Hyperemesis

Gravidarum

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Hyperemesis Gravidarum

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Hyperemesis Gravidarum…

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Hyperemesis Gravidarum…

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 Hyperemesis Gravidarum…

 Unremitting nausea and vomiting that persists after the first

trimester.
 Usually occurs with the first pregnancy and commonly affects
pregnant women with conditions, such as hydatidiform mole or
multiple pregnancy, that produce a high level of human
chorionic gonadotropin.
 This disorder occurs among Blacks in about 7 in 1,000
pregnancies and among Whites in about 16 in 1,000
pregnancies.

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Precipitating Factors
 Pancreatitis Biliary tract disease
 Dec. secretion of free HCl in the stomach
 Dec. gastric motility
 Drug toxicity
 Inflammatory obstructive bowel disease
 Vitamin deficiency (B6)
 Psychological factors (neurosis) Predisposing
Factors:
 Multiple pregnancies Heredity Sex: Female
Race: White

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Clinical manifestation
 Clinical diagnosis is based on
 the history and
 physical findings.
 A history of intractable vomiting and
inability to retain food and fluid is usually
elicited.
 Physical findings of weight loss, dry and
coated tongue, and decreased skin turgor
are very suggestive.

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Wernicke encephalopathy from thiamine
deficiency is accompanied by signs of
central nervous system involvement,
including confusion, visual symptoms,
ataxia, and nystagmus.
 vitamin K deficiency coagulopathy with
epitasis

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Management
 vitamin B6 or vitamin B6 plus doxylamine
is safe and effective and should be
considered first-line pharmacotherapy
 Thiamine, 100 mg, is added to the first
liter. Intravenous fluids are given until
vomiting is controlled.
 Antiemetic such as promethazine,
prochlorperazine, chlorpromazine, or
metoclopramide are given parenterally.

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Nursing care

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Nursing care

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AMNIOTIC FLUID
DISORDER
AMNIOTIC FLUID
 Amniotic fluid is a maximum of 800ml at 28
wks of gestation
 It it is maintained till close term and becomes
500 ml at 40 wks
 Normally ranges 500 to 1000 ml
 Balance is:
 kidney and lung fluid production
 swallowing
 Membrane and placenta absorbition
Amniotic fluid…

 Disterbance is any chamge in amniotic fluid volume

that can be:

Excess than normal (Pollyhdraminios)

Less than normal (Oligohydraminios)

 Technique of AFI

 Amniotic fluid index is done by Ultrasound

Uterus is divided in 4 quadrants
Measured by cm on 4 area (pocket)
Transducer in vertical plane
Sum of max depth excluding cord & limbs
Less than 5 cm is oligohydraminios
Greater than 25 cm is pollyhydraminios
Oligohydraminos

 AMNIOTIC FLUID VOLUME < 5th percentile for GA

 AMNIOTIC FLUID INDEX < 5 cm

 SINGLE VERTICAL POCKET < 2 cm

 Amniotic fluid volume of less than 500 ml at 32-36

weeks’ gestation
 Oligohydraminos….
 It is 40 fold increase in prenatal mortality

 Associated with congenital anomalies and growth

retardation

 Lack of cushin and umblical cord compression

 Ethology
1. Decreased production or increased
absorption
2. Utero-placental insufficiency
3. Congenital anomalies
4. Renal agenesis
5. Polycystic kidney disease(obstruction of
GUS)
6. Rupture of membrane
Diagnosis
 Ultrasound
 Single vertical pocket less than 1 cm
 AFI < 5 cm
 Fundas height less than gestational age
 Fetal heart rate is clear
 Touch fetal part as well
Treatment
 Depends on underlying cause ethiology
 Congenital anomalies
 Genetic councelling
 Plan delivery with pediatric surgery
 Labor usually induced for term and post term
 Complication
 Growth ristriction( associated with congenital anomalies
especially kidney)
 Club foot or tallipus
POLYHYDRAMNIOS
DEFINITION
 Amniotic fluid volume > 2000 ml

 Amniotic fluid index > 24-25 cm

 Single vertical pocket > 8 cm

 Incidence: 2-5 % of pregnancy

 Increased production or decreased consumption of

amniotic fluid will result in polyhydramnios.
Polyhydraminos

 Maternal diabetus
 Fetal Multiple gestation
 Congenital anomalies
 Corion angeoma of placenta/tumor
 Polyhydraminos
Etiologic Causes
 Maternal (15%)
Rh iso-immunization
DM
 Placental (less than 1%)
Placental chorioangioma/tumor
Circumvallate placental syndrome
 Fetal (18%)
Multiple pregnancies
Fetal anomalies (open spinal bifida, hydrops,
• Idiopathic (65%)
Polyhydraminos
Fetal causes >Congenital anomalies:
 Anencephaly:
◦ Transudation of CSF from the exposed meninges.
◦ Absence of swallowing of the liqour.
◦ Fetal polyuria resulting from lacking ADH or irritation of
the exposed centers.
 Atresia of the esophagus or duodenum prevents the
fetus to swallow the liqour
Polyhydraminos
Fetal causes
 Uniovular twins:
◦ Due to interconnecting vascularity in the
placenta, one fetus obtains more circulation so
that its heart & kidneys hypertrophy leading to
increased urine production. So only one
amniotic sac is affected.
Polyhydraminos
 Clinical types: Depending on the rapidity of
onset hydramnios can be
Acute – rare – appear in a matter
of few days ends up with absorbition
Chronic – more common. 10 times
more common to acute, appear in a matter of
few months, continued to term, last to late
trimester
 Polyhydraminos
 Routine OBH

