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INTRODUCTION

This is a case of a female patient, 14 years old, living at Tantangan, South

Cotabato. She was admitted last November 18, 2019, at 10:50 pm at South Cotabato

Provincial Hospital. She was scheduled for delivery under the service of Dra. Star and

was diagnosed with G1P0 Hyperemesis Gravidarum 4wks AOG UTI.

Hyperemesis gravidarum is the most severe form of nausea and vomiting in

pregnancy, characterized by persistent nausea and vomiting associated with ketosis,

electrolyte disturbance, and weight loss. Mild cases are treated with dietary changes, rest,

and antacids. More severe cases often require a stay in the hospital so that the mother can

receive fluid and nutrition through an intravenous line (IV). It is believed that this severe

nausea is caused by a rise in hormone levels; however, the absolute cause is still

unknown (Healthline, 2016).

On the other hand, Urinary Tract Infection is defined as the presence of at least

100,000 organisms per milliliter of urine in an asymptomatic patient, or as more than 100

organisms/mL of urine with accompanying pyuria (> 7 white blood cells [WBCs]/mL) in

an asymptomatic patient. A diagnosis of UTI should be supported by a positive culture

for a uropathogen, particularly in patients with vague symptoms (Platte, 2019).

According to World Health Organization, hyperemesis gravidarum is estimated to

occur worldwide in 50 to 90 percent of all pregnancies, hyperemesis gravidarum is

estimated to occur in .5 to two percent of pregnant women while over 192,000 hospital

visits and/or admissions occur in the US annually and approximately 4,000 Canadian

women a year experience hyperemesis gravidarum, according to estimates from the U.S.
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It is the second leading cause of hospitalization in early pregnancy and is more common

in non-white and Asian populations. Hyperemesis gravidarum, like nausea and vomiting

of pregnancy, usually occurs before the 20th week of pregnancy often between the fourth

and tenth week (National Organization Rare Disorders, 2015).

In Asia, hyperemesis gravidarum is the most common cause of hospitalization

during the first half of pregnancy and is second only to preterm labor for hospitalizations

in pregnancy overall in approximately 0.3-3% of pregnancies ( Basel, 2017). In 2015, the

prevalence rate of Hyperemesis gravidarum and UTI in the Philippines increases up to

276,442 (DOH,2016).

This case study will broaden the knowledge of the readers that these diseases

should not be ignored by the people who suffer from it. Also, complications will prevent

if there is an immediate action rendered. Hence, in light of the increasing rate of

Hyperemesis gravidarum and UTI this case study was conceived as a new paradigm. It is

no longer considered primarily signs and symptoms of pregnancy, but rather one of the

conditions that may affect the mother and the baby if not given immediate action.
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Objectives of the Study

General Objective:

After reading the case, the readers will be able to present important

information about the researches and analysis presented in the case study that will give

the readers a better understanding of the client’s condition. Hence, it will broaden the

knowledge of the readers to develop a positive attitude and acquired appropriate skills in

addressing the condition during exposure.

Specific Objectives:

After two hours of reading this case, the readers will be able to:

1) Analyzed the brief summary of the introduction about the client’s conditions and

its significance.

2) Identified correctly the important information regarding patient’s data in relation

to the client’s condition by presenting the following:

a) Vital Information

b) Background of the family

c) History of Past Illness

d) History of Present Illness

e) Effects and expectations of the family and the patient to the illness

f) Genogram

g) Developmental Data

3) Understood the result of the Physical Assessment cephalocaudically.

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4) Discussed comprehensively the complete diagnosis of the client based on the

textbook discussion.

5) Discussed briefly the involved anatomy and physiology of the system affected by

Hyperemesis Gravidarum and UTI specifically the reproductive system, urinary

system and digestive system. .

6) Presented the etiology and symptomatology of Hyperemesis Gravidarum and

UTI.

7) Traced schematically the pathology of Hyperemesis Gravidarum and UTI.

8) Evaluated the modifiable and non-modifiable factors thoroughly.

9) Interpreted the laboratory and other diagnostic results to the client.

10) Identified the possible nursing diagnosis to the client with applicable

interventions.

11) Presented the drugs that the physician ordered for the wellness of the client

12) Analyze the prognosis.

