HG Protocol
The HER Foundation receives e-mails from women around the
world being treated with varying medical interventions, some
being refused any medications early in pregnancy, while others
are being given high doses of risky medications. The care
varies greatly and often results in adverse outcomes for many
women including repeated terminations, psychological trauma,
or gastrointestinal injury.
"It is our goal to create a protocol that
will be adopted by hospitals and emergent care centers who
treat HG patients to ensure consistent, quality care for women
with HG."
Kimber MacGibbon, RN
HER Foundation Founder
Important Note: Women with HG are
miserable for months and their complaints and requests should
be taken seriously. Every possible comfort measure should
be taken to minimize unnecessary suffering and discomfort.
Your care and treatment of this woman may determine if she
will suffer from both physical and psychological complications,
including PTSD
(post-traumatic stress disorder), during her pregnancy and
postpartum.
1. Admit & Assess.
- Admit to a private room to minimize noxious stimuli
from other patients, and excessive interruption by medical
staff. (Your assistance with insurance reimbursement may
be needed.) Many patients cannot tolerate bright lights
and noises such as phones and TV's. They may vomit at the
sight or sound of food in the hallways or nurses station.
Thus, a quiet room at the end of the hall is strongly preferred
therapeutically. Fatigue worsens HG, so ensure she is sleeping
and ask all staff to avoid waking her.
- Establish a compasionate rapport with the mother.
- Weigh her and evaluate severity
of weight loss.
- R/O other disorders
presenting with nausea and vomiting
- General Metabolic And Hormonal Status: Check lab reports
closely, especially electrolytes, hormone levels (HCG, thyroid
function, Quantitative bHCG), U/A & culture, h-pylori,
CBC (to screen for early signs of infection), LFT's (Liver
Function Test), and glucose (for patients receiving TPN
with insulin). When performing GTT's (glucose tolerance
tests), use apple juice or jelly
beans instead of Glucola
 .
It will often be more accurate since patients can often
tolerate those better.
- Order an ultrasound to rule out gestational
trophoblastic disease
(GTD), and gall bladder or pancreatic disorders.
- Monitor I&O's
- Record weight changes (qod if inpatient)
- Check urine ketones at least every 8 hours
2. Rehydrate carefully with fluids and vitamins.
Continue hydration until able to tolerate PO fluids and little
or no urine ketones.
- Lactated ringers or D5LR with 20 KCl are typically used.
Use dextrose solutions to minimize fat breakdown. Also consider
Myer's Cocktail
or a Banana
Bag.
- Warm IV fluids for comfort, and prevention of
caloric loss. She may be anemic, leaving her prone to being
cold.
- Treat marginal electrolyte deficiency if she is dehydrated.
Vomiting will likely recur.
- Consider addition of antioxidants such as glutathione.
HG is associated with oxidative stress. (See research below)
- Add glucose, vitamins (esp. B6 & B12, C and
K), magnesium for all women, including those on TPN,
or TPPN (PDF)(Total Peripheral
Parenteral Nutrition). Use strict aseptic technique and
utmost caution when caring for a patient's central line.
Sepsis threatens mom and baby. (For more info see Nutritional
Therapies.)
Rational:
3. Prescribe Antiemetic Medicines. Review
medication history and patient response. The risk of administration
must be balanced against the sequelae of prolonged starvation
and dehydration.
Note: Medications typically work best on a schedule
v. prn. Early intervention may prevent the need for
repeated IV's. Wean slowly when patient is asymptomatic
for more than 2 weeks to avoid relapse.
Most Common Medications:
Choose the drug that targets the main symptom trigger
(e.g. motion) she experiences. If there are many triggers,
and/or her nausea and vomiting are more severe, start
with serotonin antagonists. Intervene early if she has a history
of HG.
- Serotonin Antagonists: Ondansetron (Zofran), Granisetron
(Kytril), Dolasetron (Anzemet)*
- Phenothiazines: Prochlorperazine (Compazine), Promethazine
(Phenergan)**
- Prokinetic Agents: Metoclopramide (Reglan)
- Anti-reflux Agents: Ranitidine (Zantac), Famotidine (Pepcid),
Lansoprazole (Prevacid)***
* Expense may be outweighed by decrease
in complications and admissions.
** High rate of adverse side-effects.
*** Treating reflux and decreasing acid production can significantly
decrease nausea and vomiting.
More
info on choosing a drug »
4. Refer for multidisciplinary consults as
needed.
- Physical therapy - if on bed
rest
either by necessity or prescription.
- Educate on progressive exercise to minimize atrophy.
Begin consults during first admission or after a month
of limited mobility. Continue therapy into late pregnancy
if symptoms continue to decrease pain and fatigue that
will impair her recovery and ability to care for her
newborn.
- Nutritional
- If patient loses more than 10% of her body weight
within the first few months and shows no sign of improvement,
nutritional intervention is very important. Without
support, patient is at risk for complications and may
have a prolonged recovery.
- Assess need for Nutritional
Therapies
- Consider a liver sparing diet if tolerated (carbohydrates,
no fat, fresh steamed vegetables, no sugar, no dairy
products, and very small meals, eaten often)
- Home Health
- Gastroenterology
5. Consider referral for complementary
and alternative therapies
such as hypnosis, massage, chiropractic, homeopathy, acupressure,
etc.
6. Implement patient
comfort measures.
- Warm IV fluids before administration to avoid discomfort
and calorie loss due to shivering.
- Offer warmed blankets and a quiet, odor-free room.
- Use Lidocaine for IV insertion and utilize most skilled
personnel to avoid scarring related to multiple IV attempts.
- Administer antiemetics and vitamins via IV or PR, avoid
IM injections due to muscle atrophy.
7. Offer patient
education tools.
Updated on:
Apr. 30, 2008 |