 History suggestive of Rh iso- immunization such as still birth,

fetal hydrops, jaundice in new born requiring exchange
transfusion etc.

 History suggestive of DM – Previous big baby fetal death at 35

weeks, classical symptoms of DM like polyurea, polydypsia,
polyphagia

 History of Drug intake especially in First trimester

 History of Previous fetal anomalies like Anencephaly

risk of recurrence is 2%
Acute Polyhydramnios:
 Onset is acute
 usually occurs before 20 weeks, presents usually
with symptoms & labor starts before 28 weeks of
pregnancy.
 It may present as
Acute abdomen - abdominal pain, nausea,
vomiting
Breathlessness which increases on lying down
position
Palpitation
Edema of legs, varicosities in legs, vulva and
hemorrhoids
Acute Polyhydramnios
 Signs:
Patient looks ill, with out features of shock
Edema of legs with signs of PIH
Abdomen unduly enlarged huge with shiny skin
Fluid thrill may be present

 Internal examination shows taking up of cervix or

even dilatation with bulging membranes
 Chronic Polyhydramnios: More common than acute
,10% more common

 Since accumulation of liquor is gradual and so patient may

be symptomatic or asymptomatic.

 Symptoms are mainly due to mechanical causes

Dyspnoea is more in supine position
Palpitation
Oedema
Oliguria may result from ureteral obstruction by
enlarged uterus
 Pre-eclampsia (25%)
Signs
 Patient may be dyspnoic at rest
 Pedal Oedema
 Evidence of PIH
Abdominal examination
Inspection
 Abdomen is markedly enlarged globular
with fullness in flanks
 Skin over the abdomen is tense shiny with
large striae
Palpation
 Height of uterus is more than the corresponding
periods of Amenorrhea
 Abdominal girth is more
 Fetal parts cannot be well defined external
ballottement is more easily elicited
 Malpresentations are more common and
presenting part is usually high up
 Fluid thrill is present
Auscultation
 Fetal heart sounds are not heard distinctly
Internal examination :
Cervix is pulled up
May be sometimes dilated and admits tip of finger through
which bag of membranes which is tense is felt.
 At times patient may present with complications like
◦ Pre ecclampsia
◦ PROM
◦ Preterm labour
◦ Placental abruption
◦ Cord prolapse
Differential Diagnosis
a. Causes of oversized pregnant uterus.
b.Ovarian cyst with pregnancy.
c.Ascites.
 Management
Acute hydramnios:
Termination of pregnancy by high ARM.
This allows gradual escape of liquor thus shock
and separation of the placenta are avoided.
Shock results from rapid accumulation of blood
in the splanchnic area after sudden drop of
intrauterine pressure.
Separation of the placenta occurs due to sudden
drop of intrauterine pressure and shrinkage of
the placental site following this.
Management
Chronic hydramnios
During pregnancy:
a. Termination of pregnancy by high ARMs if the
fetus is dead or malformed.
b. Expectant treatment if the foetus is healthy.
> rest,
>sedative,
>salt restriction,
> treatment of the underlying cause as diabetes
and toxoplasmosis.
> Termination of pregnancy if the condition is not
improved or get worse
 Management
Chronic hydramnios
During pregnancy:
Repeated amniocentesis may be indicated in
premature fetus with marked pressure
symptoms. 1.5-2 liters can be aspirated in a rate
not exceeding 500 ml/hour under sonographic
control.
However, the amniotic fluid is rapidly
reaccumulating and there is risk of premature
labor, injury to the foetus or umbilical cord
vessels.
Management
Chronic hydramnios
During labor:
a. Malpresentation, cord presentation and / or
cord prolapse should be detected and the labor
is managed according to the condition.
b. When the cervix is half dilated Drew Smythe
catheter is passed to rupture the hind water.
This will initiate uterine contractions which can be
enhanced by oxytocins.
c. Active management of third stage.
Complications:
Maternal
During pregnancy:
a. Abortion.
b. Preterm labor.
c. Pregnancy induced hypertension.
d. Pressure symptoms.
e. Malpresentation.
During labour:
a. PROM
b. Cord prolapse
c. AP
d. PPH
e. SHOCK
Complications
 Fetal
◦ Prematurity.
◦ Asphyxia due to cord prolapse or placental
separation
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