An example of severe pregnancy-related meth caused by pregnancy vomiting.

. First, medical records

patients, 22-year-old female, due to "stopped 15 and 6 weeks, nausea, vomiting 1 month, aggravated dizziness, fatigue 8d" as the main complaint admission, outpatient urine ketonebody: 3 plus, consider pregnancy vomiting, on February 20, 2019 at 10:30 am income to my department. Last menstruation: November 1, 2018. This is the initial pregnancy, denied the history of meldonium and other basic diseases, pre-pregnancy basic weight of 59kg, pregnancy 6 weeks appear slight nausea, vomiting and other early pregnancy reactions. Check for thyroid function, thyroid peroxidase antibodies (TPOAb) and thyroid globulin antibodies (TGAb), all of which are normal; Electrocardiogram results: heart rate 90 times /min, sinus arrhythmia. Before the month of January (pregnancy 9 plus weeks or so) there was obvious nausea, vomiting, poor eating, urine volume and weight no significant change, no fever, panic, dizziness, fatigue, abdominal pain, bloating, diarrhea, vaginal bleeding, swelling and other discomfort, outpatient oral nutrition solution and other supportive treatment. 8d before nausea, vomiting aggravated, eating ready to vomit, accompanied by panic, dizziness, fatigue, no sweating, chest tightness, shortness of breath, breathing difficulties, diarrhea and so on. Weight loss quickly by about 4kg. After entering my section to supplement the water electrolyte, vitamin B6 and methercreptoamine (Shanxi River Pharmaceuticals) anti-spitting support treatment, after active rehydration treatment, the patient vomiting, fatigue, panic and other symptoms no significant improvement, heart rate still fluctuates at about 130 times / min. Admission: Body temperature 36. 3C, pulse 140 times/min, breath 20 times/min, blood pressure 98/70mmHg. The eyes are not sudden, the fingers are not quivering, the thyroid gland on both sides is not swollen. Admission to check blood routine: white blood cell 9. 3 x 10 9/L, platelets 334 x 10 9/L, hemoglobin 129g/L, erythropoietin 34. 9%, neutrophil percentage 84. 5%; Blood clotting function: plasma fibroprotein alsoin determination 7. 2g /L, D - D-Dpolymer 0. 81mg /L, fibrinogen equivalent (FEU) , liver and kidney work and electrolytes: albumin 38g / L (normal value 40 to 55g / L), total bilirubin 49. 1 smol /L (normal value 0 to 23 smol /L), direct bilirubin 32. 5 smol /L (normal value 0 to 6. 8 smol /L), total bile acid 17 smol /L (normal value 0 to 10 smol /L), glutamate transaminase 753U/L (normal value 7 to 40U/L), gublet stomp 473U/L (normal value 13 to 35U/L), creatinine 127 smol /L (normal value 41 to 73 smol /L), potassium 2mmol/L (normal value 3. 5 to 5. 3 mmol /L), sodium 124mmol /L (positive normal value 137 to 147 mmol /L), chlorine 67mmol /L (normal value 99 to 110mmol /L), CO2 39mmol /L (normal value 23 to 29mmol/L); 1mmol /L; Thyroid function (MeE): Free triiothyroidininin (FT3)16. 56pmol /L. (Normal value 2. 63 to 5. 71pmol /L), FT4 50. 61pmol /L.L. (Normal value 9. 74 to 17. 15pmol /L), thyroid-stimulating hormone (TSH) 0 mU/L (normal value 0. 27 to 3. 80mU/L), TPOAb and TGAb were all negative; Electrocardiogram: sinus tachycardia (heart rate 126 times/min), QTc extension; Hepatobiliary ultrasound tips: sediment-like stones may, no obvious bile duct obstruction, bile duct expansion performance. According to the above-mentioned hepatum agong, liver and kidney work, electrolyte results, consider serious liver function impairment, electrolyte disorders and A-dosic abnormalities, please ICU physician after consultation to consider "severe pregnancy-related hepatic damage and electrolytic disorders", immediately transferred to ICU treatment. Anti-metformin treatment, every 4h oral propylene thioxygen (the essence of pharmaceutical) 200mg; control heart rate, oral metorlol (Sichuan Ruikang Pharmaceuticals) 25mg, 3 times a day; After the above treatment, at about 18 pm, the patient complained of panic, dizziness, general fatigue than before the obvious relief, good spirit, drinking water after no nausea, vomiting, did not complain of his other discomfort. The heart rate gradually drops to about 102 to 115 times/min. On February 21st, patients developed skin itching symptoms, no nausea, vomiting, yellow ness of the skin, abdominal pain, diarrhea and panic, fatigue and other discomfort, heart rate fluctuations in 108 to 110 times / min. Review of liver, kidney and electrolytes: in addition to albumin (25g/L) lower and bile acid (73. Transaminase and electrolytes improved compared to the previous increase of 6 ?mol/L). Continue to follow the previous procedure and supplement albumin to correct hypoproteinemia. February 22 patients have no obvious symptoms of self-complaint, normal mental appetite, heart rate fluctuations in 100 to 108 times / min, review of liver skills tips transaminase than before a significant decline, but the bile acid abnormally increased, so adjusted to each 6h oral propylene thiopenlyce 100 mg, plus intravenous infusion of smetay (Jape, Italy) bile acid treatment, the rest of the treatment. After the above treatment 4d transferred back to my department to continue to consolidate the treatment 2d. On February 27th, FT3 and FT4 were normal except for TSH 0mU/L. The liver function is basically back to normal. The heart rate is maintained at about 80 to 90 times/min, so he is discharged from the hospital and recommends the endocrinology department of the General Hospital. After the patient was discharged from the hospital, on March 5, 2019, the endocrinology department of the hospital reviewed the work, the results showed that FT3 was normal (5. 14pmol /L), FT4 Lower (5. 79pmol /L), TSH Normal (0. 24mU/L), TPOAb and TGAb are all negative, thyroid-stimulating hormone receptor antibodies are reduced (0. 3IU/L); liver function is normal, so to stop the use of propylene thiopental, after discontinuation of the patient did not complain of discomfort. Review The A-work after 10d: FT3 reduction (5. 03pmol /L), FT4 Lower (5. 66pmol /L), TSH Rise (6. 54mU/L), consider "drug-based a reduction", to Ujiale (Merkel, Germany) 50 sg, oral, after a week to review normal A-gong, and continue to maintain Ujiale treatment until full month. Tracking follow-up patients during pregnancy birth test indicators are normal, fetal system color super and heart color super unoprompted fetal malformation and developmental abnormalities, on August 9, 2019 due to "trigger ingestion failure" caesarean section caesarean section of a baby girl, weighing 3,300g, Apgar score 10 - 10 points, newborns did not find abnormalities.

