Percutaneous endoscopic gastrostomy with a jejunal port for severe hyperemesis gravidarum Peter M. Irving a , Richard J.S. Howell b and Ray G. Shidrawi a Hyperemesis gravidarum affects up to 2% of pregnancies and is characterized by severe nausea and vomiting persisting beyond the 14th week of gestation with weight loss, dehydration, electrolyte imbalance and ketonuria. We present the case of a woman with severe, refractory hyperemesis gravidarum in whom treatment with a percutaneous endoscopic gastrostomy with a jejunal extension allowed improvement of symptoms, reversal of maternal weight loss and the delivery of a healthy infant. Review of the literature reveals only one other paper describing this treatment. In all three cases successful outcomes for both mothers and children are described. We propose that percutaneous endoscopic gastrostomy with a jejunal extension is a safe, effective and relatively cheap intervention for severe, refractory hyperemesis gravidarum. Eur J Gastroenterol Hepatol 16:937–939 & 2004 Lippincott Williams & Wilkins European Journal of Gastroenterology & Hepatology 2004, 16:937–939 Keywords: enteral nutrition, hyperemesis gravidarum, gastrostomy Departments of a Medical and Surgical Gastroenterology and b Obstetrics, Homerton University Hospital, London E9 6SR, UK. Correspondence to Dr R.G. Shidrawi, Academic Department of Medical & Surgical Gastroenterology, Homerton University Hospital, Homerton Row, London E9 6SR, UK. Tel: +44 (0)20 8510 7473; fax: +44 (0)20 8510 7378; e-mail: ray.shidrawi@homerton.nhs.uk Received 23 September 2003 Accepted 28 April 2004 Introduction Hyperemesis gravidarum is a serious condition affecting up to 2% of pregnancies. Although anti-emetics control most cases of hyperemesis gravidarum, some have such severe symptoms that they require invasive procedures and nutritional support. Case report We present the case of a 32-year-old Somalian woman with recurrent severe refractory hyperemesis gravidarum and a poor past obstetric history in whom insertion of a double-lumen percutaneous endoscopic gastrostomy with a jejunal feeding extension (PEG(J)) allowed nutri- tional resuscitation and successful obstetric outcome. Her first pregnancy resulted in a miscarriage at 12 weeks gestation. Her second pregnancy required an emergency lower segment Caesarean section at 28 weeks gestation for hyperemesis gravidarum unresponsive to medication, with a successful outcome. Her third preg- nancy was complicated by hyperemesis gravidarum, biochemical thyrotoxicosis which responded to treat- ment with propylthiouracil, acute renal failure requiring admission to the intensive care unit, and a stillbirth at 24 weeks gestation. Her fourth pregnancy was termi- nated in the first trimester for relief of severe hyperem- esis gravidarum. She presented in her final index pregnancy with seizures and biochemical thyrotoxicosis (free thyroxine (fT4) 49.6 pmol/l (normal range 10.2– 24.5), thyroid stimulating hormone (TSH) , 0.03 IU/l (normal range, 0.4–4.0)) at 9 weeks gestation. There was no evidence of pre-eclampsia; she was normoten- sive and there was no proteinuria. Although some of the seizures were witnessed and described as grand mal seizures, others were thought to be atypical. Unfortu- nately, the patient failed to attend for an electroence- phalogram. The seizures were successfully treated, initially with intravenous benzodiazepines and pheny- toin, and subsequently with oral carbamezepine which was continued until term. It was withdrawn post- partum without seizure recurrence. Her hyperthyroid- ism, as in her previous pregnancy, was treated with propylthiouracil which rendered her euthyroid. This treatment was also discontinued post-partum without relapse. At 14 weeks gestation, she was readmitted with worsen- ing nausea and vomiting and a urinary tract infection. Investigations revealed hyponatraemia (Na þ 132 mmol/l (normal range 135–147)), hypokalaemia (K þ 2.9 (nor- mal range 3.4–4.9)), hypoalbuminaemia (albumin 31 g/ dl (normal range 38–50)) and a mildly raised aspartate transaminase level (151 U/l (normal range 5–35)). A mid-stream urine sample grew a coliform sensitive to cephalexin with which she was treated successfully. Anti-emetics tried unsuccessfully included prochlorper- azine, cyclizine, metoclopramide, ranitidine, prometha- zine, ondansetron and droperidol. Prednisolone was also given but failed to control her symptoms. By 16 weeks gestation, she had lost 29% of her body weight and had increasingly difficult venous access. Peripheral and central total parenteral nutrition (TPN), enteral nutrition and termination of pregnancy were Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Case report 937 0954-691X & 2004 Lippincott Williams & Wilkins