate) . Metabolic Hyperchloraeic alkalosis is common. Whole abd USG if not earlier. Meanwhile either maintains Intake output OUTPUT chart, or else weigh the woman at daily / alt day 3) LFT, RFT, compl Heamogram…                                                                                                                      

Follow up of Hyperemesis:- Weight the women daily, Vomitus chart , similarly, Na, Ka, Creatinine, Uric acid, LFT, & PCV  daily or alt day depending on the severity. Not to estimate TSH & T4 - as TSH will falsely exhibit low figure due to gest hyperthyroidism an effect of increased HCG. Vit B12 def may also follow better to suppl inj Vit B12 as safety margin is high. Like vit D.

What is Korsakoff psychosis Such psychotic changes in Hyperemesis cases is not impossible if  one mistakenly administer 5% D-5% or DNS à then what will go wrong?? Administered glucose will consume existing Vit B1 in tricarboxy Acid cycleà and utilize whatever Vit B1 is there àresulting into quick depletion of serum Vit B1 def. As such there will be 6 Th nerve palsy, Nyastagmus, gaze palsy (Wernicke’s encephalopathy).

 Additionally as because due to rpt vomiting her liver F. is already abnormalà so conversion of existing B1 by liver to its active substance i.e. Thiamine pyrophosphate IS INTERFERD WITH. Low level of RBC transketolase will confirm such diag of acute B1 def. If not cared at this early phase she will proceed to a more dangerous phase of then this encephalopathy will proceed to Korsakoff psychosis.

 To exclude Iatrogenic Korsakoff psychosis?? It may so happen DNS or 5% Dextrose plain have been administered by nurses inadvertently on admission at ER with severe vomiting or say diarrhoea-this drip can invite trouble in the form of: Korsakoff psychosis.

Take home message :- to admit all Hyperemesis cases & estimate rft lft tft , haemogram, & urine for acetone ,alb & msu . To maintain vomitus chart , initiate  iv fluids which is  a must Normal  saline 2 lit bottle-with inj B1B6 B12 (Inj MVI will, serve the purpose)  ,as explained later it will  help to revert Wernicke’s encephalopathy . Second step is to send her to USG Deptt or Portable USG:- exclude other causes for vomiting like GB,hiatus hernia, molar, twin etc. Given parenteral antiemetic and antacids too (patoprazole) , Inj Phenergan, /chlorpromazine initially will yield good result. After 2-4 days she usually will be symptom free .If starts vomiting again inspite of above quoted two agentys then there should not be any hesitation to start hydrocortisone.