HYPEREMESIS GRAVIDARUM

Description

Hyperemesis Gravidaum is defined as extreme nausea and vomiting secondary to elevated hCG
level. Nausea and vomiting is prolonged beyond 12 weeks of pregnancy and causes weight loss of 5% or
more from the woman’s weight prior to pregnancy. Some of the results of continued vomiting are
dehydration, electrolyte imbalance, ketosis, and acetonuria. Consistently depriving the fetus of
nourishment can limit its growth and increase the risk of preterm birth. Liver dysfunction may be noted
with the condition. It occurs at an incidence of 1 in 200 to 300 women. The cause is unknown, but women
with the disorder may have increased thyroid function because of the thyroidstimulating properties of
human chorionic gonadotropin. Some studies reveal that it is associated with Helicobacter pylori, the
same bacteria that cause peptic ulcers (Golberg, Szilagyi, & Graves, 2007).

Focus Assessment (Signs and Symptoms)

A woman with hyperemesis gravidarum experiences severe nausea and vomiting that she is
unable to continue eating normally. At her monthly prenatal checkup, she can have an elevated hematocrit
concentration as a result of her failure to retain hydration. Due to her poor intake, concentrations of
sodium, potassium, and chloride may be lowered, and if vomiting is particularly acute, hypokalemic
alkalosis may ensue. Some women experience polyneuritis as a result of a B vitamin deficiency. Serious
weight loss is possible. Ketones in the urine can indicate that a woman's body is metabolizing protein and
fat reserves for cellular growth. If the disease is not treated, a woman may experience intrauterine growth
restriction or a preterm birth if she becomes dehydrated and is unable to provide the necessary nutrients
for the fetus' growth.

Always make an effort to pinpoint the exact volume of nausea and vomiting that pregnant women
experience. If a lady claims that the previous day was usual, have her elaborate on the circumstances.
How long did the nauseous feeling last? How much and how often did she throw up? How much food
could she actually eat in total?

Some of the things that a pregnant woman might experience are the following:

● Vomiting over a prolonged period

● Dehydration: Poor skin turgor, dry mucous membranes
● Weight loss
● Hypotension
● Tachycardia

Diagnostic and Laboratory Test

● Urinalysis
- reveals ketones, acetones, and an elevated specific gravity.

● Electrolyte imbalances:
- Reduced sodium, potassium, and chloride.
 ● Acidosis due to vomiting of bases.
- Energy imbalance that is too negative leads to acidosis. The syndrome does not require
ketonuria in order to exist. It is generally agreed upon that high steroid levels cause
nausea.

● Elevated liver enzymes.

- Deranged liver function tests (LFT) can occur together with hyperemesis gravidarum
(HG), however the majority of patients experience smooth recovery with no fetal
damage.

● Thyroid test shows elevated levels.

- While TSH showed a considerable drop in hyperemesis gravidarum patients, serum T4
and hCG levels were significantly elevated.

● Hematocrit may be elevated

- due to dehydration and hemoconcentration.

Risk Factors

Some of the risk factors that may lead to this condition are the following:

● First pregnancy
● Pregnant woman less than 20 years of age
● Obese pregnant woman
● Multiple birth pregnancy
● History of psychiatric disorder
● Hyperthyroidism
● Vitamin B deficiencies
● Elevated stress level
● Gestational trophoblastic disease
Pathophysiology

Nursing Diagnoses by Priority (5)

● Risk for deficient fluid volume related to vomiting secondary to hyperemesis gravidarum
- Assess causative/contributing factors:
❖ Note possible conditions/processes that may lead to deficits: 1) fluid loss (e.g.,
fever, diarrhea/vomiting, excessive sweating; heat stroke; diabetic ketoacidosis;
burns, other draining wounds; gastrointestinal obstruction; salt-wasting diruetics;
rapid breathing/mechanical ventilation; surgical drains); 2) limited intake (e.g.,
sore throat or mouth; client dependent on others for eating and drinking; NPO
status); 3) fluid shifts (e.g., ascites, effusions, burns, sepsis); and 4)
environmental factors (e.g., isolation, restraints, malfunctioning air conditioning,
exposure to extreme heat).
❖ Determine effects of age. Very young and extremely elderly individuals are
quickly affected by fluid volume deficit, and are least able to express need. For
example, elderly people often have a decreased thirst reflex and/or may not be
aware of water needs. Infants/young children and other nonverbal persons cannot
describe thirst.
❖ Note client’s level of consciousness/mentation to evaluate ability to express
needs.
 ❖ Evaluate nutritional status, noting current intake, type of diet (e.g., client is NPO
or is on a restricted diet). Note problems (e.g., impaired mentation, nausea, fever,
facial injuries, immobility, insufficient time for intake) that can negatively affect
fluid intake.
❖ Review laboratory data (e.g., Hb/Hct, electrolytes, BUN/Cr).

