Transcript Cannabinoid Hyperemesis Syndrome in Pregnancy

Cannabinoid Hyperemesis Syndrome in Pregnancy
LM Manning MBBS BSc, SD Eckford FRCOG, FRCS (Ed)
Introduction
North Devon District Hospital, Barnstaple, Devon EX31 4JB
Cannabis is the most commonly used illicit drug in the
western world (1). Since 2004 a number of papers have
been published describing a cannabinoid hyperemesis
syndrome (CHS); a pattern of symptoms consisting of
recurrent nausea, vomiting and abdominal pain, in
association with chronic heavy cannabis use (2).
Compulsive bathing is a behaviour characteristically seen
amongst those suffering from this condition, hot water
providing relief of symptoms.
•Investigation results are shown in Figure 2.
•A presumed diagnosis of hyperemesis gravidarum
was made.
•Treatment with IV fluids and antiemetic medications
commenced.
•Self-discharged after 36 hours, no improvement in
symptoms evident.
Here we report on only the second published case of this
condition arising in pregnancy, with a view to increasing
awareness among obstetricians of this uncommon
disorder, which may occur in pregnancy and be mistaken
for other hyperemetic conditions of pregnancy.
Figure 3. Ultrasound of the
upper abdomen. Normal
appearances reported.
Subsequent antenatal course
•Symptom free during brief period of abstinence from
cannabis use.
•Poor engagement with drugs support worker and
antenatal clinic.
•Further admissions at 27/40, 31/40, 33/40, 34/40,
35/40 when cannabis use resumed.
•Repeat USS of abdomen and pelvis revealed
presence of gallstones but no evidence of cholecystitis.
•At 38+5 went into spontaneous labour and delivered a
live male infant without complication.
•Baby was admitted to our special care baby unit for 72
hours but no adverse signs were observed
Discussion
History of regular heavy cannabis use
Cyclical nausea &
vomiting
Compulsive
bathing in hot
water - provides
temporary relief
Relief on cessation of
cannabis use
Further admissions at 20/40, 20+2, 22/40, &
23/40:
Colicky abdominal
pain
Figure 1. Diagnostic criteria for CHS
Case Report
•Ongoing nausea and vomiting
•Colicky abdominal pain
•Repeated investigations inconclusive, USS upper
abdomen and renal tract unremarkable (figure 3).
•Symptoms remain resistant to medical therapies.
•Referral made to psychiatry team for assessment of
possible psychogenic disorder.
•Again chose to take discharge against medical advice
Background:
•History of regular heavy cannabis use since the age of
14 and previous excess alcohol consumption.
•Unplanned pregnancy, antenatal booking at 10/40
uneventful.
First presentation at 11/40
•“Morning sickness” for several weeks, intractable
vomiting for 24 hours.
•On examintion found to be pale, dry mucous
membranes and generalised mild abdominal
tenderness noted, normal vital signs.
Ketones +++, protein + (MSU Р no significant growth)
Mild leucocytosis, CRP<8, normal renal function, ALT
Serum Investigations
40, amylase normal
Pelvic ultrasound
Single viable intrauterine pregnancy, CRL = 11/40
•Requested frequent hot baths/showers during
admission, noted to provide temporary relief of
symptoms.
•History of current cannabis use, up to 2 grams per
day established.
•Diagnosis of cannabinoid hyperemesis syndrome
made.
•Referred to local Drugs Support Centre and
specialist drugs & alcohol midwife for support in
cessation of cannabis use.
•Follow-up with GP, antenatal clinic and drugs support
worker arranged.
A great deal of time and resources may be wasted on
unnecessary investigations and ineffective treatments,
when a detailed history regarding substance use and
identification of compulsive bathing behavior may be
more useful diagnostic indicators. In obstetric
populations patients may be les forth-coming in
volunteering information regarding illicit substance
misuse, making identification and management of CHS
more problematic.
