Journal of Midwifery, Women Health And Gynaecological Nursing

Volume 1 Issue 2

The Impact of Persistent Vomiting Among the Women in Early

Pregnancy
A.Alageswari1, Prof. Dr. Manju Bala Dash2,*
1
M.Sc Nursing, Department of Obstetrics and Gynaecology, Mother Theresa Post Graduate &
Research Institute of Health Sciences, Puducherry, India
2
HOD, Department of OBG, Mother Theresa Post Graduate & Research Institute Of Health Sciences,
Puducherry, India
*Email: manju_narayan@rediffmail.com
DOI: http://doi.org/10.5281/zenodo.2584955

Abstract
Hyperemesis Gravidarum is the serious and life-threatening conditions. It is prolonged upto
16 weeks of gestation. 70% of pregnant women commonly affected with nausea and 60% of
pregnant women with vomiting. The exact incidence of persistent or hyperemesis gravidarum
was not known, but it was ranged from 3 in 1000 to 2 in 1000 pregnancies. The causes of
hyperemesis during the pregnancy is still unclear or uncertain or unknown. Particularly,
increased levels of human chorionic gonadotropin (hCG), increased free thyroxin (FT4), and
decreased levels of thyroid stimulating hormone (TSH) these may induce the excessive
vomiting during the pregnancy. Usually hyperemesis gravidarum associated with the
protracted nausea and vomiting, weight loss more than 5kg of pre-pregnant weight,
dehydration and electrolyte imbalances. The treatment modalities should be the
pharmacological and non-pharmacological methods. Based on the severity of the conditions
the treatments modalities are getting vary. As the midwife, should provide emotional support
and educate the mother about the dietary and life style modifications to prevent the further
complications.

Keywords: Hyperemesis Gravidarum, Causes and risk factors and Management

INTRODUCTION mothers have no symptoms of the nausea

Hyperemesis Gravidarum is also known as
pernicious or persistent vomiting, severe
morning sickness and uncontrollable
vomiting during early pregnancy. The
meaning of Hyperemesis Gravidarum is
“Hyper” – over, “Emesis” – vomiting and
“Gravidarum” – pregnancy. It is prolonged
upto 16 weeks of gestation. Severe
vomiting causes the significant
dehydration, usually with the electrolyte
abnormalities, ketosis or ketonuria and
there will be the weight loss within the
first 12 weeks of pregnancy [1]. Nausea
and vomiting is most prevalent during
early pregnancy. It can be affected upto
80% of all pregnant mothers [2]. It
increased between 8 and 12 weeks of
gestation and declines by usually at the
beginning of the 2nd trimester. After 20
weeks of gestations nearly 90% of the
and vomiting [3]. Hyperemesis
Gravidarum is the severe form of the
nausea and vomiting that affects the 0.3 –
3.6% of pregnant mothers [4]
Nausea and vomiting’s timing, frequency
and duration may differ between the
mothers and severe cases; hyperemesis
gravidarum was categorized by the severe
form of nausea and vomiting and this can
be seen in 1-3% of pregnant women with
nausea and vomiting that lead to
hospitalization, malnutrition, weight loss,
vitamin deficiencies and low birth weights
[5]. 70% of pregnant women commonly
affected with nausea and 60% of pregnant
women with vomiting. The exact
incidence of persistent or hyperemesis
gravidarum was not known, but it was
ranged from 3 in 1000 to 2 in 1000

