Jennifer:
Welcome to this evening's webinar: Case scenarios for managing nausea and vomiting in pregnancy and hyperemesis gravidarum. My name is Jennifer, your RACGP representative for this evening. We are joined by our presenters, Dr Rachel James and Associate Professor Sandra Lowe.
Before we get started, I'd just like to make an acknowledgement of country. We recognise the traditional custodians of the land and sea on which we live and work and I would like to pay my respects to elders past, present and emerging and I'd also like to acknowledge any Aboriginal and Torres Strait Islander colleagues that have joined us online this evening.
So just like to formally introduce you to our presenters for this evening. Rachel completed medical school at Flinders University, where she completed many rural rotations in her training, leading to her passion for rural health. She further went on to complete her DRANZCOG Advanced. In 2020 she Fellowed with ACRRM as a rural generalist. Rachel is now a Rural Generalist obstetrician in. small town of Deniliquin, New South Wales. She contributes to the ACI Maternity and Neonatal Network and has been involved in the New South Wales HG initiative as a rural GP representative. She also has a role as a rural director of training at the New South Wales Health, Education and Training Institute, helping further rural generalist obstetricians develop their career path. So welcome, Rachel.
Sandra is a consultant obstetric physician at the Royal Hospital of Women and Prince of Wales Private Hospital and Clinical Associate Professor at the University of New South Wales. Sandra speaks regularly at national and international conferences on obstetric medicine and has a longstanding interest in teaching obstetric medicine. Welcome, Sandra.
We are also joined this evening by Elizabeth, and Elizabeth is a registered pharmacist with career experience across community pharmacy, poisons and drugs information and clinical pharmacy practice. She currently works at both Children's Hospital at Westmead and MothersSafe at the Royal Hospital for Women in Randwick. So welcome, Elizabeth.
I'd also like to make an acknowledgement that this presentation was developed with contributions from staff at MotherSafe. Members from the Medication Safety Team, Clinical Excellence Commission and the Projects Team from the Health and Social Policy Branch of the Ministry of Health.
And I'm just going to hand over to Rachel to start us on our presentation.
Dr Rachel James:
Thank you and thank you for everybody for joining us tonight. So by the end of this online activity, you should be able to identify nausea and vomiting and pregnancy, (NVP) and hyperemesis (HG), and we'll refer to them as NVP and HG for the remainder of the webinar, identify the emotional, physical, psychological, psychosocial and socio-economic impacts of NVP including HG, outline how multidisciplinary and holistic care contributes to the diagnosis and management of NVP, including HG and consideration for referral pathways to GP's obstetricians and maternity care providers and MotherSafe, outline best practice principles for assessment and management of NVP, including HG, demonstrate an understanding of the sensitivity and appropriate language for discussing and counselling patients with NVP, including HG, and outline the roles of GP in managing NVP, including HG.
So, we just wanted to make you aware that this is webinar one of two. So, this is webinar two of two I should say. Webinar one was really a focus on the guideline that's been produced by New South Wales Health. We went through the medication's possible side effects, possible effects on the foetus and how to dose them as well as any investigations that you may want to do. So, some of your questions tonight may be very well answered in webinar one and we would invite you to go review that webinar if you have any particular questions that weren't covered here tonight.
So the case that I wanted to present today was that a case that I actually had here in our service here in Deniliquin, where we do run an obstetric service for low risk to moderate risk women, I am providing the information of the case and we'll have Associate Professor Sandra Lowe providing expert commentary on the particularities of the case and anything that could be improved, anything that we did well and any evidence behind any of the information tonight. So, the woman that I was caring for was a 31-year-old woman. She had a background of anxiety, migraines and unfortunately appendicitis in her last pregnancy and she had vitamin B12 deficiency. Her only regular medication was oral vitamin B12 due to her previous deficiency. She was G3P2-1 with the same partner throughout. She now had a really beautiful but active two-and-a-half-year-old daughter to care for and unfortunately, in the previous pregnancy we had unexpected complications where she had a pregnancy loss at 21 weeks due to unexpected anatomical abnormalities found at morph scan despite having a normal NIPS. So that was quite a hit for this particular woman, considering she had a very straightforward pregnancy with her first one, other than having nausea in pregnancy and vomiting in her pregnancy, but then had her birth here at a low-risk centre, and then we had a very high-risk pregnancy there afterwards, which was ended with a pregnancy loss.
She had severe nausea in the first pregnancy with symptoms persisting until 24 weeks, and then she was diagnosed with HG in the second pregnancy too. So, I was very concerned about this third pregnancy and the level of symptoms that she was going to have. I've got just a little bit more background for her. So, this was a planned pregnancy and obviously we're living in my small rural town, which is an MM4 town. She did have some social supports which we know are very helpful with women that are going through these symptoms. She had her mum that lived close, and she had a partner that was very supportive, but he was sometimes away for work, and she was a teacher herself. She was seeing a counsellor every fortnight due to her grief of her previous pregnancy, but she was not wanting to connect to the pregnancy until after 20 weeks.
So, I have this patient where I felt like her risk of developing nausea and vomiting in pregnancy was quite high. Her risk of developing hyperemesis was quite high, and yet neither one of us knew whether this was going to be a viable pregnancy at this point, which can be a very demotivating factor when we know that we're going to hit some issues during first trimester. So, her first visit was at six weeks with me. I've been caring for her for the past six years.
