The Art and Science of Infusion Nursing Hyperemesis Gravidarum Strategies to Improve Outcomes 03/11/2020 on //7dIgeiLuhMkL9kWvKwgfAPGFMPj02nltGDDFVobkWqncHWQRlSg9yjBWU9jBuwQSAQCN6yy/R8eEgzReezmPfm5ALSU3NvEsywdL7iOhefmPs35WVNSjdaQz7H5GI7 by http://journals.lww.com/journalofinfusionnursing from Downloaded Downloaded Kimber Wakefield MacGibbon, BSN, RN from http://journals.lww.com/journalofinfusionnursing ABSTRACT Hyperemesis gravidarum (HG) is a debilitating and potentially life-threatening pregnancy disease marked by weight loss, malnutrition, and dehydration attributed to unrelenting nausea and/or vomiting; HG increases the risk of adverse outcomes for the mother and child(ren). The complexity of HG affects every aspect of a woman’s life during and after pregnancy. Without methodical intervention by knowledgeable and proactive clinicians, life-threatening complications may develop. Effectively managing HG requires an understanding of both physical and psychosocial by //7dIgeiLuhMkL9kWvKwgfAPGFMPj02nltGDDFVobkWqncHWQRlSg9yjBWU9jBuwQSAQCN6yy/R8eEgzReezmPfm5ALSU3NvEsywdL7iOhefmPs35WVNSjdaQz7H5GI7 stressors, recognition of potential risks and complications, and proactive assessment and treatment strategies using innovative clinical tools. Key words: antiemetic, enteral nutrition, genetics, granisetron, HELP score, hyperemesis gravidarum, intravenous, malnutrition, nausea, neurodevelopmental disorder, ondansetron, parenteral nutrition, pregnancy, premature delivery, total parenteral nutrition, vomiting, vomiting center, Wernicke’s encephalopathy, Zofran ausea and vomiting of pregnancy (NVP) affects midpregnancy in half of women; however, HG persists at least 70% of women globally, whereas severe until delivery in nearly 22%.7-9 Nausea lasts all day in most NVP, or hyperemesis gravidarum (HG), reportedly women and causes debility and malnutrition because of its affects 0.5% to 14% of women across all ethnicities severity and poor response to medications. Emesis may be Nand socioeconomic levels.1-3 Because of inconsistent diag- episodic and triggered by stimuli such as motion, smells, nostic criteria, the actual incidence is unknown yet signifi- or the thought of food.8-10 Unlike emesis attributed to food cant, given that 18% of women take antiemetics for NVP.1,4 poisoning, emesis because of HG rarely brings relief, and the In addition, some women choose therapeutic termination emetic impulse may be so forceful and continuous that oral before being diagnosed or hospitalized.5 HG is the leading intake is impossible. Some women lose consciousness and cause of hospitalization in early pregnancy and second only bladder function. Severe cases may experience extensive to premature labor as the most common cause of hospital- dental damage, organ damage, encephalopathy, esophageal ization throughout all of pregnancy.6 rupture, pneumomediastinum, and retinal hemorrhage.11-14 The onset of HG typically occurs between 4 and Poor intake causes debility and profound fatigue, which 6 weeks, peaks around 10 and 13 weeks, and resolves by impairs self-care that often continues postpartum.8,10,14 About 80% of women lose weight, use medications, Author Affiliation: Hyperemesis Education and Research and have HG every pregnancy, whereas 67% receive intra- Foundation, Clackamas, Oregon. venous (IV) treatment and only 39% are hospitalized.15 Kimber Wakefield MacGibbon, BSN, RN, is the executive director Recurrence rates exceed 70%, although women proactively and cofounder of the Hyperemesis Education and Research (HER) on manage symptoms to avoid the traumatic experience of 03/11/2020 Foundation. For 20 years, she has consulted on hyperemesis grav- 16-20 idarum cases, developed clinical tools and educational materials for hosptialization. About 30% of women report that their clinicians and families, and coauthored more than 24 peer-reviewed symptoms in future pregnancies are the same, 26% say research studies with leading universities. symptoms are worse, and 44% report better pregnancies.15 The author of this article has no conflicts of interest to disclose. Maternal quality of life is severely altered by HG; thus, pro- Supplemental digital content is available for this article. Direct URL active and compassionate intervention is imperative.10,21,22 citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s website (http://journals.lww.com/journalofinfusionnursing). CLINICAL CHARACTERISTICS Corresponding Author: Kimber MacGibbon, BSN, RN, 10117 SE Sunnyside Road, Suite F8, Clackamas, OR 97015 (kimber@ hyperemesis.org). NVP is a spectrum from mild or morning sickness, to severe, DOI: 10.1097/NAN.0000000000000363 or HG. In between are women suffering with symptoms not 78 Copyright © 2020 