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hyperemesis gravidarum [keywords]
- A Case of Severe Lactic Acidosis in Thiamine Deficiency. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):319A.
Critical Care Student/Resident CasesSESSION TYPE: Medical Student/Resident Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 04:30 PM - 05:30 PMINTRODUCTION: Lactate levels can be commonly used to evaluate patients in the setting of tissue hypoperfusion and subsequently shock. However there are a variety of other causes of hyperlactemia that may exist. We report a case of profound lactic acidosis in a patient with chronic alcohol use that corrected rapidly after infusion of thiamine.CASE PRESENTATION: A 66-year-old woman with a history of chronic alcohol use presented to our emergency department because of persistent vomiting associated with epigastric abdominal pain and anorexia for the past three days. She was found to be hypotensive (95/52 mm Hg), hypothermic (35.2 °C) with a normal heart rate and oxygen saturation. Laboratory findings were remarkable for an alcohol level of 0.21%, acute kidney injury (creatinine 1.73 mg/dL with a baseline of 0.9 mg/dL), hypoglycemia (34 mg/dL) and metabolic acidosis pH 6.98, partial pressure of carbon dioxide (pCO2) of 34 mm Hg, bicarbonate (HCO3) of 6.2 mmol/L, with an anion gap of 38 mmol/l and lactic acidosis (9.6 mmol/L). Her glucose was corrected intravenously and she received three liters of lactate-free isotonic crystalloids and was admitted to our intensive care unit. Upon arrival her lactate level had increased to 14.3 mmol/L. She was found to have a significant osmol gap with anion gap and screening for methanol and ethylene glycol was negative. She was further resuscitated with sodium bicarbonate which slowly corrected her pH. Clinically, thiamine deficiency was suspected after ruling out other causes of hyperlactemia including bowel perforation with computerized tomography scan of the abdomen and pelvis, tissue hypoperfusion, hepatic failure and hypoxia. After administration of 100 mg of intravenous thiamine, lactic acidosis and concomitantly anion gap normalized rapidly in the next few hours (Fig. 1). She was treated with intravenous thiamine supplementation over the course of her hospitalization and discharged after six days with no neurocognitive deficits.DISCUSSION: Thiamine is a necessary cofactor for enzymes involved with aerobic carbohydrate metabolism, including pyruvate dehydrogenase (Fig 2)1. When thiamine stores become depleted secondary to nutritional deficiency such as anorexia nervosa, hyperemesis gravidarum, total parenteral nutrition, and alcoholism, anaerobic metabolism predominates and the production of lactate increases. An elevated lactate level resulting from thiamine deficiency may be very easily overlooked however can be treated rapidly.CONCLUSIONS: Clinicians need to be aware of the many potential causes of elevations in lactate. In patients who present with lactic acidosis which is otherwise, thiamine deficiency must be suspected in high risk populations and thiamine should be administered.Reference #1: Andersen, Lars W., Julie Mackenhauer, Jonathan C. Roberts, Katherine M. Berg, Michael N. Cocchi, and Michael W. Donnino. "Etiology and Therapeutic Approach to Elevated Lactate Levels." Mayo Clinic Proceedings 88.10 (2013): 1127-140DISCLOSURE: The following authors have nothing to disclose: Herman Dyal, Juan Fernandez, Ruchir Patel, Nena Auraha, Bruno DiGiovineNo Product/Research Disclosure Information.
- Disturbed release of cholecystokinin in pregnant women with hyperemesis gravidarum. [JOURNAL ARTICLE]
- J Obstet Gynaecol Res 2014 Oct 20.
We aimed to investigate cholecystokinin (CCK) release in pregnant women with and without hyperemesis gravidarum (HG).In this case-control study including 40 pregnant women with HG and 40 women with healthy uncomplicated pregnancies, serum CCK levels in addition to hematological, biochemical and hormonal parameters were investigated.Serum CCK values were found to be significantly lower in pregnant women with HG (P < 0.001). Additionally, while serum blood urea nitrogen and free thyroxine levels were significantly higher, sodium, potassium, and thyroid stimulating hormone levels were significantly lower in women with HG than in control women. No correlation was detected between CCK and other parameters like ketonuria and thyroid function tests.CCK release has been found to be halved in pregnant women with HG, which supports the hypothesis that gastrointestinal motility is increased in pregnant women with HG. A causal effect remains to be confirmed.
- The oxidative stress index increases among patients with hyperemesis gravidarum but not in normal pregnancies. [JOURNAL ARTICLE]
- Redox Rep 2014 Oct 18.