I took care of her before her pregnancies and each of her pregnancies. So, we had a very, very good understanding of her health and what she needed. Already at six weeks we were noticing that her nausea was starting, but at this stage had no vomiting. I did a baseline weight, so had something to compare to a bit later on and it was 62.1 kg, and I did my usual cooking investigations. I suppose the additional things that I added because I was aware that we may encounter nausea and vomiting in pregnancy, was a urine MCS just to make sure we had no bladder symptoms or no UTIs. I also did EUCs, LFTs. I did a vitamin B12 based on her last history and a TSH, which all came back normal. So, I had ongoing concern of her risk of developing hyperemesis.
Associate Professor Sandra Lowe:
Well. Rachel, you're absolutely right that women who've had nausea and vomiting of pregnancy are at risk of getting it again. We know that the symptoms are very common. So, nausea and vomiting may occur in up to 80% of women, but in women who've previously required antiemetics in their first pregnancy, the prescription fill rate in a second pregnancy was 35.5% and 53% for women who filled antiemetic prescriptions in the previous two pregnancies. So, the more often you have NVP, the more likely you are to have it in your next pregnancy, and if you look specifically at the women with severe forms of NVP or hyperemesis, 52% of them chose not to have another pregnancy and two thirds of them stated that this was because of their HG in their previous pregnancy. In those that did go on to conceive one or more times, the recurrence rates were very high, and this is an observational study from Norway. So, it's not a selected group of women. If you look at women who select themselves by responding to a website sponsored by the Hyperemesis Education and Research Foundation, and we have to acknowledge that that's a select group of women, 7% responded that they were unwilling to become pregnant because of their experience of HG. Of those that had a further pregnancy, 81% had recurrent severe NVP and only 11% had no NVP. So, your apprehension was well founded.
In terms of the investigations for NVP and HG, some of your investigations will be attempts to determine if there's an alternate diagnosis, and the sort of things you may want to think about are, of course, gastroenteritis that can mimic NVP of pregnancy, urinary tract infection, as you stated, gallstone, and one really to watch out for is drug withdrawal, especially from marijuana, and then women with eating disorders can also present as if they've got NVP in pregnancy. But if you get women with more severe NVP or HG, you're starting to perform investigations to assess their nutritional status and the status of the pregnancy. So, these would include electrolytes, liver function tests and obstetric ultrasound to exclude multifoetal or gestational trophoblastic disease, and you may need to repeat those electrolytes, calcium, magnesium, and phosphate on a number of occasions, particularly in women who are unable to tolerate any oral fluids and are requiring IV fluids. In terms of measuring TSH, I'd recommend you only perform a TSH or look for thyrotoxicosis in women who have signs of thyrotoxicosis. We know that the normal ranges for TSH are different in pregnancy, and I've stated them here and a TSH of < 0.25 is suggestive of thyrotoxicosis, but you need to look at your local lab ranges. If there are symptoms of fever or urinary tract infection, of course you're going to look for the source of that infection.
Dr Rachel James:
So, I prescribed from that very first consult, and the choice of medications was based on what previously worked for her. This would be quite different to if this was a new patient to me, if this was her first pregnancy, and if we weren't quite sure as to what was going to work for her, but we based it on what worked for her in previous pregnancies. So, we started with Doxylamine 12.5 mg at night, as well as vitamin B6 and ginger as regular medications, and then I added two-part prn medications and that was metoclopramide and ondansetron.
Now, I would make note with the ondansetron; I did prescribe it before the ten-week mark. If you're wanting more information about that, there's a really, really great discussion in webinar one done by our Pharmacist, Elizabeth, and I would really entice you to have a listen to that because she goes through all the details of prescribing early. One thing that I did not do and one thing that I did take as a learning point from this case was that I did not prescribe aperients with the ondansetron. So, I prescribed ondansetron but didn't give any Coloxyl, and I now know that ondansetron can cause quite severe constipation which could have contributed to some of her nausea. And the other thing that I would note is with metoclopramide, I did it as a prn medication. I always say to patient; max, five days because it is a category A medication. So, we know it's very, very safe for foetuses, but it doesn't make it any more safe for humans and the risk of extrapyramidal side effects after day five really limits its use.
Associate Professor Sandra Lowe:
So, what are some of the interventions you might have used to reduce nausea in this woman? Well, the first and simple thing is to discontinue prenatal multivitamins, because two thirds of women report an improvement in their NVP symptoms just by discontinuing their Elevit or their Blackmores. The critical micronutrients that are acquired in the first ten weeks of pregnancy are folic acid, at least 400 micrograms per day and iodine 150 micrograms per day. Some other evidence-based interventions you might want to consider in the milder group are acupressure brands, the ginger and pyridoxine, which you did use, and whether you start those before the woman starts vomiting is a moot point. Early or even pre-emptive commencement of antiemetic therapy gives both physical and emotional relief for women. I'd suggest to you that prescribing, but not necessarily commencing therapy would be a good approach in this situation. You also need to establish targets and expectations for symptom relief. Treating NVP and HG is incredibly difficult and it's incredibly common. So, you're only going to be disappointed if you expect to reach negligible nausea and vomiting. You want the woman to be able to eat and drink enough to keep herself together. You want her to be able to function even if it's in a limited capacity, perhaps playing with the children an hour a day, but not changing nappies. Probably not going to work full-time, maybe working from home. Need to ensure that we maintain their mental health because we're very aware of the trauma and disability associated with having NVP and HG and the guilt that women feel and think you're going to speak more about that as we go on.
