B.

Sc DEGREE COURSE IN NURSING

(BASIC)
Midwifery And Obstetrical Nursing

UNIT-VII High Risk Pregnancy

Hyperemesis Gravidarum

DR. LATHA VENKATESAN,

PRINCIPAL
 INTRODUCTION

 Pregnancy is a unique, exciting and often joyous time

in a woman's life.

 Hormones in Pregnancy plays a major role in

disturbing the harmony.

 When the joy of creating life turns into a struggle

for survival and hope.
 LEARNING OBJECTIVES
At the end of the session the students will be
able to
Define hyper emesis gravidarum.
enlist the incidence & Risk Factors
describe the pathogenesis
Enumerate the clinical manifestations
Discuss in details about the Management including
Nursing management.
 OVERVIEW

• Introduction • Medical Management

• Definition – Nausea Alone
• Etiology – Dehydration without
Vomiting
• Pathology
– Dehydration with
• Clinical Manifestation
Vomiting
• Difference between
• Complications
Hyperemesis
Gravidarum and – Mother
vomiting – Fetus
• Investigations • Nursing Management
 DEFINITION
Hyperemesis Gravidarum is defined as protracted
Nausea and Vomiting of Pregnancy with the triad
of -

 > 5% pre pregnancy weight loss

 Dehydration and

 Electrolyte imbalance
 INCIDENCE
• The incidence of women with severe symptoms
vary from 0.3 to 3 % of pregnancies.

• In a prospective study published in 2016 which

included 800 patients, 57 % reported nausea and
27 % reported both nausea and vomiting by 8
weeks of gestation
 RISK FACTORS
Multiple gestation

Hydatidiform mole
Non-use of multivitamins before 6 weeks
of gestation or during the
peri-conceptional period
Heartburn and
acid reflux
Nulligravida
Non-pregnant women who experience nausea
and vomiting related to oestrogen-based
medication
 Continued.....

Motion sickness

Migraine

Female fetus

Family history of
Hyperemesis Gravidarum
Smoking and Alcohol are
protective factors.
 PATHOGENESIS

Psychological Hormonal
Factors Changes

PATHOGENESIS
Abnormal
H.Pylori Gastrointestinal
Motility
 PSYCHOLOGICAL FACTORS

Conversion
or
Somatization
Disorder
PSYCHOLOGICAL
FACTORS

Response to
Stress
 HORMONES
• Estrogen

• Progesterone

• Beta hCG

 These hormones relax smooth muscle and thus

slow gastrointestinal transit time and may alter
gastric emptying.

 Relax the lower oesophageal sphincter

PATHOLOGY
 CHANGES

• Metabolic changes

• Biochemical changes

• Circulatory changes
 BIO CHEMICAL CHANGES

VOMITTING

LOSS OF WATER HEPATIC NUTRITIONAL

AND SALTS DYSFUNCTION DISTURBANCES

Dehydration Keto acidosis Hypoglycemia

Hypoglycemia Elevated blood Hypoproteinurea
Hypoglycemia Nitrogen and uric acid Hypovitaminosis
 METABOLIC CHANGES
REDUCED INTAKE OF FOOD

Depletion of
Increased tissue protein
glycogen stores
metabolism
Mobilization of fat
stores Increased non protein
nitrogen
Accumulation of
ketone bodies Breath -
Ketone odour

Excretion through Urine - Ketone

+ ve
DIFFERENCE BETWEEN
 ICE BREAKER

• In which Country, CLARA- an Artificial Intelligence

Robot, was introduced to self check COVID 19 ?

A. China

B. Russia

C. Italy

D. United States
 CLINICAL MANIFESTATION
Nausea and vomiting
Weight loss (> 5% of pre
pregnant weight or >3 kg)
Ketonuria

Orthostatic hypotension
Physical signs of
dehydration
Ptyalism (Hyper salivation)
 LEVEL OF VOMITING

S.No LEVEL SIGNS AND SYMPTOMS

1. Mild Loss of weight and dehydration

2. Moderate Dehydration and circulatory

changes

3. Severe Biochemical changes with

complications
 FEATURES OF DEHYDRATION AND
KETO ACIDOSIS
•Dry coated tongue

• Sunken eyes

• Acetone smell

• Tachycardia

•Hypotension

• Hyperthermia

•Jaundice
 INVESTIGATIONS

• Electrolyte Imbalance: hypokalemia,

hypochloremia, hypomagnesaemia- If Mg2+ <

0.8 mEq/L

• Resistance to parathormone

• Hypocalcemia

• Hematocrit: due to hemoconcentration

 INVESTIGATIONS
• Liver Function Test : ALT & AST (in 50%): bilirubin
(do not rise > 4)

• Serum amylase and lipase (10 to 15 %)

• Thyroid Function: Mild hyperthyroidism due to

raise B – hCG: Transient

 Biochemical Hyperthyroidism is defined as a free

T4 index higher than the upper range of normal,
or a thyroid-stimulating hormone (TSH) level less
than 0.4 mU/L.
MANAGEMENT
 MANAGEMENT
• Nausea & Vomiting of Pregnancy (NVP) should
be treated according to the severity

 Nausea alone

Vomiting without dehydration

Vomiting with dehydration.

MANAGEMENT OF NAUSEA ALONE
• small meals every 2 hrs
Diet changes : • avoid triggers
• add ginger to diet
• 10 to 25 mg orally every 6 - 8
Pyridoxine: hours; the maximum 200 mg/day.

