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Acth in the treatment of hyperemesis gravidarum
AtWE
IN TEE l’REA!PMENT
OF HYP EiREXZWS
M. P. VANDEN BOSCH, H.D.,
N
DENVE-R,
GRAVIDAIWM SOLO.
DTWITIWI’ANDING a host of therapeutic agents recommended for tile treatment of sC\ere vomiting of pregnancy, it is still not uncommon to encounter patients in whom the> most intensive treatment by all available means leaves much to be desired. Essentially this is the result of a lack of underst:mdiug of tile cause. To suggest yet another method of treatment requires considerable temerity, cxccpt for the fact that in this single case relief was so dramatic and complete, and associated findings were so changed as to suggest a causal relationship between hypoadrenalism and vomiting of pregnancy. M. E., a 25year-old white housewife, was first seen .July 9, 1930, at which time she stated that her last menstrual period had begun on Nareh 5. 1950, and that on March 7, 1950, she ha11 begun to feel nauseated and that ever since that date she had vomited almost everything taken by month. Tn three months she had lost seventeen pounds. She also cdomplained of severe frontal heallaehe and darkening of the skin. During the week preceding her first visit she had been hospitalized, heavily sedated, and fed intravenously, but upon tlis~harge began vomiting as severely as beEore. She had been given a variety elf peda,tives and I)ramamine but was unable to retain them. The past history revealed an operation for “severe infection in the right tube and ovary’! one year before which failed to relieve x chronic pnin in the right lower abdomen, an;1 appendectomy in 1939. There had been no other serious illness. She had been married eight years and her first pregnancy had terminated in I948 at term with severe nausea :md vomiting t.hroughout, requiring almost five months of hospitalization, and with a loss of thirty pouncls, twenty of which had been regained in the interval between pregnancies. Her menses were nlrvays irregular, of four days’ duration, without pain. Miscellaneous symptoms included blurring of vision for three months, burning on urination for three ~ls,ys. She stated that she was very happily married, had no worries, loved children, but felt that sexual relations had never been very satisfactory. Examination initially revealed a thin, severely natneatetl patient. She weighed 112 pounds with clot.hing. The skin was uniformly dark, rsposed rind unexposed areas being equally pigmentrll. There nas a small palpable nodule in the right lobe of the thyroid. Blood pressure was 96/70. The abdomen showed MeBurney and right rectus surgical scars and a She was given 109’mg. each of thiamine uterine tumor extending to just below the umbilicus. and pyridoxine intravenously and 7 mg. desosycorticoxterone subcutaneously daily for five thtys with slight relief. On July 17, her weiglrt was 11.4 am1 blood pressure 94/50. On July 27, she complained of very severe frontal headache, continued severe nausea, and extreme weakness, and weight and blood pressure were 116”/ and S(i/54, respectively. She has given I5 C.C. 1 per cent procaine intravenously, following which headache and nausea were relieved for one hour and blood pressure rose to lOS/SO. On July 15, glucose tolerance test revealed :I flat curve with fasting value of 94 mg. per cent, rising to 102 mg. per cent 30 minutes after oral admini&ration of sugar, and falling t,o the previous level at 60: 120, and 180 minutes. The patient \vad admitt,e,l to Portor Hospital July 31 at ~vbich time she weighed 1151/?. Hllc was given ACTH, 10 mg. every six hours for two days, then 20 mg. every 6 hours for three ddys. On the third day all nausea, vomiting, and headache subsided and on August (i she was disehargeli. ht that time she stated that she felt completely well and her weight was 120 pounds. Blood pressure rose slowly to 116/SO on the day of discharge. On August 11, five days after ACTH was discontinued, nausea returnelI? blood pressure was 114/70, and she was given 20 mg. ACTH. On August 18, nausea recurred and 20 mg. ACTH were given t 1111next. (lay. Thereafter, A4CTH was given irregularly in tho same dosage until September 456
Volume 62 Number 2
ACTH
IN
TREATMENT
OF
HYPEREMESIS
GRAVIDARUM
457
6, when it was discontinued. During this period vomiting was controlled but some nausea persisted, relieved for about two days after administration of ACTH. After treatment was discontinued some nausea without vomiting persisted until delivery on December 9 of a normal female infant weighing six pounds. At the time of delivery the patient weighed 136% pounds and blood pressure was 100/60. A single ease of rerurrent severe vomiting of pregnancy appeared to benefit dramatically from administrat.ion of ACTH, when other means of treatment had failed. This is obviously insufficient evidence upon which to base any- conclusion. It is interesting however, to speculate that hyperemesis gravidarum may be caused by a temporary depression of adrenal function, and it suggests that more careful study of a larger series with adequate laboratory data is indicated. 2090 SOUTH
DOWNINQ
STREET
IN TEE l’REA!PMENT
OF HYP EiREXZWS
M. P. VANDEN BOSCH, H.D.,
N
DENVE-R,
GRAVIDAIWM SOLO.