You need to explain to the woman that for most women, the symptoms are going to be self-limiting, with recovery by 12 to 13 weeks, and it's just a matter of holding their hand until they reach that natural resolution of the disease. You need to give support to the people that are supporting them, particularly parents, partners, and hopefully get them some additional support for their other children. You need to provide appropriate employment expectations to both the patient and their employer, and that needs to be proactively done.
So, if we come to where your prescribing might start, we look at women in terms of the initial severity of their symptoms as being mild, moderate and severe based on the PUQE-24 score we spoke about in the first webinar and Rachel's going to mention that again in a moment. So, use that as your starting point for therapy, remembering that for most mild cases you're only going to need gentle antiemetics plus or minus some laxatives. Once you get to more moderate cases, you're going to need a bigger range of antiemetics. You almost always need to use laxatives and you may well introduce some acid suppression even in the moderate group.
Once you're getting into the severe group, you're using a greater range of drugs and you may go to third line drugs such as corticosteroids. You're intensifying your acid suppression. You may be using IV fluids, hopefully as an outpatient, and you may have to even consider some sort of supportive nutrition. Refractory cases may need admission to hospital, but they definitely need expert care, and their treatment is a specialized area. So, you're using your initial assessment to determine the starting point of your therapy and you're using this assessment to see the response to therapy. So, what you're obviously hoping to see is a reduction in the PUQE score, but just because someone moves from 13 down to 7 doesn't mean you reduce your treatment down to the mild range. You've achieved that with a certain range of treatment. You almost certainly have to sustain that until the natural resolution of the condition.
There's a question about which ginger product. It's about ginger dosing rather than the product. You need about 250 mg to 500 mg twice to three times per day, and they're all reasonable. Try to avoid products that have got multiple active agents in them. You want pure ginger and pure pyridoxine.
So, when we come to using these antiemetics, I know there's a lot of concern by both patients and doctors. I hope in the first webinar we were able to reassure you that everything that's advised in the New South Wales Health Guideline, which you can access on the website, is considered safe to use in women even in the first trimester. So, I would recommend starting with these orange group of drugs first and I'll come down to ondansetron later, but for most women with mild to moderate disease, commencing with one of these dopaminergic or histamine antagonists is a very suitable place to start. You don't want to be doubling up or duplicating at the same time slot, so you don't want to use metoclopramide and prochlorperazine in the morning, but what you can do is use the less sedating drugs during the day and the more sedating drugs in the evening. So very common sort of combination might be prochlorperazine before they get out of bed in the morning, after around lunchtime, and then using some doxylamine at bedtime.
In terms of risks, Rachel's already mentioned the concerns about extrapyramidal and anticholinergic side effects with metoclopramide. These take two forms. There's sort of an acute form of side effect, which you're probably familiar with, which is dystonia or agitation or akathisia when they get very restless, but there are also more severe extrapyramidal side effects such as tardive dyskinesia that occur with prolonged use and although they're rare in this age group, because we have alternative agents, we tend not to use these for any prolonged periods, although in some individuals they are the only option.
There are also potential drug interactions between metoclopramide and serotonergic agents, such as antidepressants, which will come up as a contraindication on your electronic prescribing. We know that many women are on antidepressants, and these drugs do have some sedation, but perhaps not as much as doxylamine, which as you know, is marketed as a sleeping tablet, but is actually a very, very good antiemetic.
So, when do we introduce ondansetron? Well, when we don't want the sedation of these drugs or the patient can't tolerate the sedation, when vomiting is prominent. The data shows us that these drugs are almost as good at reducing nausea as ondansetron, but perhaps Ondansetron is a bit better at reducing vomiting, and because of the lack of sedation, that can be a very effective drug for women who are trying to function both at home and at work, but it has a number of side effects you have to be aware of. The constipation can be profound because pregnant women already have gastric slowing, and this can be a major problem and will contribute to worsening nausea. The other thing about Ondansetron is it's much more expensive than the dopaminergic agents. There's also a concern with interaction, particularly with serotonergic agents; can cause QT prolongation. So, anybody who has a risk of QT prolongation must not be given ondansetron, and there is this potential for interaction, and it should be used with caution and with monitoring for signs of toxicity.
Dr Rachel James:
So, I see her again in two weeks. I find 1 to 2 weeks when we know that symptoms are self-limiting but may get worse through those weeks, a really good timeline to make patients feel supported. I Did this with a Telehealth visit. Now that I've seen her face to face, I had the option of being able to bill for telehealth and I found telehealth in cases of nausea and vomiting in pregnancy and HG incredibly helpful because it means that a person doesn't have to come into a clinic where there may be lots of different smells that could cause ongoing nausea. They could do the consult on their couch if that's the best place for them and the convenience when also trying to take care of children. It can be very useful as well. We did a PUQE-24 score and we got 12, so it was quite, just on the brink of the severe category, and she had lost 1 kg of weight, which really did push her into that severe category because she wasn't eating enough to maintain her weight. She could keep down some fluids, but not food, and she was getting some relief from a vitamin B6 and ginger, but not enough for the level of functioning that we were aiming for. She had already started ondansetron and was already on the max dose of 8 mg twice a day. She felt like it wasn't helping, and guess what? She developed constipation because I did not focus on that enough in our first consult, and really I should have prescribed high-dose aperients such as Coloxyl 100 mg bd or 120 mg bd to up to 240 mg bd.
With the doxylamine, we were finding that it actually did help her nausea quite a lot, but she had this hung over feeling in the morning and really we couldn't push the dose past 12.5 mg. So even though it was working for her, I wasn't able to up titrate it because of its side effect profile, and we did try metoclopramide and she did develop some restlessness and odd muscle spasms. So, she was getting the extrapyramidal side effects that we were concerned about. So, I just had to cease that outright.