The only established way of ending the symptoms of
CHS permanently is cessation of cannabis use. Case
studies have demonstrated that return to cannabis use
is almost universally accompanied by recurrence of
symptoms (5). The resistance of the hyperemesis to
standard antiemetic therapies is of concern in pregnant
cases where resulting dehydration and nutritional
deficiencies can have significant consequences on both
mother and baby. Intensive support from specialist
services in drug cessation is therefore essential.
Conclusions
With the increasing frequency of cannabis use CHS
may be seen more frequently
In pregnant cases CHS may easily be confused with
idiopathic hyperemesis of pregnancy and can result in
dehydration and nutritional deficiencies.
A thorough history regarding illicit substance use and
relief of symptoms with hot water bathing is required to
make the diagnosis.
Fifth hospital admission at 23+5/40
•19 year old primigravida, no sginificant past medical or
surgical history
Urinalysis
The recent emergence of Cannabinoid hyperemesis
syndrome (CHS) as a manifestation of chronic heavy
cannabis use means that knowledge of the precise
characteristics and pathophysiology underlying this
condition is incomplete. Based upon a number of case
reports describing CHS, a set of diagnostic and
supporting features have been proposed (3). The case
described here demonstrates these features in the
context of a pregnant patient.
In the context of pregnancy we have demonstrated
some of the obstacles in the identification and treatment
of CHS. The condition is rare and not well known
amongst many physicians, meaning that it is easy to
overlook in favour of more common conditions, in this
case for example, hyperemesis gravidarium.
Symptoms do not respond to conventional analgesic
and antiemetic treatments.
Cessation of cannabis use puts an end to symptoms
Figure 4. Effects of the cannabinoid receptors on the digestive system. Taken from
Gut 2008;57:1140-1155 doi:10.1136/gut.2008.148791
Attempts to explain the paradoxical effect of cannabis
seen in CHS fall into two main theories.
The first of these implies a dose-dependent build up of
cannabinoids and consequent effects of cannabinoid
toxicity, whereby the antiemetic actions are overridden
by other effects on the GI tract.
Immediate referral to drugs support services should
be made for assistance in withdrawal from cannabis
use.
More research is required to establish the definite
pathophysiology, diagnostic tests and effective
treatments for CHS.
References
1. The
Figure 2 (left).
Investigation results on
first admission. Raised
ALT on admission
attributed to history of
alcohol abuse, fell to
within normal limits on
later tests.
The second theory suggests that symptoms arise due
to the effects of cannabis on the cannabinoid
receptors in the brain, particularly the hypothalamus.
These are known to play a role in thermoregulation
and in the digestive tract (4). Their function in the
control of body temperature may explain the
temporary relief of symptoms from bathing in warm
water seen in subjects with CHS.
NHS Information Centre, Lifestyles Statistics. Statistics on Drug Misuse: England 2010.
Jan 2011; www.ic.nhs.uk
2. Allen JH, de Moore GM, Heddle R, et al. Cannabinoid hyperemesis: cyclical hyperemesis in
association with chronic cannabis abuse. Gut 2004;53:1566 ñ70.
3. Wallace EA, Andrews SE, Garmany CL, Jelley MJ, et al. Cannabinoid hyperemesis
syndrome: literature review and proposed diagnosis and treatment algorithm. South Med
J, Sept 2011; 104(9):659-64.
4. Chang, Y.H. & Windish, D.M. (2009). Cannabinoid hyperemesis relieved by compulsive
bathing. Mayo Clinic Proceedings 84, 76-78.
5. Allen, J.H., De Moore, G.M., Heddle, R., & Twartz, J.C. (2004). Cannabinoid hyperemesis:
Cyclical hyperemesis in associationwith chronic cannabis abuse. Gut 53, 1566-1570.
6. Simonetto, D.A., Oxentenko, A.S., Herman, M.L., & Szostek, J.H. (2012). Cannabinoid
hyperemesis: A case series of 98 patients. Mayo Clinic Proceedings 87, 114-119.