Hyperemesis Gravidarum

Started by iish
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iish

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Basic story is 22 G1P0 F at 9 wks w/ viable IUP presenting w/ RLQ pain x 1.5 mos and persistent N/V for 2-3 wks, unable to tolerate PO. WBC 19 on initial labs. MRI abd/pelvis neg for appy, TVUS neg for ectopic, torsed ovary, shows viable IUP w/ appropriate FHR. After w/u pt being treated for presumed hyperemesis gravid arum.

I signed this pt out and check back approx 10 hrs later and pt is still in ED after 6 L D5 NS and multiple rounds antiemetics and an ob consult recommending more D5 NS and antiemetics. This is 22 hrs after initial assessment. Is this an appropriate ED course for this pt? Do we manage hyperemesis gravid arum in the ED for 22+ hrs or should this pt be admitted to an inpatient service for management?
 
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Should be admitted. You've already got a 23 hr obs admission going right there. Sounds like the patient got signed out and slapped with an "OBs problem" label one them and forgotten about for 3 shifts in a row without anyone watching the clock. You can see how fast you'd run out of beds if you allow every service to turn your ED into their own obs unit where the ED and ED staff do all their heavy lifting for them. Any consultant that thinks that you'll just do their work for them will run with it. Get 'em upstairs. Do you think an FP or Ortho will let a single patient sit in one of their office exam rooms for 9 hours and take up a room? No. Why? Time is money.

Also, with admin obsessing about these numbers just think what one patient with a 22 hr length of stay does to the initial docs LOS numbers. One patient like that will throw off the average for a whole month. The 22 hr won't get divided amongst the 3 successive doctors shifts. It'll get pinned on one of them, likely the one who's name is on the chart (doc #1). It all depends if you care about these numbers or not. The people writing the checks do.
 
As soon as the meet inpatient criteria, they are getting admitted.
I think intractable n/v, just needs two doses of antiemetics to meet criteria.
RLQ pain for 1.5 months sounds like crazy to me, not appy, torsion.
Maybe ectopic, but a bedside u/s tht visualizes an IUP makes this unlikely.
The inpatient team can mess around with the rest of the workup.

Maybe get a formal u/s for preg and ask them to try to visualize the appendix.
If neg admit and ask team if they want an MRI.
Patient can get scan and rest of managment as inpatient.

I probably would have refused signout from you on this patient.
They needed a dispo, either admit or go home with antiemetics.
 
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I generally wait until I'm through 2-3 different antiemetics before pulling the trigger... because I want my presentation to sound like I've really, really tried. "Yeah, she's gotten 16 of zofran, 20 of reglan, and 25 of phenergan and is still not close to tolerating po." Of course, the last OB I threw this at implied she was going to send her home after we shipped the pt to L&D triage. (This one happened to be a 3rd trimester UTI vs pyelo, so yeah, right.) Still, that many hours is absolutely ridiculous. Admit and get it over with.
 
New literature is saying no for Zofran in first trimester. Diclegis is being recommended to us by our OB colleagues here.
 
RustedFox said:
Diclegis ?

No Zofran?

Grryyahh. - "No Zofran" makes that UCG ever the more important.
Click to expand...
Diclegis = doxylamine + B6

Individual components = pennies
Combo pill = bennies

Works like gangbusters, but I can't justify the price... so, zofran & reglan are my meds of choice. Don't like sending people out on meds I haven't used on them in the ED to control symptoms.

-d
 
Daiphon said:
Diclegis = doxylamine + B6

Individual components = pennies
Combo pill = bennies

Works like gangbusters, but I can't justify the price... so, zofran & reglan are my meds of choice. Don't like sending people out on meds I haven't used on them in the ED to control symptoms.

-d
Click to expand...

Far out. Doxylamine is in all your commercially available NyQuil-like preparations. Lets me sleep.
 
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I'm not sure why you bothered with an MRI for 1.5 months of pain =p She's pregnant and she's in distress, of course that WBC is high. This patient would get an u/s, u/a, pelvic exam, labs (electrolytes and lft's since this isn't your average hyperemesis pt), and 2 rounds of anti-emetics from me, and max 2 liters of fluids. the rounds of antiemetics by the way would be 8mg Zofran (there's no reason to give 4 to a vomiting pt since that fails half the time), and 2nd round would be 10mg reglan and 25mg Phenergan. This way I can tell ob that they got 4 doses worth of antiemetics and have failed ED treatment and need admission for intractable vomiting.
 
I wonder how much of the anti-zofran stuff out there is directly related to its now-cheapness... I've given tens of thousands of doses in my career, and it is my most commonly used drug, period. I have seen exactly 3 reactions to it.

Literature please?
 
dchristismi said:
I wonder how much of the anti-zofran stuff out there is directly related to its now-cheapness... I've given tens of thousands of doses in my career, and it is my most commonly used drug, period. I have seen exactly 3 reactions to it.

Literature please?
Click to expand...

Literature? Literature? It has nothing to do with "literature" you silly goose. It has everything to do with the predatory medical-legal environment we are in.

Zofran? That's nothing. Check out these guys, and notice the phone number, "1-800-bad-drug."

http://www.bad-drug.net/bad-drug-list

Look at this gargantuan list of "bad drugs."

http://www.bad-drug.net/bad-drug-list

"Have you ever prescribed any of these 'bad drugs,' doctor?"

"If so, doctor, what kind of doctor does that make you?"