Associate Professor Sandra Lowe:
Just to comment about the doxylamine, Rachel, if you give it a little bit earlier in the evening, you can sometimes deal with the hangover. So, most people are going to bed at 7 o’clock when they're in early pregnancy anyway, but the duration of effect of doxylamine is about 8 to 10 hours. So sometimes you can manage the hangover by giving the drug a little bit earlier.
Dr Rachel James:
That's a good point, which I didn't consider, and I suppose the other side of things, I was dealing with her weight loss, looking at her electrolytes, trying to manage her nausea and vomiting to maintain a hydration status, but also as GPs, we need to consider her mental health and how she's coping during all of these symptoms, and she was really struggling. She was struggling to shower, and she was feeling very guilty and low because she was struggling to now take care of her daughter because her symptoms were so severe, and then there was this issue that we really didn't know how this pregnancy was going to go. We didn't know whether this was going to end up in a live birth. We didn't know whether we're going to have some anatomical abnormalities once again. So, she really felt like she couldn't go through this if the HG couldn't be controlled. They just felt like there was too many unknowns with the ongoing grief that she was experiencing from her last pregnancy loss, and also there was concerns that she did have family support, but how much she was relying on that support. She was struggling to cook dinner at night for her daughter because of the smells from the fridge and cooking was just too much to bear, and then there was an issue of her job where she really wasn't able to maintain her full-time job as she was previously. All of this adding to quite a lot of grief and concern for her going through a pregnancy. So, I suppose it's important to note that when you are getting these complex cases, not just to focus on the medication, focus on the woman in front of you as well. Think about an endogenous depression scale. See as to whether or not we're actually tipping over any signs of depression and see whether or not they need any other supports in place to deal with the emotional side of going through hyperemesis.
Associate Professor Sandra Lowe:
Sorry. So, this comment that she doesn't feel she can go through with this if her HCG can't be controlled is a comment that I hear from many, many women with HG, particularly if I ask them, giving them the opportunity to voice their concerns, to voice their guilt, is really very important part of their management. So, some women with HG may seek a termination of pregnancy, and again, the Hyperemesis Research Foundation reports that 10% of pregnancies complicated by HG and internment end in termination in women who would not otherwise have chosen this. I believe it's mandatory to ensure women have been offered the full range of treatments before they get to that point, and for me, that includes access to expert advice regarding management of HG. That can be through psychological counselling, but it also needs expert medical counselling from the person who has most expertise where you are. So sometimes that will be an obstetrician, sometimes it will be a gastroenterologist. Fortunately, in the big tertiary centres we have obstetric physicians who have expertise in HG, and our other source of expertise is in New South Wales, at least, the MotherSafe service, which is providing counselling for out of hours and expert advice to women and doctors to help them manage HG.
Dr Rachel James:
So, I've just moved a bit closer to the screen because there was a comment there to say that there was some difficulty in hearing me. So, I hope that's a little bit better.
Just following on with what Sandra said, I just want to make sure everybody is aware of this 4001 Code, which is nondirectional pregnancy counselling. It does require extra training, but it's only on an online module, so it doesn't require too much time outside of your busy lives and it does allow you to build this particular code for consults above 20 minutes and you can fill three times in one pregnancy, and it's for any condition that can help from a nondirectional counselling approach. So obviously, if you're in this situation where you're reaching quite severe hyperemesis and the conversation of terminations coming up, this could be a great example where this code could be used. A lot of the time it's not that women want to go through with the termination, but they want to be able to explore it in a safe space, and doing this counselling can give you the extra skills to provide that service to your patients. In addition to that, it's not just related to termination conversations. If you're having a person who is struggling with the concept of maybe starting some medications and you're doing quite a lot of counselling regarding the risks and benefits of medications to use for nausea and vomiting in pregnancy, that can be a really good time to use that code as well. So, you can use it any time that you feel that a nondirectional counselling approach is useful and it gives you that ability to show what effort and what skill you're giving to your patient to provide them a wrap-around service of care.
In addition to the medications, if we just go on to the next slide with Sandra. We did make some changes outside of medication to help coping with situation. We started to get an idea of what was working and what part of the day. So, we found that the nausea was much worse in the afternoon. So, what we ended up doing was really focusing on that morning time, looking at meals and fluid and prior to 4 p.m. and then after 4 p.m., really just trying to be able to cope. In addition to that, we also cut, or we shouldn't say me or we, the patient, cut down to half days at work because she found that the nausea was quite hard in the afternoon, so she still managed to maintain some employment in this time, but it was certainly at a reduced capacity to what she's usually able to provide. I did mention that she did have a counsellor and that was a face-to-face support that we had here in Deniliquin.
So, we did not proceed with the mental health care plan because she felt that that was filling her needs and she preferred face to face with what was the other option, which was seeing a psychologist through Telehealth because we don't have any face-to-face Telehealth or psychology services available in our town.
Associate Professor Sandra Lowe:
So, let's talk about women-centred care for this situation. So, it depends on your setting, whether that care will be in a hospital or an outpatient. It might be in your surgery. It might be in the Early Pregnancy Assessment Service at the Maternity Clinic or at the ED, wherever the patient is going to get the best care is the best place for them, and as I said, there are a range of physicians who may be able to help you with this care, and with Telehealth, you have much better access to those services. Just a few words about the MotherSafe service in New South Wales. That's the statewide free telephone, Terada Genesis Service, which gives you advice about exposures and pregnancy and lactation, which can be drug exposures, they can be environmental exposures, alcohol and illicit drugs. It's a specialised service funded by the Ministry of Health. It's situated at the Royal Hospital for Women, but it is actually a statewide service, and now they have these extended hours for NVP services up to 9 p.m. during the period of this project, so I can only promote this service as giving everybody more access to expert help.
