Suggested 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.
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:
Nov. 20, 2006 |