(Lol. I should've been a plaintiffs attorney.)
 
Birdstrike said:
Literature? Literature? It has nothing to do with "literature" you silly goose. It has everything to do with the predatory medical-legal environment we are in.

Zofran? That's nothing. Check out these guys, and notice the phone number, "1-800-bad-drug."

http://www.bad-drug.net/bad-drug-list

Look at this gargantuan list of "bad drugs."

http://www.bad-drug.net/bad-drug-list

"Have you ever prescribed any of these 'bad drugs,' doctor?"

"If so, doctor, what kind of doctor does that make you?"


(Lol. I should've been a plaintiffs attorney.)
Click to expand...

I've seen this list before, its basically a list of all drugs, ever.

Black box warning! Acetaminophen! Clindamycin! Cipro! LOLZapril~!
 
Daiphon said:
Diclegis = doxylamine + B6

Individual components = pennies
Combo pill = bennies

Works like gangbusters, but I can't justify the price... so, zofran & reglan are my meds of choice. Don't like sending people out on meds I haven't used on them in the ED to control symptoms.

-d
Click to expand...


[noobquestion]

So why not give your patient both doxalamine and B6? Both of them are available otc.

[/noobquestion]
 
iish said:
Basic story is 22 G1P0 F at 9 wks w/ viable IUP presenting w/ RLQ pain x 1.5 mos and persistent N/V for 2-3 wks, unable to tolerate PO. WBC 19 on initial labs. MRI abd/pelvis neg for appy, TVUS neg for ectopic, torsed ovary, shows viable IUP w/ appropriate FHR. After w/u pt being treated for presumed hyperemesis gravid arum.

I signed this pt out and check back approx 10 hrs later and pt is still in ED after 6 L D5 NS and multiple rounds antiemetics and an ob consult recommending more D5 NS and antiemetics. This is 22 hrs after initial assessment. Is this an appropriate ED course for this pt? Do we manage hyperemesis gravid arum in the ED for 22+ hrs or should this pt be admitted to an inpatient service for management?
Click to expand...

This behavior from consultants must be anticipated -- especially from OB! They learn this as PGY 0.01.

The key is to define the limits at the first phone call (if in an academic center with OB residents), as it does not matter how many liters or rounds you have given before the first call. 1 =5 =7. They will beg for "just one more round".

"Ah, yes, Dr. OB, I think one final, last, ultimate round of reglan and one final liter sounds like reasonable. I'll do that and if she still can't take PO, I'll admit. Thanks." quick hang up...even faster liter (pressure bag!) and reglan...wait 30 minutes and admit.

Community ED: just admit.

HH
 
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dchristismi said:
I wonder how much of the anti-zofran stuff out there is directly related to its now-cheapness... I've given tens of thousands of doses in my career, and it is my most commonly used drug, period. I have seen exactly 3 reactions to it.

Literature please?
Click to expand...

http://www.abstracts2view.com/ispe/view.php?nu=ISPE13L1_576
http://www.obgynnews.com/index.php?id=11370&type=98&tx_ttnews[tt_news]=221089&cHash=da03e20e36

It's not the greatest studies but there is some data discussing an increased risk of cardiac defects in women taking zofran in early pregnancy. It's hard to say how legitimate of a claim it is as it's a pretty commonly used medication in the OB community.

I will say that technically according to ACOG (American Congress of OB GYN), Vitamin B6/Doxylamine are first line therapy while everything else (reglan, phenergan, zofran) is supposed to be second/third line due to limited data on safety compared to doxylamine/pyridoxine.

Commenting on the above case, the patient at that point should have been admitted for further management and evaluation, ideally to OB. I'm a resident so these cases routinely get sent to us and shouldn't generate that much push back (usually patient's will present to L and D and undergo evaluation up there).
 
gman33 said:
In the community, OB will never even return the call. Admit to medicine and they can consult.
Different if she was 24 weeks pregnant.
Click to expand...
depends on your community facility. I have all the ob/gyn's cell numbers, call them up, and get an ob bed for these. I still can't get them to admit PID that doesn't have a TOA though, lol. medicine and consult.
 
Hamhock said:
This behavior from consultants must be anticipated -- especially from OB! They learn this as PGY 0.01.

The key is to define the limits at the first phone call (if in an academic center with OB residents), as it does not matter how many liters or rounds you have given before the first call. 1 =5 =7. They will beg for "just one more round".

"Ah, yes, Dr. OB, I think one final, last, ultimate round of reglan and one final liter sounds like reasonable. I'll do that and if she still can't take PO, I'll admit. Thanks." quick hang up...even faster liter (pressure bag!) and reglan...wait 30 minutes and admit.

Community ED: just admit.

HH
Click to expand...

Pretty sure my answer is "Sure, I'll make sure they get that while they are waiting on your evaluation and admission orders."
 
Rendar5 said:
depends on your community facility. I have all the ob/gyn's cell numbers, call them up, and get an ob bed for these. I still can't get them to admit PID that doesn't have a TOA though, lol. medicine and consult.
Click to expand...
The 2 community hospitals I work at don't have L&D. There is gyn on call, but they don't want anything to do with these patients.
Different story at the academic hospital.
 
gman33 said:
The 2 community hospitals I work at don't have L&D. There is gyn on call, but they don't want anything to do with these patients.
Different story at the academic hospital.
Click to expand...
Why my preference is to work at a facility with L&D. I don't want to deal with crap like breech deliveries on my own.
 
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