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PATIENT’S DATA

Vital Information

Patients Name: Ana

Age: 14 years old

Sex: Female

Birth Date: September 2, 2005

Birth Place: Tantangan, South Cotabato

Address: Prk.Paghidaet, New Iloilo, South Cotabato

Occupation: Student

Tribe: Maguindanaon

Citizenship: Filipino

Religion: Islam

Civil Status: Single

Educational Attainment: Junior High School Level

Name of Institution: South Cotabato Provincial Hospital

Date and Time of Admission: November 18, 2019 @ 10:50 pm

Chief Complaint: excessive vomiting and dysuria

Post-Operative Diagnosis: G1P0 Hypermesis Gravidarum 4wks AOG UTI

Attending Physician: Star, MD

Spouse Name: Kristoff

Age: 14 years old

Educational Attainment: Junior High School Level

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Occupation: Student

Parents Name

Father’s Name: Mr. Jeremy

Age: 58

Occupation: Farmer

Educational Attainment: High School Graduate

Mother’s Name: Mrs. Stacy

Age: 53 years old

Occupation: Housekeeper

Educational Attainment: High School Graduate

Siblings:

Name Age Educational Attainment

Jing 29 High School Graduate

Bubble 19 High School Graduate

Jay 17 High School Graduate

Ana 14 Junior High School Level

Jay 11 Elementary Level

Source of Income: Patient’s parents

Source of Information: Patient

Patient’s Chart
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Family Background

Ms. Ana is a Maguindanaon and Islam. She is the fourth daughter among the five

children of Mr. Jeremy and Mrs. Stacy. She belongs to a nuclear type of family in which

both of her parents take care of her and her siblings.

She is not yet married to Mr. Kristoff since her pregnancy is unexpected.

However, after she will be discharged in the hospital they were planning to get married.

According to the patient, they lived in a concrete house with appliances of TV, radio, and

electric fans. Her parents were very disappointed after they knew she was pregnant on the

day she was admitted to the hospital due to vomiting and fever. Both of her parents are

very disappointed with her because she got pregnant at a young age and her soon to be

husband is the same age as her whom she met at school. But still, her family accepts them

wholeheartedly.

Additionally, her family is experiencing common illnesses such as coughs, colds,

flu, and fever. They used over the counter drugs like paracetamol, decongestant, pain

reliever and tepid sponge bathing for fever. Sometimes they also practice utilizing herbal

medicines and even going to quack doctors and trained hilots.

However, if they cannot ease the pain they go to the nearest hospital. Their family

has a history of hypertension. The client is knowledgeable of a good lifestyle like

completing her pre-natal check-ups and she is taking ferrous sulfate supplement.
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HISTORY OF PAST ILLNESS

The client claims of having chickenpox and measles during her childhood and she

also admits that during her childhood she is vulnerable to illnesses due to her weak

immune system. Also, she is not fully immunized because of inadequate knowledge of

her mother of the importance of immunizations. The client also experiences common

illness such as cough, colds, flu, and fever. They utilize over the counter drugs and even

go to the quack doctor before going to the hospital. The client denies having previous

admissions to any hospital because. The patient also denies of having allergies in foods or

any drugs.

HISTORY OF PRESENT ILLNESS

The client also claims that she experienced probable signs of being pregnant like

morning sickness and amenorrhea. But she ignored it since she doesn’t have an idea that

she is pregnant not until she was admitted to the hospital due to excessive vomiting and

fever. She claims that she cannot eat due to her excessive vomiting. Her mother thought

that it is because of her fever so they utilized paracetamol particularly Biogesic.

However, her vomiting did not stop so they decided to admit her to the hospital.

She undergone laboratory tests and it was confirmed that she is pregnant. She

stays in the hospital for almost 3 days and every morning she eats plain crackers.
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EFFECTS TO SELF

After pregnancy was confirmed, the client experience anxiety on how to tell her

boyfriend and parents that she is pregnant. She is having a hard time whether to tell her

parents the truth or not. However, she encourages herself to admit it even if she will be

abandon by her parents or accept the truth wholeheartedly. She claims that her parents

were very disappointed but they still prepared for her wedding. Her pregnancy greatly

affects her in the physical, emotional and spiritual aspects. She decided to stop going to

school so, she can give her time on her baby and soon to be husband.

