Invictus Reviews

Navigating Pregnancy Complications: A Sneak Peek

• Mel Herbert

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Britt Guest's lecture on pregnancy complications with expert emphasis from Matt Delaney. This preview focuses on differentiating normal pregnancy nausea from hyperemesis gravidarum while demonstrating effective board exam question strategies.

• Normal pregnancy nausea can be managed with pyridoxine (B6), doxalamine, ondansetron, ginger, and eating smaller frequent meals
• Hyperemesis gravidarum causes severe dehydration, weight loss, vitamin deficiencies, and potential complications including Wernicke's encephalopathy
• Severe vomiting can lead to mechanical complications like Mallory-Weiss tears, pneumomediastinum, and pneumothorax
• Treatment escalation includes IV/IM medications and possibly steroids (with caution in first trimester)
• Board-style questions demonstrate proper management of a dehydrated pregnant patient and recognition of molar pregnancy signs
• Matt Delaney demonstrates how to work through unfamiliar terms on exams using clinical reasoning

Check out the full video version with visuals on YouTube - link in the show notes.


Speaker 1:

Hey Invictus peeps, Mel Herbert here. I have been a bit slack on these because I've gotten so busy. The Pit Season 2 is kind of sucking the life out of me but it's going to be so good. But we've got Matt Delaney on board and he is up to speed and the faculty are putting together the lectures. They're getting edited and he's adding emphasis and I'll be doing some of that as well and I just wanted to throw you a little piece of one that's coming up. The speaker is Brit Guest. Matt Delaney is doing the emphasis.

Speaker 1:

This is on some complications of pregnancy. This is only part of a much bigger talk that will be on the Invictus show when it goes live, hopefully sometime around the end of the summer. And all right, here it is. And actually at the end of this there's some questions. So we've asked the faculty not only to give their talks but within their talks embed some sort of classic questions and some explanatory answers and at the end Delaney also goes through one of the questions that Brit does and shows you how to work through it, even if you don't know the answer, and this kind of skill set is needed when you are doing multi-guess questions. So here we go. Complications in pregnancy. The first voice is Matt Delaney. The second is our Britt guest, Herbert out. Talk to you all soon. Oh, and this is also on the tube. That is you, because there's a lot of visuals on this as well, so you can check that out. Link in the notes that are showy.

Speaker 2:

Herb it out. All right, we're going to talk pregnancy complications with Brett. For me, this is a tricky area because I see a lot of pregnant patients, I see a lot of complications of pregnancy and, honestly, what I do at the bedside is sometimes a little bit different than what they want us to answer on the boards. So this is the kind of section where I have to remind myself, slow down, think this through and go with the right answer the boards is going to be looking for.

Speaker 3:

Now let's dive about nausea and vomiting, because nausea and vomiting can really just be an expected change. That happens, right. A lot of women experience nausea and vomiting, especially in the first trimester. So if somebody has mild symptoms, there's a few things we can do to make them more comfortable. So we can do pyridoxine, which is B6. You can give 10 to 25 milligrams PO. You could do doxalamine, you can do odansetron. There are a lot of different medications here that we can use that will help the patient feel more comfortable. Also, non-pharmacological things that we can advise the patient to try is ginger. Ginger can be really helpful. And then, of course, you don't want to sit there and try and eat a big full three meals a day, but try multiple smaller meals, so it doesn't really stimulate so much nausea and vomiting.

Speaker 3:

Now, of course, just some nausea and vomiting isn't the emergency. The emergency is when somebody has hyperemesis gravidarum Now this is really persistent. Hyperemesis gravidarum Now this is really persistent, horrible nausea and vomiting that results in severe dehydration and even weight loss. So maternal complications for this. This can cause really bad vitamin deficiencies, b1 deficiencies you can even get Wernicke's encephalopathy. B6 and B12 can give the patient peripheral neuropathy. There can be mechanical ventilations from just such aggressive vomiting where you can have not only a Mallory-Weiss tear but Borhoff's. You can get pneumomediastinems, and even pneumothorax has been reported in patients with such severe vomiting. Now also there are physiologic complications. You're pregnant, you've got all these hormones pumping through your veins and you're vomiting your brains out. This can lead to a lot of anxiety and depression. So this is a very severe complication of this nausea and vomiting. Fetal complications from hyperemesis include prematurity, intrauterine growth restrictions, low birth weights. We're just not able to keep in nutrients to get to baby, so baby can be smaller.