2, discussion

pregnancy nausea, vomiting is a common symptom of women in the early stages of pregnancy, affecting about 70% to 85% of women in the early stages of pregnancy, the general symptoms are mild, self-relief in the middle of pregnancy. Pregnancy vomiting refers to persistent severe frequent nausea and vomiting, and may lead to dehydration, ketone urination, body weight than before pregnancy decreased by more than 5%, mostly accompanied by body fluid electrolyte imbalance and metabolic disorders, and need to eliminate other diseases causing nausea, vomiting. Studies have confirmed that pregnancy vomiting is associated with serum high-level serotonin-induced gonadotropin (HCG) levels. Because the HCG and TSH substructures are similar, they can produce a TSH-like effect that stimulates T4 secretion, and negative feedback inhibits TSH secretion. Studies have shown that early pregnancy due to rapid increase in blood HCG levels, resulting in a decrease in TSH and an increase in T4, clinically known as pregnancy-once hyperthyroidism (GTT), common in pregnancy vomiting patients, also known as pregnancy vomiting and sexual hyperthyroidism (TTHHG) Thyroid function in TTHG patients generally recovers normally at 14 to 20 weeks of pregnancy, without treatment, and cases of severe performance of meldonium and combined severe liver damage are rare. It is reported that about 30% to 60% of pregnancy vomit patients can have a sexual hyperthyroidism, clinically often manifested as sustained severe nausea, vomiting with weight loss of 5% on, dehydration and ketosis, and no positive signs of thyroid detection, only a few patients due to severe vomiting and dehydration caused by abnormally high serum HCG levels, and ultimately induce severe pregnancy-related meldonium. This patient is a typical case of severe pregnancy-related meth caused by severe vomiting. This case of patients pregnant 6 weeks to check the normal, before no history of meldonium, outpatient doctors according to their vomiting symptoms and ketouria performance, the first consideration of pregnancy vomit ingestion admission to hospital. At the time of admission, the heart rate was as high as 140/min, but no diarrhea, sweating, sudden eyes, hand tremors and other symptoms, consider long-term vomiting to blood capacity is insufficient caused. Therefore, only to stop vomiting, supplemental water electrolytes and B vitamins and other supportive treatment, its panic, fatigue and other symptoms no obvious improvement. The results of the test indicate obvious damage to methicillin and liver function, immediately transferred to ICU anti-merace and other treatment, patientsymptoms significantly alleviated, heart rate gradually decreased, indicating that the
diagnosis
correct and effective treatment. The patient was tested for severe nausea and vomiting after pregnancy, which eventually induced severe pregnancy-related meth. Clinically, the general pregnancy and pregnancy caused by insufficient blood volume heart rate fast, after rehydration to rehydration should be improved, this case patients after active rehydration heart rate is still not significantly reduced, at this time should consider whether to combine other high metabolic diseases. However, it is not easy to distinguish between meldonium and THHG during pregnancy. It is reported that the incidence of meldonium during pregnancy is about 1/500 , Graves' disease is the main cause, but often exists before pregnancy, vomiting may be an important clinical characteristic of patients with untreated meldonium. And pregnancy vomit caused by the general lysis is generally relatively minor, and is a sexual, rarely serious performance of meldonium, so to my physician caused diagnostic errors. However, in the past there is a history of meldonium, T3/T4 ratio greater than 20 and have symptoms of palpitations to help diagnose the cause of meldonium, so in the diagnosis and treatment of pregnancy patients should do carefully to inquire about the medical history and check the body, improve thyroid function detection. Methyl arose have a certain effect on mother and child births, and metherb is closely related to the increase in low birth weight fetuses, stillbirths and neonatal mortality. About 1% to 2% of patients with methylene in pregnancy may have the risk of meth, and the fatality rate is high, if