● Imbalanced nutrition, less than body requirements, related to prolonged vomiting

- Assess causative/contributing factors:
❖ Identify client at risk for malnutrition (e.g., institutionalized elderly; client with
chronic illness; child or adult living in poverty/low income area; client with
jaw/facial injuries; intestinal surgery/post malabsorptive/restrictive surgical
interventions for weight loss; hypermetabolic states [e.g., burns, hyperthroidism];
malabsorption syndromes/lactose intolerance; cystic fibrosis; pancreatic disease;
prolonged time of restricted intake; prior nutritional deficiencies).
❖ Determine client’s ability to chew, swallow, and taste food. Evaluate teeth and
gums for poor oral health, and note denture fit, as indicated. All factors that can
affect ingestion and/or digestion of nutrients.
❖ Ascertain understanding of individual nutritional needs to determine
informational needs of client/SO.
❖ Note availability/use of financial resources and support systems. Determine
ability to acquire and store various types of food.
❖ Discuss eating habits, including food preferences, intolerances/aversions to
appeal to client’s likes/dislikes.
❖ Assess drug interactions, disease effects, allergies, use of laxatives, diuretics that
may be affecting appetite, food intake, or absorption.
❖ Determine psychological factors/perform psychological assessment, as indicated,
to assess body image and congruency with reality.
● Anxiety related to hyperemesis influence on the health of the fetus.
- Assess level of anxiety:
❖ Review familial/physiological factors, such as genetic depressive factors;
psychiatric illness; active medical conditions (e.g. thyroid problems, metabolic
imbalances, cardiopulmonary disease, anemia, or dysrhythmias); recent/ongoing
stressors (e.g., family member illness/death, spousal conflict/abuse, or loss of
job). These factors can cause/exacerbate anxiety anxiety disorders.
❖ Determine current prescribed medications and recent drug history of prescribed
or OTC medications (e.g., steroids, thyroid preparations, weight loss pills, or
caffeine). These medications can heighten feelings/sense of anxiety.
❖ Identify client’s perception of the threat represented by the situation.
❖ Monitor vital signs (e.g., rapid or irregular pulse, rapid
breathing/hyperventilation, changes in blood pressure, diaphorsesis, tremors, or
restlessness) to identify physical responses associated with both medical and
emotional conditions.
❖ Observe behaviors, which can point to the client’s level of anxiety

Nursing Management/ Intervention

- Typically, hyperemesis gravidarum patients require a 24-hour hospital stay to monitor their blood
chemistries, intake, and output while also rehydrating them.
 - Usually, no oral food or liquids are consumed. To improve hydration, intravenous fluid (3000 mL
of Ringer's lactate with added vitamin B, for example) may be given. Metoclopramide (Reglan),
an antiemetic, may be administered to treat nausea and vomiting. Keep meticulous records of
your intake, output, and vomitus during this time.

- After the first 24 hours of oral restriction, if there is no vomiting, tiny amounts of clear fluid may
be administered, and the woman may be sent home, usually with a recommendation for home
care. Every two or three hours, small amounts of dry toast, crackers, or cereal may be offered if
she is able to maintain clear fluid intake. After that, a soft diet and finally a normal diet can be
introduced to her gradually. Enteral feeding or complete parenteral nutrition may be advised if
vomiting reappears at any time. After hospital discharge, home care follow-up offers more details
regarding the client's condition.

Medical/ Surgical Management

Surgical Management

It's crucial to treat electrolyte imbalances and dehydration brought on by vomiting, such as with
intravenous fluid replacement. Feeding and nutritional support should also be considered, especially in
cases of persistent vomiting. This can be done either enterally (via nasogastric or nasojejunal tubes,
depending on clinical context) or parenterally. In the presence of a functioning gut, the former is preferred
as it helps gut remodelling (especially important in the context of inflammatory bowel disease) and also
has a safer side-effect profile than parenteral nutrition. For those patients who are malnourished or who
have had a prolonged period of starvation, nutritional supplements and vitamins (intravenous Pabrinex or
oral Forceval capsules) should be given to replenish stores and minimise the risk of developing refeeding
syndrome.

● Nothing by mouth (npo) for 24 to 48 hours.