Infusion Nurses Society Journal of Infusion Nursing Copyright © 2020 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited. requiring hospitalization or nutritional intervention. They TABLE 1 continue some daily activities and maintain marginal intake and hydration, so they are often dismissed until symptoms Differential Diagnosis are severe. Objective signs and symptoms of moderate NVP are challenging to distinguish, yet aggressive intervention Gastrointestinal Genitourinary Metabolic and Gastroenteritis Pyelonephritis Endocrine may help prevent progression (Figure 1). Gastroparesis Uremia Diabetic ketoacidosis HG typically presents with nausea, vomiting, retching, Intestinal Ovarian torsion Porphyria weight loss, hyperolfaction, ptyalism, abdominal pain, obstruction Kidney stones Addison’s disease debility, gastroesophageal reflux, gastroparesis, electrolyte Peptic ulcer Uterine Thyroid disease 23,24 disease leiomyoma deficiency, malnutrition, and dehydration. About 25% Helicobacter of women lose 15% or more of their preconception weight pylori and are much more likely to have prolonged symptoms, Pancreatitis gallbladder and liver dysfunction, and retinal hemor- Appendicitis rhage.8 Although significant weight loss and ketonuria are Miscellaneous Neurologic PG Complications common, they are not reliable diagnostic criteria for HG.25 Drug toxicity Pseudotumor Acute fatty liver Infection cerebri Preeclampsia Proactive antiemetics may reduce weight loss and patient Migraines distress. CNS tumor Abbreviations: CNS, central nervous system; PG, pregnancy. DIFFERENTIAL DIAGNOSIS migraines, thyroid disease, high-fat diet, vegetarian/lac- 7,14,26,29-33 When a patient presents with NVP, determining possible tose-free diet, and gastrointestinal (GI) disorders. causes requires consideration of the timing. Nausea and Incidence increases slightly if mothers are carrying a child 30 vomiting beginning after 9 weeks’ gestation or refrac- that is female or has Down syndrome. However, the tory to medications requires an in-depth workup. Other predominant risk factor is a previous HG pregnancy or a conditions such as infections, hepatic and renal dysfunc- family member with HG. A woman has a 17-fold increased tion, intestinal obstruction, peptic ulcers, gastroenteri- risk if her sister has HG and a 27-fold risk if her mother 34 tis, thyrotoxicosis, gallbladder disease, and intracranial had it with both daughters. Some studies find HG risk lesions should be evaluated.23,26 Careful history-taking decreases in those with higher body mass index (BMI), is paramount, because HG has a multifactorial etiology. advanced age, and in those who smoke tobacco, which In addition, some disorders may develop secondary to could be attributed to reduced olfactory sensation or 29,35-37 dehydration and medications, worsening symptomatolo- decreased expression of placental proteins. Newer gy, so close monitoring is crucial until symptoms resolve research finds genetic evidence that overexpression of the 16 (Table 1).27,28 GDF15 risk allele is linked to recurrent HG. Multiple studies confirm that HG is not associated with pre-existing psychiatric diagnoses, including anxiety, depres- RISK FACTORS sion, bipolar disorder, or eating disorders.17,38-41 Rather, psy- chological sequelae are the result of prolonged symptoms, The risk factors for HG include multiple gestation, younger malnutrition, medications, and/or hospitalization and may age, first pregnancy, extreme high or low body weight, his- improve dramatically with resolution of HG. Psychological tory of motion sickness, allergies, premenstrual syndrome, support may lessen psychological sequelae, but a clinician’s focus should be on alleviating the misery of NVP. CONTRIBUTING FACTORS HG is complicated by secondary factors that may worsen symptoms but alone are not the cause of HG. For example, gallbladder dysfunction may worsen HG, but a cholecys- tectomy does not cure HG. Helicobacter pylori (H. pylori), present in about half of the world’s population, may be more prevalent in HG, possibly activated by changes in gut motility and gastric emptying, poor nutrition, and the hormonal and immunological changes of pregnancy.28,42-44 However, positive H. pylori tests do not reliably predict Figure 1 NVP spectrum. Abbreviations: EN, enteral nutrition; IV, intravenous; PN, parenteral nutrition; PO, oral or by mouth; Rx, the occurrence and severity of HG, its complications, or prescription medication. outcomes, and treating H. pylori may not resolve NVP.43,45-47 VOLUME 43 | NUMBER 2 | MARCH/APRIL 2020 journalofinfusionnursing.com 79 Copyright © 2020 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited. Sensory sensitivity increases symptoms