Review article: Management of hyperemesis gravidarum and nausea and vomiting in pregnancy.

Nausea and vomiting in pregnancy (NVP) are common in early pregnancy but there is a wide spectrum of severity in terms of the duration and acuity of symptoms throughout gestation. Adverse maternal and fetal outcomes have been seen in women who experience severe symptoms, also known as hyperemesis gravidarum (HG). Evidence-based, assessment and management can reduce symptom severity, avoid physical and psychological deterioration and minimise the impact on quality of life and function. A pathway for assessment and management of NVP and HG in the emergency room is presented based on the Society of Obstetric Medicine of Australia and New Zealand Guideline for the Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum. Assessment requires an objective evaluation using a validated scoring system such as the PUQE-24 score, as well as calculation of hydration and nutritional status. Ketonuria is not associated with either the diagnosis or severity of HG. Further investigation including biochemistry is only required in severe cases. Many women will have tried a range of therapies and an important aspect of treatment is to recognise the validity of their symptoms. Treatment may require a combination of intravenous fluids, anti-emetics, acid suppression and laxatives. Outpatient management is optimal but admission may be required for refractory symptoms, organ dysfunction or concurrent significant co-morbidities. Emergency management of NVP and HG requires an appropriate pathway of care to support women until the natural resolution of their condition. Both underuse of safe therapies and overuse of ineffective medication must be avoided.

Update on pulmonary embolism in pregnancy and post-partum: The Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post-partum.

In this clinical review we highlight aspects of the diagnosis and management of pulmonary embolism (PE) in pregnancy and post-partum and how this may impact on antenatal and postnatal management. Investigation for PE in pregnancy is challenging and includes appropriate patient selection and knowledge of the risks and benefits of pulmonary imaging modalities. The complete Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post-Partum comprehensively reviews all aspects of diagnosis, investigation and management and is accessible at https://www.somanz.org/guidelines.asp. It includes a summary of all recommendations and a guide to developing a management plan for birth in women on anticoagulation.

SOMANZ position paper on the management of nausea and vomiting in pregnancy and hyperemesis gravidarum.

This is a brief summary of the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) evidence-based guideline for the management of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum (HG). The full guideline and executive summary including auditable outcomes are freely available on the SOMANZ website [https://www.somanz.org/guidelines.asp]. The guideline includes a proposed SOMANZ definition of NVP and HG and evidence-based practical advice regarding the investigation and management of NVP, HG and associated conditions including thyroid dysfunction. A practical algorithm for assessment and management as well as an individual patient management plan and self-assessment tools are included.

Ionizing radiation for maternal medical indications.

Ionizing radiation should be considered an avoidable exposure although all pregnant women receive some radiation from their environment. The potential effect of ionizing radiation on the fetus is determined by the dose and the timing of the exposure with growing interest in the potential risks of transgenerational effects of radiation as an epigenetic phenomenon. High dosage exposure is very unlikely in routine situations such as occupational, diagnostic, or therapeutic exposures. Individual diagnostic radiation procedures (fetal dosage <50 mGy), are not associated with any increase in lethality (miscarriage or stillbirth), genetic damage, teratogenicity, growth impairment, mental retardation, or sterility. More recent modeling has suggested that a 10 mGy fetal dose is associated with an excess risk of childhood cancer risk as low as 1 in 4545, well below historical estimates.When the mother's condition necessitates diagnostic radiation it is necessary to balance the risks of the procedure with the benefits to be gained. As almost all diagnostic imaging involves doses below the 50 mGy threshold, clinically indicated investigations should not be withheld because of concerns regarding fetal radiation exposure. Even radiotherapy directed away from the abdomen or pelvis may be considered during pregnancy, if the benefits outweigh the risks and no suitable alternative is available.

Pre-eclampsia and long-term cardiac dysfunction: A review of asymptomatic cardiac changes existing well beyond the post-partum period.

BACKGROUND: Pre-eclampsia is a disease of pregnancy characterised by the manifestations of multi-organ dysfunction. The recent use of transthoracic echocardiography in the assessment of women with pre-eclampsia has allowed the detection of cardiac systolic and diastolic dysfunction in the acute phase. Women with a history of pre-eclampsia also have increased lifelong risks of cardiovascular disease and mortality that persists well beyond the post-partum period. These developments raise the possibility that pre-eclampsia may be an early marker of cardiovascular disease and the potential role for echocardiography in guiding the detection and management of this. This review aims to summarise the existing evidence of echocardiographic cardiac assessment of women with a history of pre-eclampsia performed more than 12 weeks post-partum. METHODS: A systematic search of PubMed and OVID EMBASE databases was performed to identify studies featuring assessment of cardiac function performed after 12 weeks post-partum in women with a history of pre-eclampsia. Studies without post-partum cardiac assessment or with other documented causes for cardiomyopathy were excluded. RESULTS: Thirteen studies were identified that measured cardiac function by transthoracic echocardiography between 6 months and 18 years following a pregnancy complicated by pre-eclampsia. Common findings across the studies were of increased diastolic dysfunction, increased left ventricular mass index (LVMI) and concentric hypertrophy in women with a history of pre-eclampsia, as compared to women with uncomplicated pregnancy histories. This was predominantly seen in those with a history of early or preterm pre-eclampsia. CONCLUSIONS: Women with a history of early or preterm pre-eclampsia have an increased prevalence of diastolic dysfunction. This review demonstrates that the cardiac dysfunction associated with previous pre-eclampsia is quantifiable and persistent. Progression of heart failure from asymptomatic to symptomatic stages carries a fivefold increase in mortality. The use of echocardiography could detect cardiac dysfunction in the asymptomatic stage and guide more intensive risk factor modification in these women.

