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75% of all women experience N/V. When does it begin and resolve
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- Begins around 6 weeksResolves around 16 weeks or 100 days
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Proposed etiology of Hyperemesis (0.3-2%) of population
- Hormones:
- Progesterone and E2 on GI motility
- HCG (↑ levels with molar pregnancy)
- Genetics:
- Increased familial risk
- Lower risk in Eastern European, highest in India and Sri Lanka
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What are the risks of untreated Hyperemesis Gravidarum?
- Esophageal Ruptureretinal hemorrhage
- renal damage
- IUGRFetal Death
- Voluntary preg termination
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Clinical criterion for HE Grav
- Severe N/V unresponsive to outpat treatment
- Weight loss >5% prepregnancy wt
- Ketonuria
- get urine dip - Abnormal labs - hypokalemia, Metabolic alkalosis ↑ HCT and LFTs
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What labs and what reason would you get US in HG
Labs: Ketones, TSH, lytes, LFTs, Creatinine, mag&phos
- U/S: to confirm Gestational Age
- R/O molar pregnancy
- R/O multifetal gestation
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DD for Hyperemesis
- Hepatitis
- Pancreatitis
- Pyelonephritis
- Bowel obstruction
- ↑ ICP
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What is IVF management for HE Grav
2 Liters of D5 NS
100mg Thiamine in 1st liter - then 100 mg QDX3
- Gradually ↑ plasma Na
- 10-12 meq/L day 1, then 18meq total X2days
Replace K+, Mg, &phos
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Medications for HE Grav
- Benadryl - 1st line therapyPhenothiazines - phenergan
- Zofran
- Metoclopramine - Reglan
- Corticosteroids - severe refractory casesVitamin B6+Reglan (Pyridoxine)
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When is HCG produced
After blastocyst implantation at
23 menstrual days around 8 days after conception
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What is the predicable rise in Quantitative HCG
Doubles q36-48 hrs x10 weeks. Peaks at about 70 days
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When does HCG start to decline and what does it get down to?
Down to 5-20 mIU/mL @ 120 days
Consider Molar pregnancy with rapid rise
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When and what is the peak of HCG?
at 7-10 weeks HCG rises to 100,000
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All products of conception expelled without need for medical or surgical intervention
Complete Abortion
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Only some POC have been passed; Retained products are fetal, placental, or membranes
Incomplete abortion
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Cervix is dilated, but POC are not expelled
Inevitable abortion
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Known fetal demise but no uterine activity to expel POC
Missed abortion
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>3 consecutive pregnancy losses
Recurrent abortion
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Pregnancy complicated by bleeding <20 wks gestation
Threatened
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Spontaneous AB complicated by intrauterine infection
Septic Abortion
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From what is the highest percentage of spontaneous abortions
49% from random chromosomal anomalies
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What are maternal risk factors for SAB
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- Rapid repeat pregnancy (3-6 mos)IUD use
- Maternal infection
- Advanced Maternal Age
- Substance use/abuse
- Medications
- Multiple abortions
- Anesthetic gas exposure
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1st TM workup
- Quant hCG
- Wet prep (GC & Chlamydia)
- CBC, Type & Rh
- US
- +FHTs
- Dilated cervix= SAB inevitable
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