Objective The etiology and pathogenesis of hyperemesis gravidarum (HG) is still undetermined and has been suggested to involve oxidative stress. We aimed to evaluate the status of oxidative stress in HG by measuring the levels of total oxidant status (TOS), total antioxidant status (TAS), and by calculating the oxidative stress index (OSI). Methods In a case-control trial, fasting morning blood samples of patients with HG (n = 41) and healthy pregnant women (n = 39) were collected for analysis of serum TOS and TAS values as well as for calculation of OSI according to the formula: OSI = TOS / TAS × 100. Results Serum TOS and TAS levels were similar in both groups. However, serum TAS levels were lower among HG patients compared to controls, which resulted in an increase in OSI (P = 0.025). Discussion The present study supports the role of systemic oxidative stress, reflected by an imbalance between the TOS and TAS, in patients with HG. Our findings distinguish the mechanism underlying oxidative stress to result from reduction of antioxidants rather than an increase in oxidants.
- Clinical course and management of acute and chronic viral hepatitis during pregnancy. [JOURNAL ARTICLE]
- J Viral Hepat 2014 Oct 7.
Pregnancy is a para-physiologic condition, which usually evolves without any complications in the majority of women, even if in some circumstances moderate or severe clinical problems can also occur. Among complications occurring during the second and the third trimester very important are those considered as concurrent to pregnancy such as hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, HELLP syndrome and acute fatty liver of pregnancy. The liver diseases concurrent to pregnancy typically occur at specific times during the gestation and they may lead to significant maternal and foetal morbidity and mortality. Commonly, delivery of the foetus, even preterm, usually terminates the progression of these disorders. All chronic liver diseases, such as chronic viral hepatitis, autoimmune hepatitis, Wilson's disease, and cirrhosis of different aetiologies may cause liver damage, independently from pregnancy. In this review we will also comment the clinical implications of pregnancies occurring in women who received a orthotopic liver transplantation (OLT) Therefore, the management of immunosuppressive therapy before and after the delivery in women who received liver transplant is becoming a relevant clinical issue. Finally, we will focus on acute and chronic viral hepatitis occurring during pregnancy, on management of advanced liver disease and we will review the literature on the challenging issue regarding pregnancy and OLT.
- Marijuana Use and Maternal Experiences of Severe Nausea During Pregnancy in Hawai'i. [Journal Article]
- Hawaii J Med Public Health 2014 Sep; 73(9):283-7.
Recreational use of marijuana is relatively common in the United States, and medicinal use is gaining popular and legal support. Marijuana has been proposed as a potential treatment for hyperemesis gravidarum. Research into this topic is complicated by associations between marijuana use and poor birth outcomes. Cannabinoid hyperemesis syndrome, which can cause severe nausea and vomiting in marijuana users, is another complicating factor. Hawai'i Pregnancy Risk Assessment Monitoring System data from 4,735 respondents were used to estimate prevalence of self-reported marijuana use during and in the month before pregnancy, as well as severe nausea during pregnancy. Data were weighted to be representative of all pregnancies resulting in live births in Hawai'i between 2009 and 2011. Prevalence ratios (PR) and 95% confidence intervals (CI) were computed to estimate associations. Of recently-pregnant women in Hawai'i, 6.0% reported using marijuana in the month before pregnancy, and 2.6% reported using marijuana during pregnancy. Approximately 21.2% reported severe nausea during pregnancy. Women who reported severe nausea during pregnancy were significantly more likely to report marijuana use during pregnancy (3.7% vs 2.3%; PR=1.63, 95% CI: 1.08-2.44). More research is needed to investigate the relationship between marijuana use and severe nausea during pregnancy, and to quantify associated risks to mother and fetus.
- [Two Cases of Wernicke´s Encephalopathy That Developed during Total Parenteral Nutrition in Colon Cancer Patients Treated with 5-Fluorouracil-based Chemotherapy]. [English Abstract, Journal Article]
- Korean J Gastroenterol 2014 Sep 25; 64(3):158-63.
Wernicke's encephalopathy (WE) caused by thiamine deficiency is an acute neurological disorder. Clinically, the classic triad of WE consists of ophthalmoplegia, ataxia, and mental status changes. Thiamine deficiency is known to occur commonly in chronic alcoholic patients. Sometimes, it can occur in patients after gastrointestinal surgery and in those with malabsorption. In addition, patients undergoing renal dialysis, suffering from hyperemesis gravidarum, receiving total parenteral nutrition (TPN), and being treated with chemotherapeutic agents are also prone to develop thiamine deficiency. Herein, we report two cases of WE that developed following simultaneous 5-fluorouracil (5-FU) chemotherapy and TPN in colon cancer patients which was successfully treated with thiamine administration.
- Relation of inflammatory markers with both presence and severity of hyperemesis gravidarum. [Comparative Study, Journal Article]
- Ginekol Pol 2014 Aug; 85(8):589-93.
