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Three Part Question

In [pregnant females (≤20/40) presenting to the Emergency Department with nausea and vomiting] are [glucose-containing intravenous fluids better than solutions without a carbohydrate source] at [reducing ketonuria +/- ketonaemia, reducing ED length of stay or improving symptoms]?

Clinical Scenario

A 24 year old woman in her first trimester of pregnancy presents to the Emergency Department with nausea and vomiting, with no other concerning features of alternative pathology. She provides a urine sample at triage and is found to have 4+ ketones present. On examination she is clinically dehydrated and you wish to start intravenous fluids. You wonder, would dextrose-containing solutions be better at switching off ketogenesis and providing symptomatic improvement than intravenous fluids without glucose?

Search Strategy

(exp “MORNING SICKNESS”/OR exp “HYPEREMESIS GRAVIDARUM”/) AND exp “FLUID THERAPY”/

Medline 1946 – 07/16
Embase 1974 – 07/16
The Cochrane library Issue 5 2016

Search Outcome

288 results of which one randomised controlled trial was identified as relevant, and one Cochrane Review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Tan PC et al 2013 Malaysia	222 women at first hospitalisation for HG (on clinical grounds) randomised to receive either 3 litres 5% dextrose-0.9% saline or 0.9% saline by intravenous infusion over 24hours	RCT (1)	Primary – resolution of ketonuria and well-being (by 10-point visual numerical rating scale) at 24hours Secondary – vomiting, resolution of hyponatraemia, hypochloraemia and hypokalaemia, length of hospitalisation, duration of intravenous antiemetic , and rehydration	Persistent ketonuria rates were similar at 24hours (~10%); well-being scores were the same There was a significant difference in nausea score favouring the 5% dextrose-0.9% saline arm at 8 and 16 hours, but the advantage had dissipated by 24hours Second outcomes otherwise showed no difference	Patients allowed to take oral intake as desired during the study period and was not recorded Not ED-based – fluids given over first 24hours once patient admitted to the ward Possibly underpowered
Boelig RC et al 2016 Worldwide	25 trials met inclusion criteria – only 1 related to fluid choice in HG	Systematic review (Cochrane review)	To assess the effectiveness and safety, of all interventions for hyperemesis gravidarum in pregnancy up to 20 weeks’ gestation	Single paper identified (Tan et al) - There was no difference in duration of hospital stay with dextrose saline fluids versus normal saline for rehydration	No mention of further need for research in this area – focus on specific treatments rather than on fluid choice – defaulted to expert opinion on fluid choice

Comment(s)

The only relevant study found was based in women deemed to require admission for parenteral fluids and vitamin supplementation and thus does not include the wider population of women presenting to the ED with nausea and vomiting related to their pregnancy, many of whom will not necessarily require admission. Expert opinion remains that dextrose-containing solutions should be avoided, given the theoretical risk of precipitating Wernicke’s encephalopathy in those who are thiamine deficient, or central pontine myelinolysis in those with hyponatraemia. However, these complications are rare and their risk can be reduced by giving thiamine supplementation prior to dextrose-containing solutions and careful monitoring of sodium levels.

Clinical Bottom Line

There is insufficient evidence currently to direct intravenous fluid choice in patients with nausea and vomiting of pregnancy presenting to the Emergency Department.

References

1. Tan PC, Norazilah MJ, Omar SZ Dextrose saline compared with normal saline rehydration of hyperemesis gravidarum; a randomized controlled trial Obstet Gynaecol 2013;121:291-8
2. Boelig RC, Barton SJ, Saccone G, Kelly AJ, Edwards SJ, Berghella V Interventions for treating hyperemesis gravidarum (Review) Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD010607