Speaker 3:

Our first initial evaluation and treatment in the emergency room is going to start with labs. We want to look for electrolyte abnormalities. You can get A mild bump in LFTs can be seen with hyperemesis gravidarum, but this is a mild transaminitis. If you're seeing numbers three times, four times, the upper limits of normal, you need to be thinking about something else that could be causing this nausea and vomiting. And then, of course, we're going to check the urine because if we see ketones, that is a very strong indicator that this patient is severely dehydrated.

Speaker 3:

Now, if our patient has severe symptoms, what can we do to help? Well, we can give higher doses of things. So we can give diphenhydramine 25 to even 50 milligrams IV, im, po Patient's probably not going to tolerate PO, so we need to lean towards things that are IV, im or even rectal there is metoclopramide towards things that are IV, im or even rectal there is metoclopramide. There's odansetron. You can give even higher doses of up to eight milligrams IV or IM. If you're giving it IV, you need to give it over 15 minutes. Those higher doses is a slow infusion. And then there's even our promethazine, which again can be given rectally if this patient just cannot tolerate anything oral, and maybe we're trying to get them home Now.

Speaker 3:

Steroids often come up in the treatment of hyperemesis gravidarum. Now it's a little bit controversial because we've seen that in the first trimester steroids can be associated with things like cleft palate. Outside of the first trimester we use them if we need to. You know, of course, if we have a severe asthma exacerbation and in a patient like this, where they absolutely cannot tolerate anything orally they're vomiting like crazy, we need to give them something, and steroids might be one of the things that work for them. So you can do methylprednisolone 125 milligrams IV and then that would be followed by prednisone 40 milligrams and you taper down to the lowest effective dose.

Speaker 3:

Now let's do an example of how the boards might test this. So you've got a 40-year-old woman. She's presenting with nausea and vomiting. She was just seen by her primary care doctor a week ago and you can see that note. And in that note the vital signs at that time were heart rate of 105, blood pressure of 100 over 60, temperature of 37, respiratory rate of 20, and a weight of 140 pounds. Today her vital signs are heart rate of 120, bp of 90 over 55, she's afebrile, respiratory rate 26, and she only weighs 123 pounds. 26, and she only weighs 123 pounds. Her lab testing done at that time showed a positive HCG of about 100,000, and her last menstrual period was a month ago. She's having copious nausea and vomiting. What is the next best step? Give her Zofran PO challenge, see if she can go home. Fran PO challenge, see if she can go home. B give promethazine PO challenge and see if she can go home.

Speaker 3:

C admit to OB service. Or D get two large-bore IVs and start fluid resuscitation. I'll let you take a second to read them. The answer is D start resuscitating this patient. She is tachycardic, she is hypotensive, she is so dehydrated from this nausea and vomiting and she's had a significant weight loss. We know that she's pregnant because she had a beta HCG of 100,000. So we need to start resuscitating her because this is very concerning and this is hyperemesis gravidarum.

Speaker 3:

Now let's take the previous patient. You've stabilized her. What are you likely to find, given her underlying diagnosis A hypothyroidism, b snowstorm sign, C proteinuria or D empty uterus? I'll give you a second to look at those options and the answer is B snowstorm sign. So let's break this question down a little bit. One we know that this patient has severe nausea, vomiting, weight loss, dehydration. We've resuscitated her. We know that her beta HCG is very high. Her last menstrual period was only a month ago and in that first month of pregnancy, 100,000 beta HCG is through the roof. This in combination is very concerning for a molar pregnancy and on ultrasound that might show up as a snowstorm sign in the uterus. So that is why B is correct.

Speaker 2:

So this is a great example of a two-part question. I'll be honest, I had forgotten that I ever knew what the snowstorm sign was, but I can think through this right. So the first part of the question is just picking up. This is a dehydrated patient. I'm going to do the normal medical stuff, but then they throw me these answers. They say hypothyroidism, snowstorm sign, proteinuria, empty uterus, and we're thinking pregnancy complications. So I know it's not going to be empty uterus, or shouldn't be that? Because patient's pregnant, having protein in the urine. Yeah, I might see that that's not going to cause this. I'm going to skip over snowstorm sign because, again, I don't remember what that is. And hypothyroidism, could that cause this? It doesn't seem like that's the answer and so, just kind of thinking through this, simply I can get down to yeah, it's probably this snowstorm sign.