Hyperemesis Gravidarum Complicated by Wernicke Encephalopathy: Background, Case Report, and Review of the Literature

Abstract

Wernicke encephalopathy (WE) is a rare but known complication of severe hyperemesis gravidarum caused by thiamine deficiency. This article presents an unusual case that occurred at our institution and reviews the 48 previously published cases of WE in pregnancy. Considering all the 49 cases, the mean (+/-standard deviation) patients' age was 26.7 +/- 4.9 years, the mean gestational age when WE manifested was 14.3 +/- 3.4 weeks, and the mean duration of vomiting and feeding difficulties was 7.7 +/- 2.8 weeks. Wernicke's classic triad (confusion, ocular abnormalities, and ataxia) manifested in only 46.9% (23 of 49) of the patients. Confusion affected 63.3% (31 of 49) of the patients, ocular signs 95.9% (47 of 49) and symptoms 57.1% (28 of 49), and ataxia 81.6% (40 of 49). Deterioration of consciousness affected 53.1% (26 of 49) of the subjects and memory impairment 61.2% (30 of 49). Complete remission of the disease occurred in only 14 of 49 cases. Symptom resolution required months and permanent impairments were common. The overall pregnancy loss rate, directly (spontaneous fetal loss) and indirectly (planned abortion) attributable to WE, was 47.9% (23 of 49). The diagnosis of WE is clinical and can be rapidly confirmed by magnetic resonance imaging. We emphasize the importance of thiamine supplementation to women with prolonged vomiting in pregnancy, especially before intravenous or parenteral nutrition. We also underline the necessity to promptly replace vitamin B1 when neurologic symptoms and/or signs develop in a patient with hyperemesis gravidarum.

Clinical Characteristics and MR Imaging Features of Nonalcoholic Wernicke Encephalopathy

“…Apart from these factors, the literature reports that nonalcoholic WE could occur after most gastrointestinal surgical procedures, including gastric bypass surgery, 7-9 gastrojejunostomy, 10 gastrectomy, 11 colectomy, 12 and even therapy with an intragastric balloon. 13 In addition, hyperemesis gravidarum, [14][15][16] chemical therapy, 17 anorexia nervosa, 18 AIDS, 19 and even wrong formula feeding 20 were also reported as predisposing factors (Table 1). 6,[21][22][23][24][25][26][27] Because the healthy body's reserves of thiamine are sufficient for up to 18 days, any condition that induces thiamine deficiency lasting 2 to 3 weeks may lead to WE.…”

Wernicke?s Encephalopathy Secondary to Prolonged Total Parenteral Nutrition: Case Report

“…[26][27][28] Sunulan olgu, uzun süre hastane yatışı ve parenteral beslenme sonucu riskli gruplar arasındadır. Olgu kliniğimize danışıldığında, enfeksiyöz öyküsü göz önünde bulundurulup ilk önce ensefalit tanısı dış-lanmış, sonrasında tipik görüntüleme sonuçlarıyla WE tanısı alıp tedavi edilmeye başlanmıştır.…”

Wernicke’s encephalopathy: a case report and mri findings

“…WE is a rare but known complication of hyperemesis gravidarum resulting from the combination of poor nutritional intake, frequent vomiting, and increased metabolic demands of pregnancy (3). WE can also be precipitated by parenteral nutrition or infusion of glucosecontaining solutions without prior administration of thiamine (4,5).…”