What else could we have done? Well, we know that there are multiple physiological components to NVPHG not just the nausea. So, there's nausea and vomiting. These women are much more likely to be anorectic than the average person who has morning sickness, whether the morning sickness is in the morning or the evening. Women with morning sickness want to eat. That's what reduces their nausea. Women with severe NVP and HG are usually very anorectic and don't want to eat and don't get relief with eating, but that doesn't mean they can't eat, and I do force them to eat as Rachel did during the best part of the day.
They almost all have gastroesophageal reflux as part of their gastric dysmotility and constipation. We've already talked a bit about the mood disturbance and psychosocial distress, and you need to be monitoring that very, very carefully. You need to individualise the treatment for that patient and that will include your drug choices. The timing of those drugs. So, in Rachel's patient's case, you want to be giving more drugs in the evening when she's worse, and perhaps may not need quite as much in the morning. So, time the drugs for when the symptoms are worst and adjust your dosage in response to what the patient's telling you. So, there's not a one size fits all for this at all, and that's why writing this guideline has been incredibly difficult and it's incredibly difficult to explain to people how to do it. But you just have to take your patient, have the confidence in your drug choices, and then individualise the plan.
So, what else might have helped here? Well, I would have adjusted the antiemetics a little bit. She seems to be particularly responsive to doxylamine. She's already reduced her workload. So, you may get away with a very small dose of daytime doxylamine despite the sedation, or I might have tried some prochlorperazine. Now that we're not using any metoclopramide, I would have definitely added acid suppression. I use rabeprazole, but you can use any of the PPIs. They're all they're all safe to use in pregnancy. Definitely add the laxatives we've discussed, and they often do need enemas as well. You can use Movicol-type laxatives. If they can tolerate that volume of fluid, you can use things like lactulose. The only thing we try to avoid is Senna because it's an irritant to smooth muscle and the uterus is a smooth muscle.
So, then we come to what the role of IV fluids are. They definitely reduce nausea as well as treating dehydration, but for most people with mild to moderate symptoms, they are able to get enough fluid in to avoid IV fluids, but anyone with more severe nausea and vomiting will need IV fluids, and don't wait until they're dehydrated to start them.
Once you've commenced them, until the disease remits, they will continue to need IV fluids and they may need them 2 or 3 times a week, usually something like a litre of normal saline over one hour. We usually add some IV thiamine because these women can become thiamine depleted and are at risk of Wernicke's encephalopathy, and we mustn't forget to ensure that they get their usual antenatal care. They need their scans, they need their NIPT, they need to book in at the hospital. Often this gets left out in the equation when you're concentrating so hard on the nausea.
Because of these very complicated plans, it's really important to write down what the patient needs to do. So, we've in the New South Wales guideline, we've included this template which allows you to list the drugs you're using for nausea so the patient knows why they're taking what they're taking, what they're taking for acid, what they're taking for constipation, what vitamins they need to take, what they might do if they're feeling worse and what they might do if they're feeling better, and then it also includes a template to suggest what sort of feedback the patient can give you to help you do a better job. Rachel, you wanted to comment about the value of these templates.
Dr Rachel James:
Well, yes, because I just started using them and I've been finding a really, really good response from my patient group. So I felt originally that I give quite good instructions on my actual scripts and that may be doing a template which is going to add extra time, and I do think in the first consult it adds a little bit of time because you do have to write it out, but the feedback has been amazing actually, that people have been coming back, women have been coming back and they have this folded up sheet of paper, so you know that they're holding on to it and using it. It means then we can actually have like a bit of a back-and-forth discussion about what's been working for them very easily. It’s actually easier to make changes then because it's all kind of laid out. So, the feedback I've gotten from women that I've used it recently have said that they felt very, very supported and they feel very confident with what they're doing with the number of medications I've started all at once.
Associate Professor Sandra Lowe:
That is what I meant about women holding them in their hands. I've had women bring them to me from their last pregnancy. They bring their last note into their next pregnancy because they remember what worked and they’re clutching onto these notes. They do seem to have a magical power about them, so I would encourage you to use them.
Dr Rachel James:
So, just with progress. So, we got to the ten-week mark. You might be noticing here that I'm doing two-weekly appointments. I found that that was working, but the patient was always able to call in and have a sooner appointment if they felt it was required. We did restart ondansetron, but this time with appropriate laxatives, which helped, and we were getting to the point of requiring IVT at the hospital through our ED Department. We're a small rural hospital, so for this patient we were trying to not go to this step because she knew lots of people at the hospital. She didn't want everybody to know she was pregnant this early on, but it got to the point where we just had to say, well, we need you to have some help, and this is how we can achieve it in our town. So, we started with some normal saline with thiamine added and was getting some relief, but still having poor intake and some ongoing weight loss. A PUQE-24 score was going down slightly down to ten. We were really helping with the vomiting, but we still had this ongoing intractable nausea, which was just incredibly hard to manage and just didn't feel like I was winning.
So was certainly there for the patient and she felt supported, but just didn't feel like I was coming up with a solution. So, I was getting to this point where I didn't feel like I had the solution. She felt like she couldn't care for her daughter. She was really finding it hard to attend work, and then we had this overlying grief of the last pregnancy that was also contributing to her low mood. So, it was a really complex case, so I felt that steroids were the next step, but given my training as a GP obstetrician, I was a bit nervous about jumping into that next step. So that's when I decided to seek out advice and talk with one of our regional obstetricians about the next step in managing her symptoms.