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 Journal of Midwifery, Women Health And Gynaecological Nursing
pregnancies. Yet, many of the researchers
reported that an incidence of 1 in 200 [6].
Causes and Risk factors
The causes of hyperemesis during the
pregnancy is still unclear or uncertain or
unknown. But there was certain theories
explain the causes of hyperemesis
gravidarum.
Hormonal Theories: Due to the
consequences of hormonal changes there will
be excessive nausea and vomiting during the
pregnancy. Particularly, increased levels of
human chorionic gonadotropin (hCG),
increased free thyroxin (FT4), and decreased
levels of thyroid stimulating hormone (TSH)
these may induce the excessive vomiting
during the pregnancy [7]. Not only the hCG,
other endocrine factors also may involve such
as changing of oestrogen and progesterone
levels have been responsible in the
occurrence of hyperemesis gravidarum
[2,3,7]
Psychogenic theories: it maybe exacerbates
when nausea starts at once. It was decreased
when transfer the mother from home to
Figure 1: Mechanism of vomiting
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Volume 1 Issue 2
hospital, in that neurogenic component acts a
protagonist.
Dietetic Deficiency: Possibly starvation leads
to low carbohydrate especially occurs at night
(After the dinner, the mother did not take
food till morning). Allergic or immunological
basis and reduced the gastric motility is
identified to be the causes of nausea [1].
Risk factors have not definitely been
recognized. Some researchers like Zhang J &
Cai WW (1991), Kallen B, et al. 2003 and
Davis M, 2004 highlighted that occurrence of
nausea and vomiting was associated with
older maternal age, working women,
smoking habits and gender of infants and also
the women with hypertension, liver and renal
diseases, use of vitamins and induced stress.
Louik C, et al. 2006 explained that
multiparity and having multiple miscarriages
also been found that the increase risk for
nausea and vomiting and the long duration of
symptoms were more common in the young
age mother. As per the prospective pregnancy
cohort study, analysed the possible risk
factors depend on the severity, time of onset
and duration [8].
 Journal of Midwifery, Women Health And Gynaecological Nursing
Mechanism of Vomiting
Normally Nausea and Vomiting may be an
evolutionary protective mechanism. It may
protect the pregnant woman and her
embryo from harmful substances in food,
such as pathogenic microorganisms in
meat products and toxins in plants, with
the effect being maximal during
embryogenesis (the most vulnerable period
of pregnancy) (Fig.1). This was supported
by the studies which was showed that
Flow Chart 1: Pathophysiological Changes
Signs and symptoms
The following symptoms are occurred
when hyperemesis gravidarum severe or
not treated properly. Loss of body weight
upto 10-40 % or more of pre-pregnant
weight, Dehydration leads to ketosis and
constipation, Nutritional disorders like
Vit – B1 (thiamine) deficiency, Vit – B6
(Pyridoxine) deficiency and Vit – B12
(Cobalamin) deficiency may occurred,
Metabolic imbalances like metabolic
ketoacidosis and thyrotoxicosis may
occurred, Physiological and emotional
stress due to pregnancy, Inability to do
the daily physical activities. Symptoms
can be worsened because of hunger,
fatigue, prenatal vitamins (particularly
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Volume 1 Issue 2
women who had nausea and vomiting
were less likely to have miscarriages, birth
defects and stillbirth. And also protect the
mother by depressing the maternal cell-
mediated immune system in pregnancy
[9].
Pathophysiology
The probable pathophysiological changes
are described in the following (Flow
Diagram. 1 & 2) [10].
Iron) and dietary pattern. Some women
very profound to smell in the
surroundings; only particular odour can
stimulate the symptoms called as
hyperolfaction. Ptyalism also can be felt
by the pregnant women those who are
suffered with persistent vomiting [10].
There will be the manifestations of
Wernicke’s encephalopathy as
drowsiness, nystagmus and loss of vision
then coma. Some women may have the
manifestations of starvation and
dehydration: loss of weight upto 5kg,
sunken eyes, dry tongue, teeth covered
with sores, acetone breath smell and late
slight jaundice, rapid or weak pulse and
low temperature [1, 10].
 Journal of Midwifery, Women Health And Gynaecological Nursing
Volume 1 Issue 2

Flow chart 2: Pathophysiology of Nausea and vomiting

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 Journal of Midwifery, Women Health And Gynaecological Nursing
These conditions can be identified and
diagnosed with detailed history collection,
complete physical examination and blood
investigations. Usually hyperemesis
gravidarum associated with the protracted
nausea and vomiting, weight loss more
Table 1: Pregnancy – Unique Quantification of Emesis (PUQE) Score (RCOG Guideline)
Management
If the mother has the severe form of
nausea and vomiting to be treated in
hospitals. In general, based on the severity
of the symptoms the mother to be
categorized in to three groups and
treatment also vary accordingly. Mild with
no sign of dehydration can be managed in
primary care centre. Moderate with sign of
mild dehydration needed the intravenous
therapy and if it is severe needed the
hospitalization for further management.
The treatment modalities should be the
pharmacological and non-pharmacological
methods. In pharmacological methods,
fluid replacement therapy either normal
saline or ringer lactate are used to prevent
the risk of dehydration and Wernicke’s
encephalopathy. Antiemetics have been
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Volume 1 Issue 2
than 5kg of pre-pregnant weight,
dehydration and electrolyte imbalances. To
describe the severity of the nausea and
vomiting, the Pregnancy – Unique
Quantification of Emesis (PUQE) score
can be used [4]. (Table.1)
advised when the mother complaining the
severe vomiting. (Table.2). Vitamins also
reduce the risk of the Wernicke’s
encephalopathy. So, along with the
antiemetics, pyridoxine and folic acid to be
considered as a drug of choice especially
during the first trimester [4, 11-14]. In
non-pharmacology method, many studies
have been supported with dietary and life
style modifications, promoting the
emotional support will reduce the anxiety
and some studies showed that giving
pressure on inside the wrist will control the
nausea and vomiting, furthermore studies
explain that ginger has the effect on
chemoreceptor trigger zone to reduce
nausea and vomiting [4, 12-17]. Based on
the hospital settings and the available
facility the treatment modalities are getting
vary. (Flow chart.1).
 Journal of Midwifery, Women Health And Gynaecological Nursing
Volume 1 Issue 2

Flow Chart 3: Treatment modalities of Nausea and vomiting.(RCOG Guidelines, 2016)

Table 2: Recommended Antiemetic therapies and dosage.(RCOG Guidelines, 2016)

CONCLUSION identifying the signs of dehydration,

Hyperemesis gravidarum is the serious and
life-threatening problems especially in the
first trimester. It is occurred due to the
hormonal, genetic factors, dietary
modifications and psychological factors. It is
treatable when it was diagnosed early by
electrolyte imbalance. It can be treated with
either pharmacological or non-
pharmacological measures based on the
severity of the condition and as per the
hospital protocols. Health education given to
the mothers to avoid further complications.

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 Journal of Midwifery, Women Health And Gynaecological Nursing
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