● Advance diet if no vomiting within 24 hours to 6 small meals.
● Enteral nutrition by feeding tube or total parental nutrition if vomiting persists.

Medical Management

Numerous medications can contribute to nausea and vomiting, as has already been outlined, and
sometimes the only management needed is simply to withdraw the offending agent. In some conditions, it
is not always easy to treat the underlying cause, or it may take time. Equally, emesis is a known
side-effect of chemotherapy, but it is one where the potential benefit is likely to outweigh the risk of
discontinuing treatment. In such situations, pharmacotherapy can be extremely beneficial in controlling
symptoms and maintaining patient quality of life.

● Fluid therapy as needed to maintain hydration: Ringer’s lactate.

● Electrolyte replacement as indicated.
● Vitamin B6 and other vitamins as indicated.
● Antiemetic (promethazine or metoclopramide) to control nausea and vomiting.
 Drug Analysis

DRUG NAME INDICATION MECHANISM OF SIDE EFFECTS NURSING

ACTION RESPONSIBILITIES

Generic Prevention/treatment of Coenzyme for various Occasional: Stinging INTERVENTION/E

name:Pyridoxine vitamin B6 deficiency. metabolic functions, at IM injection site VALUATION:
OFF-LABEL: including metabolism
Brand name: Pyridoxine-dependent of proteins, Rare: Headache, Observe for
Aminoxin seizures in infants, carbohydrates, fats. nausea, drowsiness, improvement of
drug-induced neuritis Aids in breakdown of sensory neuropathy deficiency symptoms,
Dosage: 10-20 mg (e.g., associated with glycogen and in (paresthesia, unstable glossitis. Evaluate for
isoniazid). Treatment of synthesis of gait, clumsiness of nutritional adequacy.
Frequency: Daily for 3 peripheral neuropathy gammaaminobutyric hands) with high
weeks associated with acid (GABA) in CNS. doses PATIENT/FAMILY
isoniazid; nausea and Therapeutic Effect: TEACHING
Route: PO vomiting of pregnancy Prevents pyridoxine •  Discomfort may
________________ deficiency. Increases occur with IM
excretion of certain injection. 
Drug Classification: drugs (e.g., isoniazid) •  Consume foods
Vitamin B6 that are pyridoxine rich in pyridoxine
antagonists. (legumes, soybeans,
eggs, sunflower seeds,
hazelnuts, organ
meats, tuna, shrimp,
carrots, avocados,
bananas, wheat germ,
bran).

DRUG NAME MECHANISM OF INDICATION SIDE EFFECTS NURSING

ACTION RESPONSIBILITIES

Generic name: Block postsynaptic Treatment of allergic Frequent: BASELINE

Promethazine dopaminergic receptors; conditions, motion Drowsiness, dry ASSESSMENT:
competes with sickness, nausea, mouth, nose, throat;
Brand name: Phenergan histamine for histamine vomiting. May be used urinary retention, Assess allergy symptoms.
receptors; possesses as mild sedative. thickening of Assess B/P, pulse for
Dosage: 25 mg muscarinic blocking Adjunct to bronchial secretions bradycardia, tachycardia
effect. Therapeutic postoperative analgesia. if pt is given parenteral
Frequency: q 4 to 6 Effect: Prevents allergic OFF-LABEL: Occasional: form. If used as
hours prn responses mediated by Nausea/vomiting Epigastric distress, antiemetic, assess for
histamine (urticaria, related to pregnancy. flushing, visual dehydration (poor skin
Route: PO or PR pruritus). Prevents, disturbances, hearing turgor, dry mucous
___________________ relieves disturbances, membranes, longitudinal
nausea/vomiting. wheezing, furrows in tongue).
Drug Classification: Produces mild sedative paresthesia, Assess LOC.
Antihistamine, effect. diaphoresis, chills,
antiemetic, disorientation, hy INTERVENTION/EVA
sedative-hypnotic potension, confusion, LUATION:
syncope in elderly.
Monitor serum
Rare: Dizziness, electrolytes in pts with
urticaria, severe vomiting. Assist
photosensitivity, with ambulation if
nightmares. drowsiness, dizziness
occurs. Monitor for relief
of nausea, vomiting,
allergic symptoms.

PATIENT/FAMILY
TEACHING:

Drowsiness, dry mouth

may be expected response
to drug.

Avoid tasks that require

alertness, motor skills
until response to drug is
established. 

Sugarless gum, sips of

water may relieve dry
mouth. 

Coffee, tea may help

reduce drowsiness.

  Report visual
disturbances, involuntary
movements, restlessness.