Associate Professor Sandra Lowe:
I think that's very fair. I think by the time you're using steroids in a woman with HG, you do need some expert advice because you're going to see one woman like this per year. Whereas in a large centre, for example, I'm seeing five women like this every week. So, you do need to get some experience to know when to use steroids and how to use them, and even things like the IV, how often to give IV fluids. So don't hesitate to get some help with these very, very intractable patients. So, corticosteroids are considered third line treatment after nonpharmacological agents and antiemetics and they're reserved for severe NVP or HG. So, women who are refractory to treatment, women who are unable to eat and/or drink despite trial of multimodal therapy, and by that, I mean potent antiemetics, acid suppression, appropriate laxatives and IV fluids, and that would be the largest group of women who end up getting steroids because even women with ongoing nausea can make themselves eat and drink. It's a very odd, odd thing, but I see it very regularly. They don't want to, but they can. Those who have an ongoing requirement for IV fluids or nutritional support therapy are also candidates for steroids, or those who can't tolerate antiemetics because of side effects. So, I've got patients who've got a high risk of QT prolongation who can't be given ondansetron, or patients who get extrapyramidal side effects that can't tolerate antiemetics and they may need to go on to steroids as well.
We recommend beginning with either IV hydrocortisone or oral prednisolone if we know they can absorb it. So, there's no point giving oral steroids if they're not going to keep them down. So most often we start with IV to make sure that we've got absorption. If they're not working after 24-48 hours, when I say, they're working, the woman notices a substantial change in her condition. She may still have nausea, she may even have some vomiting, but what she's noticing is improved energy, improved ability to eat and drink, improved sense of wellbeing, usually a reduction in vomiting, usually a significant reduction in vomiting and a reduction in nausea, but if you don't see that response between 24-48 hours, then they are a nonresponder and I would cease therapy, but the vast majority of carefully selected women will get a response. They may get some acute side effects, including insomnia, agitation or mood disturbance, and there is a potential for a number of other side effects, both maternal and pregnancy-related in women who require high-dose and prolonged treatment with steroids. Although that's not the norm, the usual is we can wean the treatment down quite quickly, and I'll show you a typical weaning. So, they start with IV. Soon as they're able to, we switch them to oral prednisolone and we start weaning by 12.5 mg every three days until we find the minimum effective dose, and it's often somewhere between 7.5 mg and 12.5 milligrams per day, and in the women with severe HG, they may need this for weeks or even months and I have some women that require a small dose of steroids throughout pregnancy. That starts to lead to long-term side effects from steroids, and it needs expert counselling to ensure that they understand the benefits and the risks. If they’re remaining on steroids for two weeks. I recommend supervision by a specialist and a discussion of the maternal and foetal steroid side effects.
Dr Rachel James:
So, for our patient here in Deniliquin, I did seek expert advice and we did admit to hospital, starting with some IV hydrocortisone and along with IV preparations of ondansetron and IV Pantoprazole with the thought that maybe she's not actually absorbing the oral ondansetron and the oral pantoprazole as to the full benefit of the drug and we continued some of the medications that were working for her, and we increased the aperients again to a very high dose of 240 mg twice a day and added some Microlax enemas as well to help with the constipation burden, and we did get a response. So once again, as Sandra quite rightly identified, that we still had some nausea, but overall, there was an improvement in her symptoms and we were able to maintain some fluids, and that's kind of the ceiling of where we had to go to optimise her symptom management for this pregnancy.
So, I think we just skipped a slide there for progress. Okay. So, by 12 weeks, it felt like we were winning a little bit. It kind of felt like we were over the hill of the worst of the symptoms. We were now able to eat and drink small amounts. Our PUQE-24 score was seven. So, starting to reduce and we weren't requiring IVT therapy anymore and she was able to start a multivitamin again. I referred her to the Maternal Foetal Unit, but that was more related to the complications with the previous pregnancy rather than anything that had occurred in this pregnancy, and we started with our routine antenatal care, doing a first trimester screen, and she actually regained like 1 kg of weight. So thought it was very impressive through all of this that we at least stayed weight neutral for the most part of it, which was showing that even though we had a hard period, we managed it well.
Associate Professor Sandra Lowe:
It's interesting. What you've probably seen here is the natural resolution of the condition rather than any particular response to treatment. I Think you are in a holding pattern as we often are in these women? Our treatments are very primitive. They are symptom related. We're not curing anything. We're not fixing anything. We're buying time until the natural resolution, and there's two points at which women resolve. There's one group that get better around 12-13 weeks, and there's a second group that get better around 16 weeks. The tiredness of pregnancy doesn't resolve until 16 weeks, and for many women, tiredness is a trigger for their nausea and vomiting. So, I think in this woman, we were fortunate that with good treatment, she was able to resolve naturally by 12 weeks. I would suggest to you that careful management of gastro-oesophageal reflux and constipation also reduces the duration of treatment, because hormonally this condition should improve sort of by about 12-16 weeks, and the women that go on to 24 weeks or even until term are often experiencing nausea-related to gastric dysmotility.
Dr Rachel James:
So, at 16 weeks, things continue to improve again. We still had some ongoing mild nausea, but it was much easier to be controlled and we're just using ondansetron on a prn occasion. and then unfortunately, at 28 weeks when we thought everything was going really well, we started to have an up spike of nausea again, but this time it was looking more like reflux due to gravid uterus. So started omeprazole 20 mg for relief there afterwards.
