Successful management of hyperemesis gravidarum using steroid ...

More documents

Recommendations

Info

104 R. Taylor Examination confirmed severe muscle wasting and loss of subcutaneous fat. After assessment and full discussion, treatment was commenced with i.v. hydrocortisone 50 mg b.d. Vomiting stopped within hours. She was able to eat on the second day of treatment and oral prednisolone (10 mg b.d.) was commenced. She was discharged on day 3 of treatment. The ptyalism did not settle for a further 3-4 weeks. No further vomiting occurred, and it was possible to decrease the dosage of prednisolone to 7.5 mg b.d. after 6 weeks. Further decreases in dosage were not possible without recurrence of nausea until 24 weeks gestation. Thereafter steroid dosage was decreased in a stepwise fashion over 4 weeks and stopped 3 weeks later. No hospital admission was required after steroid therapy started. The rest of the pregnancy was unremarkable and a 2.5 kg female infant was born following a normal labour at term. Patient 2 A 33-year-old woman was referred at 14 weeks gestation following 20 days of continuous intravenous fluid therapy on her fifth admission to hospital with hyperemesis. This was her second pregnancy, the first (by a different husband) having been uneventful. The details are summarized in Table 1. On a previous admission, serum TSH was noted to be suppressed (
day by 23 weeks. Weight gain was rapid and satisfactory from the time of starting prednisolone 15 mg t.i.d. and she became able to perform a squat test 6 weeks after starting steroid treatment. The severe ptyalism continued until 23 weeks gestation but then remitted rapidly. Steroids were decreased and then stopped at 24 weeks gestation. Pregnancy was uneventful thereafter, and a 3.5 kg male infant was delivered at 40 weeks gestation after a normal labour. Patient 3 A 34-year-old woman was admitted with hyperemesis six times between 6 and 17 weeks gestation. Blood had been noted in the vomit on two occasions, both after particularly violent vomiting. Examination showed muscle wasting to be severe, and she was unable to perform the squat test. The nausea and vomiting was controlled within 2 h of commencing hydrocortisone therapy 50 mg b.d., but three times daily administration was required for continued control of symptoms. Oral prednisolone 15mg t.i.d. allowed discharge on day 6. During the first 48 h of refeeding, preprandial blood glucose levels were noted to be elevated at about 7.5 mmol/l. All subsequent readings were normal. This was regarded as being a starvation/refeeding transient impairment of glucose tolerance. Weight gain was rapid and satisfactory. On her first out-patient review the patient commented: 'It's a miracle'. Vomiting recurred 25 days later when the dose of prednisolone was decreased to 10mg twice daily and because of inability to keep down the tablets, a 3-day readmission was necessary to regain control with i.v. hydrocortisone. A further short admission within days was precipitated by a prolonged physical exertion. She remained very well throughout the rest of pregnancy, but it was not possible to decrease the prednisolone dosage below 7.5 mg b.d. without recurrence of nausea. A male infant of 2.8 kg was delivered after a normal labour at 37 weeks gestation. The nausea remitted entirely after delivery and the prolonged prednisolone therapy was tailed off over a 3-week period. Bone density performed 8 weeks post partum was normal. Patients 4-7 The details of these four patients are summarized in Table 1 and each followed the general pattern described above. These patients had been admitted on fewer previous occasions because by then awareness of successful treatment had increased in the unit. However, all had lost at least 6 kg in weight, and all were severely dehydrated and ketotic on the readmission during which prednisolone Steroids in hyperemesis gravidarum 105 therapy was started. None had the muscle strength necessary to perform a squat test, but all could do this after 6 weeks of prednisolone therapy. Figure 1 shows the mean changes in body weight. Mean absolute weights were: Pre-pregnant, 74.9 + 20.7 kg; at start of steroids, 64.4 + 18.6 kg; after 6 weeks, 69.3 ± 17.2 kg; after 10 weeks, 74.0 + 19.2 kg. Total weight gain during pregnancy for the three women who have delivered to date was 7.5 + 6.7 kg. Discussion The uniform effectiveness of steroids in suppressing the vomiting of hyperemesis and permitting weight gain in this consecutive series of seven patients is striking. The return of muscle strength and resumption of weight gain is documented above for each patient, but the considerable personal and social benefits of restoration of well-being and discharge from hospital are less easy to describe objectively. In at least two of the patients a termination of pregnancy was being contemplated. Additionally, the financial cost to the Health Service of a hospital stay lasting weeks or months cannot be overlooked. The major question surrounding any therapy in pregnancy is that of safety. There is no clear evidence of any adverse effect of steroid therapy upon human fetal development. Safety data is available relating to women who received steroid therapy for severe asthma and inflammatory bowel disease. 7 " 10 As a doctrine of caution, to establish the safety of prednisolone therapy for the dosage and duration of treatment necessary for hyperemesis, careful future follow-up of the offspring is required with docu- -15 J V> T~ Figure 1. Loss of body weight during hyperemesis gravidarum, and subsequent weight gain after commencement of steroid therapy (mean + SE). Arrow indicates the period of steroid therapy, which varied in individual patients from 9 to 24 weeks. Downloaded from http://qjmed.oxfordjournals.org/ by guest on March 25, 2013
Page 1: Ql Med 1996; 89:103-107 Original pa
Page 5 and 6: ilateral caudate lesions on compute

Successful management of hyperemesis gravidarum using steroid ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?