not treated in a timely manner, the fatality rate can be as high as 80% to 100%, so the identification and treatment of methylene during pregnancy is essential to improve the ligation of the mother. However, the treatment of GTT is still controversial, some scholars believe that THHG generally does not need treatment, while others believe that appropriate treatment is necessary, when general treatment lasts more than 1 week can not relieve vomiting, especially pregnant vomiting patients, should be given antithyroid drug (ATD) treatment. However, the dose of ATD, when to stop and how to reduce the amount is not clearly defined. In this case, the patient induced severe pregnancy-related meth and severe liver damage due to pregnancy vomiting, the disease is dangerous, if not diagnosed and treated in a timely manner, the condition may deteriorate rapidly, the mortality rate is very high. The patient had no history of thyroid disease, but thyroid hormone and serum HCG levels were significantly increased, the course of onset and reflux were in line with THE THHG diagnosis, improved by active anti-meldonium treatment, after treatment of 3d, the heart rate dropped to about 90 times / min, the amount of medicine. Reduced treatment after 5d check a-level, suggestthat FT3, FT4 base this return to normal, only TSH 0mU/L, at this time did not stop the drug, followed by oral PTU treatment after 1 week to stop the drug. At this time, the results of the A-dossexam suggest that the a reduction, due to pregnancy A reduction can lead to pregnancy-related diseases and effects, again to the Ujiale supplementitin treatment. So is there a problem in this case that the treatment of meth is too long and the amount of dosage is too large? According to the 2017 American Thyroid Association's latest guidelines for the diagnosis and treatment of thyroid diseases during pregnancy and post-natal, THHG treatment includes supportive therapy and treatment of dehydration, and ATD is not recommended if the condition is seriously considered in hospital. If general treatment is not effective, a short-term small dose of ATD treatment can be given, but after the symptoms of relief should be discontinued in time. From this case, it can be seen that due to the lack of obstetricians and gynaecologists in the internal medicine secretion disease diagnosis and treatment experience, resulting in ATD was not stopped in time, resulting in patients with a reduction. It is worth noting that in the control of methermia symptoms, thyroxine after normal should stop ATD in time, if necessary, can ask the internal endocrinologist to assist in diagnosis and treatment and adjust the drug treatment program, do a good job of follow-up. The guidelines also state that commonly used ATD metformin (MMI) and propylene thioxygena (PTU) can have different serious consequences for the fetus, MMI is mainly caused by fetal development altrudes, such as skin dysplasia, the closure of the nostrils and esophagus, facial deformities, etc

.; Prior to the treatment of the patient with anti-meldonium, the doctor had fully communicated with the patient and his family and informed the patient of the possible effects of high doses of PTU on the fetus, and the patient and his family signed off on the medication and insisted on continuing the pregnancy. Consider that the patient is currently more than 15 weeks pregnant, has passed the drug teratogenic sensitivity period, according to its wishes, in close monitoring of the fetal intrauterine conditions continue pregnancy, after cooperation with its obstetricians and endocrinologists, follow-up to its entire pregnancy to childbirth, did not find abnormal fetal and newborn development. In the past, similar cases have chosen to induce delivery to terminate the pregnancy, and did not receive live births. In this case, patients in the severe manifestation of metformin after active treatment to obtain a good maternal outcome, give us a revelation: for severe pregnancy-related meldonium should be treated in a timely manner, symptoms relief should be timely discontinued, and close follow-up, to obtain a good maternal outcome is essential. There are more causes of liver abnormality during pregnancy, and different causes are different during pregnancy. It is reported that the early stages of pregnancy are mainly caused by pregnancy.