Associate Professor Sandra Lowe:
That's a very common thing that women panic when they get nausea towards the end of pregnancy, but virtually always it's not a recurrence of their NVP. It is gastroesophageal reflux. They may not be aware of it. It can be silent reflux. but if you treat the reflux, you'll get rid of the nausea. They can use simple measures like sitting up in bed. They can use antacids. Staying upright after meals can be very helpful as well, but what you have to reassure them is that it's not a recurrence of their HG because they do get very distressed when the nausea appears to come back.
Dr Rachel James:
This was the final outcome. That was a photo that was allowed to be shared, and we had a healthy baby boy here in Deniliquin in our low-risk birthing centre. So, it was an absolutely wonderful outcome after all that work that the patient went through. So, tips that I would have as a GP would be to use the PUQE-24 score. I have been using it quite a bit and I find that women really under-report their symptoms, especially in some cultural minorities as well, where they feel like it's just expected and a small amount of nausea and vomiting in pregnancy can be expected, but when you go through that score, it gives you a real understanding of what women are dealing with at home. In addition to that, though, it can't be the only thing. You got to ask about food and fluid intake as well, and weight loss, because if you're not eating any food, it's very easy or easier not to vomit. So, their vomiting scores might be reduced in that PUQE-24 score because they're just not taking anything in. So that's not a good situation either.
I find that it's really good to be informed to give women confidence with what we're prescribing and think that's where the guideline comes in, because I think one of the comments previously was that GP's have been doing this for a long time and it's true. We're the first point of call. You know, people come into us for six weeks when there's no other specialties involved and of course we're the first point of call, but I think what the guideline gives us is the ability to be able to say, Yep, we're going to use this drug at this dose at this time. and we've got support from a guideline that says that this is safe prescribing in pregnancy, which gives a lot of confidence to women that they can take these medications in pregnancy and be safe about taking them and therefore improve their pregnancy journey.
Certainly, the written plans are really, really helpful, especially when you're starting several medications all at once, and it does help that woman be informed of their care, and it helps you to discuss the plan back and forwards and make adjustments. So it might be that a little bit more time in the first consult, but it certainly speeds up your timing in your second and third consult, and my other tip would be that I prescribe everything with HG, even Coloxyl, anything that's even over the counter I still prescribe on a script.
- I think that gives importance to the woman that I want them to take it.
- think that's the best way to communicate with our pharmacists who are just trying to make sure that we're prescribing safely for people in pregnancy and if I write on there that I want them to have this medication at this time and I put it in the box for nausea, in pregnancy, for hyperemesis, then the pharmacist knows that I know that this patient is pregnant.. I have considered that in my prescribing, and this is what I'm prescribing. So, I think it gives a bit more information, a bit more for the pharmacist to go on so that they can help that woman as well when she goes to fill those scripts.
Associate Professor Sandra Lowe:
We've also just mentioned that we're doing a lot of education with pharmacists as well as with doctors about HG and NVP to give them the confidence, because there is a lot of reluctance amongst pharmacists to the point where I often send the husbands with the prescription so that the woman doesn't have to face the retribution of an ignorant pharmacist, saying that they can't be given particular medications. So, it is education of women to speak up and report their symptoms exactly as you say, education of clinicians so that you feel confident about what you're dealing with. Is it normal, is it abnormal? Does it need treatment? We're not trying to create a condition here. We're not trying to create a new disease. We're acknowledging that for some women, these symptoms are severe, and they need to be managed. I always compare it to childbirth. Childbirth is natural, too, but most women want an epidural.
Dr Rachel James:
I think we just had one more slide there Sandra. So, to finish off ways that I felt that I helped as a GP. So I suppose it can never be underestimated that the more support you can provide, sometimes you might not know the answer yourself and it feels like nothing you are doing is helping, and I certainly felt that way probably at that 10-week mark, but just the fact that that person has a regular person that they can talk to that can find out help and help them through that journey is a big game changer for a lot of women.
When asked this particular patient if I could share her story tonight, she said, yes, my HG was horrible, but I felt very supported through it. I think as GPs, we are that first point of call. So, it's really important that we do this well and the way that we support our patients, especially in that first consult, can change as to how they feel about their pregnancy, and they will remember that consult. We all know that people come in and say, “hey, you remember that, that that exact phrase from two years ago”. “You said to me”, So we know our words are powerful. I think as a GP that we have the ability to see that whole patient. So, I was able to focus on her mental health. I was able to have a very good understanding of her past health because I was there for that too, and I was able to focus on her physical health as well. When things did get quite complex, I was able to coordinate care between the hospital, GP clinic, and talking to specialists and maintaining that continuity of care, especially here in a country town where it would be me as her doctor over in the hospital as well, which is always a nice thing of working rural. I felt that really using the Telehealth that's now available to us is a great means to do follow up for patients and really provide that extra support and convenience. I felt that I was able to provide some expert advice and support that that she may not have otherwise had. I do think that being involved in this project, I always felt that I was good at managing nausea and vomiting in pregnancy. I always felt I was good at managing hyperemesis, but reading the guideline, working with people like Sandra in this project has really felt that I've been able to hone my skills even further. So, I feel like I'm doing a better job now with these patients as a result of this guideline.