Ergometrine for postpartum hemorrhage and associated myocardial ischemia: Two case reports and a review of the literature.

Ergometrine is recommended for use in the medical treatment of postpartum hemorrhage. Ergometrine can occasionally precipitate myocardial ischemia in the setting of significant anemia in women without preexisting cardiac risk factors, and it is important to recognize and treat myocardial ischemia in affected patients to prevent severe complications.

The way forward.

Improving maternal health and reducing maternal morbidity and mortality into the future will require a range of health-related and non-health-related strategies. The latter include education for women, better communication, access to transport and technology and cultural change. The role of obstetric medicine practice, research and education in achieving these objectives is discussed in this article. We need to recognise that it will require improvements in health provision and access to achieve our goal of safer childbirth for women and babies throughout the world.

SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014.

This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.

Guidelines for the management of hypertensive disorders of pregnancy 2008.

This is the Executive Summary of updated guidelines developed by the Society of Obstetric Medicine of Australia and New Zealand for the management of hypertensive diseases of pregnancy. They address a number of challenging areas including the definition of severe hypertension, the use of automated blood pressure monitors, the definition of non-proteinuric pre-eclampsia and measuring proteinuria. Controversial management issues are addressed such as the treatment of severe hypertension and other significant manifestations of pre-eclampsia, the role of expectant management in pre-eclampsia remote from term, thromboprophylaxis, appropriate fluid therapy, the role of prophylactic magnesium sulfate and anaesthetic issues for women with pre-eclampsia. The guidelines stress the need for experienced team management for women with pre-eclampsia and mandatory hospital protocols for treatment of hypertension and eclampsia. New areas addressed in the guidelines include recommended protocols for maternal and fetal investigation of women with hypertension, preconception management for women at risk of pre-eclampsia, auditing outcomes in women with hypertensive diseases of pregnancy and long-term screening for women with previous pre-eclampsia.

Hepatic ischemia associated with coarctation of the aorta in pregnancy: key issues in differential diagnosis.

BACKGROUND: Hepatic ischemia associated with coarctation of the aorta has not previously been reported in an adult; pregnancy increases the pressure gradient across a coarctation. CASE: A young woman with known coarctation of the aorta developed severe hepatic ischemia in pregnancy. A pregnancy-induced increase in the mean pressure gradient across the coarctation, from 18 mm Hg before pregnancy to 40 mm Hg in the third trimester, predisposed to critical hepatic hypoperfusion in the setting of dehydration. CONCLUSION: This case documents an association between coarctation of the aorta and hepatic ischemia, precipitated by pregnancy and dehydration in combination. It emphasizes the need in the assessment of patients with liver disease in pregnancy to consider not only "traditional" pregnancy-related conditions such as acute fatty liver and the hemolysis, elevated liver enzymes, low platelets syndrome, in which delivery may be necessary as a clinical emergency, but also those in which the circulatory and metabolic demands of pregnancy may precipitate liver injury.

Diagnostic radiography in pregnancy: risks and reality.

BACKGROUND: The use of X-rays, computed tomography scanning and nuclear medicine imaging in the pregnant woman is a source of great anxiety for the patient, her family and the treating doctor. METHODS: A literature review of appropriate databases, articles and relevant institutional protocols was performed. Data was sought regarding any adverse effects of diagnostic radiation in pregnancy, fetal absorbed dose of diagnostic radiation and how the timing of exposure and form of administration might influence these effects. RESULTS: The estimated radiation dose for a fetus from background sources as well as medical imaging was identified. Most diagnostic radiation procedures will lead to a fetal absorbed dose of less than 1 mGy for imaging beyond the abdomen/pelvis and less than 10 mGy for direct or nuclear medicine imaging. Potential adverse outcomes related to radiation exposure during pregnancy include teratogenicity, genetic damage, intrauterine death and increased risk of malignancy. The only adverse effect statistically proven at the dose levels associated with diagnostic radiation procedures is a very small increase in childhood malignancy, with an estimated increase of one additional cancer death per 1700 10 mGy exposures. The important exception was the risk to the fetal thyroid from radioiodine exposure after 12 weeks' gestation. CONCLUSION: In practice, diagnostic radiography during pregnancy not involving direct abdominal/pelvic high dosage, is not associated with any significant adverse events. Counselling of pregnant women who require diagnostic radiographic procedures as well as those inadvertently exposed should be based on the available human data with an emphasis on the minimal impact of such procedures.