DTWITIWI’ANDING a host of therapeutic agents recommended for tile treatment of sC\ere vomiting of pregnancy, it is still not uncommon to encounter patients in whom the> most intensive treatment by all available means leaves much to be desired. Essentially this is the result of a lack of underst:mdiug of tile cause. To suggest yet another method of treatment requires considerable temerity, cxccpt for the fact that in this single case relief was so dramatic and complete, and associated findings were so changed as to suggest a causal relationship between hypoadrenalism and vomiting of pregnancy. M. E., a 25year-old white housewife, was first seen .July 9, 1930, at which time she stated that her last menstrual period had begun on Nareh 5. 1950, and that on March 7, 1950, she ha11 begun to feel nauseated and that ever since that date she had vomited almost everything taken by month. Tn three months she had lost seventeen pounds. She also cdomplained of severe frontal heallaehe and darkening of the skin. During the week preceding her first visit she had been hospitalized, heavily sedated, and fed intravenously, but upon tlis~harge began vomiting as severely as beEore. She had been given a variety elf peda,tives and I)ramamine but was unable to retain them. The past history revealed an operation for “severe infection in the right tube and ovary’! one year before which failed to relieve x chronic pnin in the right lower abdomen, an;1 appendectomy in 1939. There had been no other serious illness. She had been married eight years and her first pregnancy had terminated in I948 at term with severe nausea :md vomiting t.hroughout, requiring almost five months of hospitalization, and with a loss of thirty pouncls, twenty of which had been regained in the interval between pregnancies. Her menses were nlrvays irregular, of four days’ duration, without pain. Miscellaneous symptoms included blurring of vision for three months, burning on urination for three ~ls,ys. She stated that she was very happily married, had no worries, loved children, but felt that sexual relations had never been very satisfactory. Examination initially revealed a thin, severely natneatetl patient. She weighed 112 pounds with clot.hing. The skin was uniformly dark, rsposed rind unexposed areas being equally pigmentrll. There nas a small palpable nodule in the right lobe of the thyroid. Blood pressure was 96/70. The abdomen showed MeBurney and right rectus surgical scars and a She was given 109’mg. each of thiamine uterine tumor extending to just below the umbilicus. and pyridoxine intravenously and 7 mg. desosycorticoxterone subcutaneously daily for five thtys with slight relief. On July 17, her weiglrt was 11.4 am1 blood pressure 94/50. On July 27, she complained of very severe frontal headache, continued severe nausea, and extreme weakness, and weight and blood pressure were 116”/ and S(i/54, respectively. She has given I5 C.C. 1 per cent procaine intravenously, following which headache and nausea were relieved for one hour and blood pressure rose to lOS/SO. On July 15, glucose tolerance test revealed :I flat curve with fasting value of 94 mg. per cent, rising to 102 mg. per cent 30 minutes after oral admini&ration of sugar, and falling t,o the previous level at 60: 120, and 180 minutes. The patient \vad admitt,e,l to Portor Hospital July 31 at ~vbich time she weighed 1151/?. Hllc was given ACTH, 10 mg. every six hours for two days, then 20 mg. every 6 hours for three ddys. On the third day all nausea, vomiting, and headache subsided and on August (i she was disehargeli. ht that time she stated that she felt completely well and her weight was 120 pounds. Blood pressure rose slowly to 116/SO on the day of discharge. On August 11, five days after ACTH was discontinued, nausea returnelI? blood pressure was 114/70, and she was given 20 mg. ACTH. On August 18, nausea recurred and 20 mg. ACTH were given t 1111next. (lay. Thereafter, A4CTH was given irregularly in tho same dosage until September 456
Volume 62 Number 2
ACTH
IN
TREATMENT
OF
HYPEREMESIS
GRAVIDARUM
457
6, when it was discontinued. During this period vomiting was controlled but some nausea persisted, relieved for about two days after administration of ACTH. After treatment was discontinued some nausea without vomiting persisted until delivery on December 9 of a normal female infant weighing six pounds. At the time of delivery the patient weighed 136% pounds and blood pressure was 100/60. A single ease of rerurrent severe vomiting of pregnancy appeared to benefit dramatically from administrat.ion of ACTH, when other means of treatment had failed. This is obviously insufficient evidence upon which to base any- conclusion. It is interesting however, to speculate that hyperemesis gravidarum may be caused by a temporary depression of adrenal function, and it suggests that more careful study of a larger series with adequate laboratory data is indicated. 2090 SOUTH
DOWNINQ
STREET