Doxylamine • each tablet contains doxylamine

succinate and 10 mg and pyridoxine 10 mg, 2 – 4
pyridoxine: tabs/day

Acupuncture or • P6 acupressure wristbands

acupressure –

Hypnosis
VOMITING WITHOUT DEHYDRATION

Antihistaminic (H1 • Diphenhydramine,

antagonists): • Meclizine, Dimenhydrinate

• Metoclopramide, Promethazine,
Dopamine Antagonist:
• Prochlorperazine

• Ondansetron, granisetron,
Serotonin Antagonist:
• dolasetron

• antacids, H2 blockers, proton pumpinhibitors

Acid-reducing agents:
 VOMITING WITH DEHYDRATION

IV Fluid &
Vitamins Diet
Electrolyte Antiemetics
& Mineral therapy
Correction
 IV REHYDRATION &
ELECTROLYTE CORRECTION
Serum K – 3.0- 3.4
Dextrose 5% in
-2L IV RL Infused mEq/L. Treatment
0.45% saline with
over 3 to 5 hrs is usually started
20 mEq KCl at 150
- Isotonic Saline if ml /hr to patients with 10 to

serum Na levels > with normal K 20mEq/L of K+

120mEq/L given 2 times per
Levels
day
 VITAMINS AND MINERALS
THIAMINE:
FOLIC ACID:
100mg IV for 3
0.6mg daily
days
VITAMIN B6:
MVI: 10 ml with
25mg in 1 litre
fluid daily IV Fluid

MAGNESIUM : 2 g (16 mEq)

magnesium sulfate infused as a
10 percent solution over 10 to 20
minutes, followed by 1 g (8 mEq)
in 100 mL of fluid per hour.z
 REFRACTORY CASES
CORTICOSTEROIDS:
• Methylprednisolone (16 mg) IV/ 8 hours for
48 to 72 hours

• Hydrocortisone 100mg IV BD for 2 – 3

days

• After IV, Prednisolone 40mg for 1 day, 20

mg for 3 days, 5mg for 7 days

• Parenteral Nutrition : continued till the

women is able to take 1000kcal/day per
oral
 ICE BREAKER

• “MO JEEBAN” (My Life) is an initiative of which

Indian state to advise people to stay indoors amid
the COVID 19 pandemic?

A. West Bengal

B. Odisha

C. Telangana

D. Bihar
 ROLE OF MIDWIFE
• Provide emotional support – Listen without judgment

• Provide practical support – Help with household chores

and childcare, transportation to medical appointments

• Provide financial support – The more severe HG is, the

higher the medical care costs involve

• Be an advocate –to find practical ways that you can help

those who may struggle with it in the future
COMPLICATIONS FOR THE MOTHER
• Debilitating fatigue – inability to work or take
care of their families

• Malnutrition and dehydration

• Frequent vomiting of blood or bile

Complications for the Mother
• Neurologic complications —
– Wernicke’s encephalopathy due to thiamine
deficiency
– Pontine myelinolysis
– Peripheral neuritis
– Korsakoff’s psychosis.
 Complications- Mother
• Stress ulcer in stomach
• Esophageal tear (Mallory-Weiss syndrome)
• Jaundice
• Convulsions
• Coma
• Renal failure
 COMPLICATIONS FOR THE BABY

• Pre-term labor

• Low birth weight

• Developmental delays

• Congenital heart disease

NURSING MANAGEMENT
 REDUCE NAUSEA AND VOMITING

• Ensure medication is provided on time to enable

stable blood levels of anti-emetics.

• Reduce sensory stimulation by providing a side

room away from ‘smelly areas’, if possible, and

ensuring staff are quiet and free from perfume

whilst providing care.

 Continued....
• Provide snacks when required where possible.

• Review effectiveness of medication and

interventions daily or as required.
 REDUCE PRESENCE OF KETONES
• Provide IV fluids as per prescription.

• Warm IV fluids to 37 degrees - This is to reduce

calorific loss from cold IV fluid administration.

• Encourage oral fluids when they can be tolerated.

• Monitor ketones as per hospital policy or three times

per day.
 PREVENT FURTHER WEIGHT LOSS

• Encourage oral food intake where possible.

• Provide information on fortifying food and
fluid.
• Ensure medication regime is controlling
vomiting and nutrient loss. Adjust timings to
maximise ability to eat at mealtimes.
• Provide snacks as and when feels able to eat..
 PROVIDE A COMFORTABLE ENVIRONMENT
• Provide a side room where possible to reduce
sensory stimulation

• Ensure staff are free from perfumes or cigarette

smoke.

• Provide pressure relieving mattress.

• Ensure vomit bowls and urine samples are removed

promptly and adequate empty receptacles provided
 CONCLUSION

• Nausea and vomiting in pregnancy is the most

common indication for hospitalization in 1st
trimester.

• Diet changes, avoidance of the trigger and

Doxylamine + Pyridoxine is the 1st line of therapy

• PUQ> 13 with dehydration should be treated with IV

rehydration, electrolyte correction and ondansetron.
 REFERENCES

D.C. Dutta’s (2018),” Textbook Of Obstetrics,

Hiralal Kona; 9th edition”, Jaypee.
Lowdermilk (2012),” Maternity and Womens
Health Care; 10th Edition”,. Perry Cashion. Alden.
Susan Scott Ricci (2006),” Maternity And
Paediatric Nursing “, Lippincot Williams and
Wilkins.
 Continued.....

 https://www.slideshare.net>hyper emeses
gravidarum.

 www.yourarticlelibrary.com>family
 ASSIGNMENT

• Write 6 interventions for Fluid volume deficit

related to vomiting during pregnancy