The aim of our study is to determine the newly introduced systemic inflammation marker, neutrophil lymphocyte ratio (NLR) in hyperemesis gravidarum (HG) patients and to investigate the association between severity of the disease and NLR.The study population consisted of 55 pregnant patients with HG and 50 pregnant women without complaints matched for gestational age as a control group. The HG patients were grouped as mild (n = 16), moderate (n = 19) and severe (n = 20) according to Modified Pregnancy- Unique Quantification of Emesis and Nausea Scoring Index Questionnaire. Furthermore, hsCRP, neutrophils, lymphocytes, and NLR were evaluated with complete blood count.The HG group had significantly higher NLR values compared to the control group (2.69 +/- 1.81 vs 1.97 +/- 1.34, p = 0.004). HsCRP levels were significantly higher among HG patients compared to the control group (1.95 +/- 2.2 vs 0.56 +/- 0.30, p < 0.001). The subgroup analysis revealed statistically significant increases in NLR and hsCRP values with increased HG severity (p < 0.001, p = 0.002). The correlation analysis demonstrated a strong correlation between NLR and hsCRP levels (r: 0.703, p < 0.001).Our study results showed that NLR and hsCRP levels are increased in HG disease compared to gestational age matched control group subjects. Furthermore, NLR and hsCRP values are correlated with severity of disease. NLR could be used as a marker for both presence and severity of hyperemesis gravidarum.
- Potential maternal symptomatic benefit of gabapentin and review of its safety in pregnancy. [REVIEW]
- Eur J Obstet Gynecol Reprod Biol 2014 Aug 17.:280-283.
Restless legs syndrome (RLS) and nausea and vomiting of pregnancy (NVP) are both common maternal conditions affecting quality of life. Gabapentin is currently FDA-approved for treating RLS and preliminary results have shown it may be effective for treating the most severe form of NVP, hyperemesis gravidarum (HG). Because NVP and HG symptoms peak early in pregnancy, the potential teratogenicity of gabapentin needs to be considered. We reviewed published pregnancy registries and cohorts for pregnancy outcomes associated with maternal gabapentin use. Gabapentin exposures from 5 pregnancy registries, 1 HG pilot study and 2 additional cases were reviewed. Among 294 first trimester gabapentin-monotherapy exposures, there were 5 major congenital malformations (MCMs) reported (1.7%), which favorably compares to the MCM rate in the general population (1.6-2.2%). Two of the registries reported maternal gabapentin use among 261 singleton pregnancies to be associated with roughly equivalent rates of premature birth, birth weight after correction for gestational age at delivery and maternal hypertension/eclampsia as those that have been reported in the general population. These data support the safety of gabapentin use in pregnancy; however, the number of exposures to date is still small. If future pregnancy registry data confirm this positive safety profile, gabapentin therapy would likely be a safe and effective treatment for RLS during pregnancy. Controlled, clinical trials are needed to assess gabapentin's effectiveness for HG.
- Elderly primigravidae versus young primigravidae: a review of pregnancy outcome in a low resource setting. [Journal Article]
- Niger J Med 2014 Jul-Sep; 23(3):220-9.
The elderly primigravida is defined as a woman who goes into pregnancy for the first time at the age of 35 years or older. Progressively, this has become more common in our contemporary society and traditionally such pregnancy is regarded as high risk.This was to determine and compare the pregnancy outcomes in elderly primigravidae aged 35 years and above with those of young primigravidae aged 20-25 yearsThe pregnancy outcomes of 82 elderly primigravidae (study group) with a singleton gestation, who delivered in the Teaching Hospital from 1st July, 2005 to 30th June, 2010 were compared with those of 131 young primigravidae (control group) who delivered during the same period in the same hospital.During the study period, there were 3,189 deliveries, given an incidence of elderly primigravidity as 2.6% or 1 in 39 deliveries. The mean age of the study group and control group were 36.4 +/- 0.9 years and 23.1 +/- 1.6 years respectively. The incidence of anaemia, antepartum haemorrhage, hyperemesis gravidarum, malpresentation, intrauterine growth restriction, diabetes mellitus and fibroid were statistically higher in the elderly primigravidae than in the control (p < 0.05). Cephalopelvic disproportion, prolonged second stage, fetal distress and primary post partum haemorrhage were also statistically higher (p < 0.05) including the caesarean section (53.7%) and episiotomy rates (94.6%).Elderly primigravida remains a high risk pregnancy and the incidence is high. They were significantly associated with adverse pregnancy outcomes and operative obstetric interventions. Early booking and more obstetric vigilance shall improve their pregnancy outcomes.
- Nausea and vomiting of pregnancy. [Journal Article]
- Am Fam Physician 2014 Jun 15; 89(12):965-70.
Nausea and vomiting of pregnancy affects nearly 75% of pregnant women. The exact cause is unknown. In most cases, it is a mild, self-limited condition that can be controlled with conservative measures and has no adverse fetal sequelae. About 1% of women develop hyperemesis gravidarum, which may result in adverse outcomes for the mother and fetus. Patients with nausea and vomiting of pregnancy should be evaluated for other causes, particularly if symptoms are unremitting or presentation is atypical. Initial treatment is conservative and includes dietary changes, emotional support, and vitamin B6 supplementation. Several safe and effective pharmacologic therapies are available for women who do not improve with initial treatment. Women with hyperemesis gravidarum may require more aggressive interventions, including hospitalization, rehydration therapy, and parenteral nutrition.