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HIPEREMESIS GRAVIDICA
1.- CONCEPTOS
EMESIS (40-65%): Naúseas y vómitos esporádicos, preferentemente matutinos, que resultan molestos para la gestante, pero que no impiden su correcta alimentación
HIPEREMESIS (2´5% ): Vómitos incoercibles que impiden la correcta alimentación de la paciente, ocasionándole pérdida de peso > 5% y trastornos electrolíticos
2.- ETIOPATOGENIA
HCG : niveles séricos directamente proporcionales a intensidad de vómitos.
Estrógenos :Estradiol
C. Lúteo ovario derecho: esteroides sexuales en sist. portal hepático
H. Tiroideas : 2/3 hipertiroidismo transitorios
Primiparidad, <35 años, rechazo gestación, no pareja estable...
Pérdida de control de la corteza cerebral sobre los centros subcorticales del vómito.
Reacción imunológica por proteínas de la placenta
3.- CLINICA
Vómitos
Epigastralgia
Sialorrea
Pérdida de peso
Sg. de hipovolemia y deshidratación
Cetosis
Casos graves (ictericia, neuritis periférica, encefalopatía, insuf. hepatorrenal...)
4.- LABORATORIO
SANGRE: Hto
densidad osmolar sérica
urea
Na+, K+ ,Cl- ( Alcalosis Metabólica)
ORINA: Vol. Urinario
CCr
Osmolaridad
Cetonuria
Casos graves: GOT, Ictericia leve, C. Cetónicos, Ac. Úrico, reserva alcalina, Na+, K+...
5.- DIAGNOSTICO
Anamnesis y exploración
Datos de laboratorio
Control de peso
Ecografía
Fondo de ojo
6.- DIAGNOSTICO DIFERENCIAL
Causas Digestivas : apendicitis, gastroenteritis, hernia hiato, pancreatitis ...
Causas Neurológicas : meningitis, HT intracraneal...
Otras : pielonefritis, torsión quiste ovárico, cetosis DM, exposición a tóxicos...
7.- TRATAMIENTO
AMBULATORIO (Evitar naúseas y vómitos leves)
MEDIDAS DIETETICAS:
FARMACOLOGICO
Comprimidos de 10mg de Clorhidrato de Diciclomina, 10mg de Succinato de Doxilamina y 10mg de Piridoxina (2 comp. al acostarse y 1 a media mañana)
5-10 mg de Metoclopramida antes de comida con la que se tienda al vómito
Carboxilasa ( 1-2 supositorios de 20 mg/día o 100 mg c/12h IM) si cetonuria
Sulpiride: antiemético/psicotropo
Omeprazol
HOSPITALARIO
CRITERIOS DE INGRESO
MEG ( fiebre, tq...)
Diuresis < 750 ml/día
HCO3- > 40-50 mEq/l o Cl- < 60 mEq y Ph > 7´4-7´7 (Alcalosis metabólica descompensada)
C. Cetónicos >200 mg/100 ml o HCO3- <20 mEq/l (Acidosis progresiva)
Aporte de líquidos suficiente cuando diuresis diaria > 1500ml y contenga < 2-3 g Cl Na
Piridoxina ( 300-600 mg Dosis de choque y desp. 300 mg/día o alternos) + Tiamina ( 100-200 mg/ día) + 1 g Vit. C
Aconsejable los 1-2 primeros días un sedante-antiemético (dehidrobenzoperidol, haloperidol)
Si agitación psicomotriz: sedación (diazepam)
Otros: antihistamínicos (maleato de dexclorfeniramina), Ondansetron
Si grave desnutrición: alimentación parenteral
Tras 24 horas sin vómitos y cuando se normalicen los electrolítos, la urea, el hto y la diuresis Ingesta Oral ( consejos ambulatorios)
Alta cuando la pérdida de peso cese
Acupuntura, psicoterapia y terapia conductual: complemento de tto.
8.- COMPLICACIONES
Neumonía por aspiración ( Sd. Mendesson)
Sd. Mallory- Weiss
Sd. Boherhave
Encefalopatía de Wernicke
Infiltración grasa de hígado y riñones
9.- PRONOSTICO Y EVOLUCION
- Bueno si manejo correcto de balance hidroelectrolítico
- No se prolonga tras embarazo pero puede recurrir en los siguientes
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Enviado por: Residentes Ginecología Málaga Idioma: castellanoPaís: España