Gestational malnutrition, hyperemesis gravidarum, and Wernicke's encephalopathy: What is missing?

Abstract

Hyperemesis gravidarum (HG), or the severe nausea and vomiting of pregnancy, is one of the most dreaded complications of gestation, affecting between 1.5% and 3.0% of pregnant women. From the late 1800s to the mid-1980s, the etiology was frequently cited to have psychological and/or-laterperhaps hormonal origins, which have numbered at least 10. Current research has unearthed a genetic basis for HG that implicates growth differentiation factor 15, insulin-like growth factor binding protein 7, and hormone receptors (namely, glial cell line-derived neurogenic factor family receptor alpha-like and the progesterone receptor). Whatever the origins of this disease, it has caused immeasurable physiological and psychological damage to women, their fetuses, and their families. The psychological trauma includes a high rate of suicidal ideation as well as posttraumatic stress disorder. Whereas the healthcare costs are substantial for the mother with HG, the lifetime costs to the neonate include that which accompanies reduced employment earnings related to cognitive compromise. Another devastating outcome of severe HG can be Wernicke's encephalopathy (WE), which has a high fetal and maternal mortality rate. Our study explored 18 current reports of HG and WE. We highlighted additional presenting features we believe also accompany, and sometimes replace, the classically taught triad components of WE: ataxia, confabulation, and nystagmus. We agree with the conclusion made by Sheehan and Ironside in 1939 that thiamin alone may not reverse WE, and we offer possible explanations. Lastly, we offer suggestions for remediation.

The Effect of Hyperemesis Gravidarum on Macular Thickness, Corneal Thickness, and Intraocular Pressure in Pregnancy

“…Our findings on the eye may be coincidental in HG, and it should definitely be considered in the HG management of obstetricians, as HG may aggravate the existing disease if it develops with a pre-existing systemic disease. The first-line treatment of HG patients is fluid depletion and antiemetic therapy, and in severe HG, sepsis, thrombosis secondary to parenteral nutrition, and albeit rare, Wernicke's encephalopathy (WE) [13].This condition (WE), which is defined as a sign of optic disc swelling that causes a diagnostic dilemma in pregnancy, can be diagnosed with a high index of suspicion by clinical signs and radiological evidence, and generally patients experience rapid improvement in clinical symptoms with intravenous thiamine thera-py [14][15][16]. For all these reasons, it is extremely important for obstetricians to take any necessary precautions.…”

“…The inclusion criteria for the study were as follows: first trimester (8-14 weeks of gestation) pregnancy with positive fetal heartbeat and no history of systemic disease, no history of continuous drug use, diagnoses of hyperemesis gravidarum (ketone positivity in urine analysis and weight loss of more than 3 kilograms or 5 % of body weight), body mass index (BMI) within normal limits (18. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24], age between 18 and 40, no alcohol use or smoking, and no use of vitamins or supplements during the study. It was determined that the use of food supplements would be cause for exclusion from the study (▶Fig.…”

Gestational Malnutrition is Still the Skeleton in the Closet: Where Are the Malnutrition Risk Screening Criteria?

“…We began this investigation by using data from our previous study of 27 women with severe HG whose condition worsened into WE which followed the 2019 seminal systematic review by Oudman et al of 177 cases [12,13]. We subsequently removed Stephens from this current review, as on closer inspection this report was included in the Oudman review, albeit the publication was cited "in press 2017" [14].…”

Exploring a Multidisciplinary Approach to Wernicke's Encephalopathy in Pregnancy

“…The psychological burden of hyperemesis gravidarum alone necessitates early diagnosis and treatment, but complete remission in severe cases occurs in a minority of patients. And in such cases, ultimate resolution of symptoms may take months 33,34 …”

“…And in such cases, ultimate resolution of symptoms may take months. 33,34 Because our patient was often nonverbal, it is possible that providers were unable to fully realize the psychosocial burden of hyperemesis gravidarum and prolonged hospital course. Patients with hyperemesis often report that their providers do not understand how ill they are, terminate their pregnancies because of the condition, or are wary of subsequent pregnancies due potential recurrence.…”