Associate Professor Sandra Lowe:
Rachel, I'd like to read something from the Q and A because I think it's really relevant. It's from one of our attendees. It was an anonymous attendee as someone who went through NVP and HG until 33 weeks where it was so debilitating, it's difficult to emphasise how bad it is until you've gone through it, anything we do as GPs to reassure and manage is so important to support these women through pregnancy. So, I think that's a really pertinent comment by one of our attendees. I'm really sorry that you experienced that until 33 weeks. As I as I've tried to emphasise, good management in the first 16 weeks has a huge impact on later pregnancy. We know that the sort of complications we're concerned about in women with HG, which include small for gestational age babies and increased risk of preterm delivery, worse breastfeeding rates, high rates of posttraumatic stress disorder, the better we treat this condition in the first part of pregnancy, the less we will see those significant maternal and foetal adverse events.
This is not an easy condition to treat, but it is possible to manage it better, and I think someone like Rachel who has some experience already, feels like she can manage it better and feels supported. I hope you all feel a little bit more supported also from the questions: Are PPIs safe in the first trimester? Yes, they are. We've talked about all the safety issues in the first webinar. So, if you weren't able to attend the first webinar, I'd recommend you watch the recording, and I guess we're open for questions.
Dr Rachel James:
Sandra, I think there was a question there about iron deficiency and taking iron supplements and how that may contribute to HG.
Associate Professor Sandra Lowe:
It's the iron in multivitamins definitely makes nausea and vomiting worse. As I said in one of the early slides, two thirds of women had an improvement in their NVP if they ceased their multivitamin. Don't worry too much about iron deficiency. You'll catch up later on. Should you use an intravenous iron? It can all be done a bit later. I wouldn't rush to give intravenous iron in the first trimester. They may be fine by 12 or 13 weeks, and you recommence oral iron at that point. So yes, I wouldn't give oral iron in the first trimester to someone with HG. Would I rush to give an iron infusion? Only if I absolutely needed to.
Jennifer:
Thank you, Rachel and Elizabeth. We still do have about five minutes left. So, if anyone did have any questions, please feel free to put them into the Q and A. I don't know if Sandra or Rachel, you had any further comments to make before we wrap up?
Associate Professor Sandra Lowe:
What a great question. Can I just answer that last question, please? What works best for the constant spitting? So, in women, funny things that me cheer me up. In women that get HG a certain percentage of them get this condition called ptyalism. It's actually not an excess salivation, although it seems to be that. It's a reluctance to swallow your own saliva. So, there are two approaches that I use for that. The first is chewing gum. Chewing gum changes the taste of the saliva, and many women can start swallowing it. So that's one approach, and the second is to use the anticholinergic effects of particular drugs to dry the mouth a little bit, which is a little counterintuitive in someone who's having trouble drinking, but it's these women can be sitting there with a bowl or a plastic bag, drooling for most of the day and most of the night. So, the other drug you can use in that situation is a small dose of nortriptyline 5 mg or 10 mg nocte will dry at least the salivation at night, but I'd start with chewing gum and there's some really interesting data about why these women get ptyalism and how it relates to what causes HG.
Jennifer:
There has been a couple of other questions come through. If a patient is iron deficient but not HG, can iron be given as an oral supplement given there is a chance, they may develop nausea and vomiting soon?
Associate Professor Sandra Lowe:
You can always stop it. Yeah, just start the iron, and then just stop it if they get… people who have got nausea and vomiting, the regular PUQE of up to seven is in the normal group often have a PUQE of seven. They'll often tolerate multivitamins. It's the more severe group that you need to stop the iron containing multivitamins, and a question about the safety of steroids in pregnancy. Again, we went through that in webinar. one, it should be used in expert hands.
There is controversial data to suggest an increased risk of oral clefts in women given steroids in early pregnancy. But that data is not very strong, and if the alternative is a termination of pregnancy, most women will accept the steroids.
Dr Rachel James:
We have a question here about IV fluids and GP practice. Is this achievable? Because it doesn't seem to be a done thing? I suppose from my experience, because I work quite closely with our local hospital, I do it over at the hospital setting, but I think and the main limiting factor I find is my nursing time and the ability to observe these patients in clinic. But if you do have that nursing time and you do have that ability to observe and you do have a pump, so you know that you're giving a certain volume. It could certainly be done. You just have to make sure that you're monitoring the electrolytes quite closely, not hourly, but on a day-to-day basis. Did you have anything to add to that, Sandra?
Associate Professor Sandra Lowe:
It just depends on your setting. I'd be delighted if GPs could give IV fluids in their in their rooms because giving it in the Emergency Department is a really bad experience for most women. It often takes a whole day to get an hour's worth of fluids. With the New South Wales Health Project, we are rolling out a whole range of facilities, including hospital in the home, to provide IV fluids for women. So, I think yes, if you can do it, it's a great idea, but there may be other places where you can achieve this, Early Pregnancy Clinics, Early Pregnancy Services, Infusion Centres, we do it in our Pregnancy Day Stay, but general practice is the heart for women in early pregnancy and it is where I'd love them to be able to get most of their care.
Dr Rachel James:
Well, I think everybody would feel more comfortable going to their local GP where they've gone for the last few years versus a strange, ED lounge. So, it certainly would give more comfort.
Associate Professor Sandra Lowe:
I think what we're trying to do is give holistic, empathetic care and I think general practice is the centre of that.
Dr Rachel James:
And yes, we do need MBS numbers for IV fluids. I totally agree with that one.
Jennifer:
All right. It is just about to hit 8:30, so I'd like to extend my thanks to Rachel and Sandra for presenting this evening. We do hope that you enjoyed the session and, of course, enjoy the rest of your evening.