Avoid alcohol, other

CNS depressants. 

  Avoid prolonged
exposure to sunlight.
DRUG NAME INDICATION MECHANISM OF SIDE EFFECTS NURSING
ACTION RESPONSIBILITIES

Generic name: Prevention/treatment of Blocks serotonin, both Frequent INTERVENTION/E

Ondansetron nausea/vomiting due to peripherally on vagal (13%–5%): Anxiety, VALUATION:
cancer chemotherapy nerve terminals and dizziness, drowsiness,
Brand name: Zofran (including high-dose centrally in headache, fatigue, Assess degree of
cisplatin). Prevention chemoreceptor trigger constipation, nausea, vomiting.
Dosage: 4 mg and treatment of postop zone. Therapeutic diarrhea, hypoxia, Assess for
nausea, vomiting. Effect: Prevents urinary retention. dehydration if
Frequency: Once a day Prevention of nausea/vomiting. excessive vomiting
radiation-induced Occasional occurs (poor skin
Route: IV/IM nausea, vomiting. (4%–2%): turgor, dry mucous
___________________ OFF-LABEL: Abdominal pain, membranes,
Breakthrough treatment xerostomia, fever, longitudinal furrows
Drug Classification: , of nausea and vomiting feeling of cold, in tongue). Provide
Antinausea, antiemetic. associated with redness/pain at emotional support.
chemotherapy, injection site,
hyperemesis paresthesia, asthenia INTERVENTION/E
gravidarum. (loss of strength, VALUATION:
energy)
Monitor EKG in pts
Rare (1%): with electrolyte
Hypersensitivity abnormalities (e.g.,
reaction (rash, hypokalemia,
pruritus), blurred hypomagnesemia),
vision. HF, bradyarrhythmias,
concurrent use of
other medications that
may cause QT
prolongation. Provide
supportive measures.
Assess mental status.
Assess bowel sounds
for peristalsis.
Monitor daily pattern
of bowel activity,
stool consistency.
Record time of
evacuation.

PATIENT/FAMILY
TEACHING
• Relief from
nausea/vomiting
generally occurs
shortly after drug
 administration.

• Avoid alcohol,
barbiturates 
•  Report persistent
vomiting
•  Avoid tasks that
require alertness,
motor skills until
response to drug is
established (may
cause drowsiness,
dizziness).

DRUG NAME INDICATION MECHANISM OF SIDE EFFECTS NURSING

ACTION RESPONSIBILITIES

Generic name: ORAL: Symptomatic Stimulates motility of Doses of 2 mg/kg or BASELINE

Metoclopramide treatment of diabetic upper GI tract. Blocks greater, or increased ASSESSMENT:
gastroparesis, dopamine/serotonin length of therapy,
Brand name: gastroesophageal receptors in may result in a Antiemetic: Assess
Reglan reflux. chemoreceptor trigger greater incidence of for dehydration
zone. Enhances side effects. Frequent (poor skin turgor, dry
Dosage: 1-2mg/kg IV/IM: Symptomatic acetylcholine response (10%): Drowsiness, mucous membranes,
treatment of diabetic in upper GI tract; restlessness, fatigue, longitudinal furrows
Frequency: 5 dose/day gastroparesis, increases lower lethargy. in tongue).
placement of enteral esophageal sphincter Assess for nausea,
Route: IV feeding tubes, tone. Therapeutic Occasional (3%): vomiting, abdominal
________________ prevent/treat Effect: Accelerates Dizziness, anxiety, distention, bowel
nausea/vomiting with intestinal transit, headache, insomnia, sounds.
Drug Classification: chemotherapy or after promotes gastric breast tenderness,
GI emptying adjunct, surgery. emptying. Relieves altered menstruation, INTERVENTION/E
peristaltic stimulant, nausea, vomiting. constipation, rash, VALUATION:
antiemetic. dry mouth,
galactorrhea, Monitor for anxiety,
gynecomastia. restlessness,

extrapyramidal
symptoms (EPS)
during IV
Rare (less than 3%): administration.
Hypotension, Monitor daily pattern
hypertension, of bowel activity,
tachycardia. stool consistency.
Assess skin for rash.
Evaluate for
therapeutic response
from gastroparesis
(nausea, vomiting,
bloating). Monitor
renal function, B/P,
heart rate.

PATIENT/FAMILY
TEACHING
• Avoid tasks that
require alertness,
motor skills until
response to drug is
established.

• Report involuntary
eye, facial, limb
movement
(extrapyramidal
reaction).

• Avoid alcohol