She still perceives the baby as a blessing to her even it is unplanned she

knows there is a reason. They decided to reside in her parents’ house. She is happy

because she witnessed how her family takes care of her most especially her D-day.

EFFECTS TO FAMILY

When she confessed the truth to her parents, her father was irate and dismayed

because they were expecting that She will graduate and go to college. But they still

accept their daughter and agreed on their marriage after she will be discharged.
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EXPECTATIONS TO SELF

After being admitted, the patient expects that she will get well soon after being

hospitalized for three days and be able to do her responsibility as a mother to her baby.

She is also expecting that the hospital will give her proper treatment and medications to

help her and her baby to be healthy.

She is expecting that her family will accompany her throughout the procedures

and they will support her morally by staying on her bedside always. They will be the ones

who will remind her medications always and to process her PhilHealth to lessen the

hospital bills during her recovery period.

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GENOGRAM

NKD HPN
NKD

NKD

NKD
NKD
NKD NKD

HG
NKD NKD
NKD
NKD

LEGEND:

MALE

PATIENT
Connected by blood Not connected by blood

FEMALE HPN- Hypertension HG- Hyperemesis Gravidarum

NKD- no known disease

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Narrative Interpretation:

Ms. Ana’s genogram reveals that she had a familial history of disease such as

hypertension at his paternal side.

DEVELOPMENTAL DATA

Stages of Psychosocial Development Theory

Erik Erikson. (1950,1963) a german psychoanalyst heavily influenced by

Sigmund Freud, explored three aspects of identity. The Ego Identity (self), the Personal

Identity, (personal idiosyncrasies that distinguish a person from another)m the

Social/Culture Identity (collection of social roles a person might play).

Erikson’s Psychosocial Theory of Development considers the impact of

external factors, parents and society on personality development from childhood to

adulthood. According to Erkison’s theory, every person must pass through a series of

eight (8) interrelated stages over the entire life cycle.

Task Justification Remarks

In adolescence (ages 12–18), children

face the task of identity vs. role The patient claims that

confusion. According to Erikson, an during this stage she

adolescent’s main task is developing a become more > Achieved

sense of self. Adolescents struggle with independent, she begin to Successfully

questions such as “Who am I?” and look in the terms of

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“What do I want to do with my life?” relationship and search for

Along the way, most adolescents try on a sense of personal

many different selves to see which ones identity.

fit; they explore various roles and

ideas, set goals, and attempt to discover

their “adult” selves.

Psychosexual Theory

(Sigmund Freud)
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Sigmund Freud introduced a number of concepts about development that

are still used today. The concepts of the unconscious mind, defense mechanism, and the

id, ego, superego are Freud’s.

According to Freud’s theory of Psychosexual Development, the

personality develops in five overlapping stages from birth to adulthood. The libido

changes its location of emphasis witinte body from one stage to another. Therefore, a

particular body area has special significance to a client at a particular stage.

If the individual does not achieve satisfactory progression at each stage,

the personality becomes fixated at that stage. Ideally, an individual progresses through

the tasks of each stage and balance is achieved between the id, ego and superego.

Task Justification Remarks

Genital Stage At this age, the patient

Puberty-death was starting to have her

own decision about >Achieved

>the genital stage is a time of small things and this Successfully

sexual reawakening. time she started to have

>the source of pleasure now a relationship..

becomes someone outside of

the family.

>it is the puberty period when

sexual urges reawaken that

may lead to children exploring

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their sexuality.

Developmental Task Theory

(Robert Havighurst)
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Robert Havighurst believed that learning is the basic to life and that people

continue to learn throughout life. He described growth and development as occurring

during six stages. Each associated wuth 6-10 tasks to be learned.

Havighurst promoted the concept of Developmental Tasks in the 1950’s.

A developmental task is “a task which arises about a certain period in the life of an

individual, successful achievement of which leads to his happiness and to success with

later task, while failure leads t unhappiness in the individual disapproved by the society

and difficulty with later tasks.”

Task Justification Remarks

Adolescence

⮚ Leads or lasts from 13 She admits that this was her

first relationship. >Achieved Successfully

to age 18, comes with

hormonal changes and

learning about who

you are as an

individual.

Review of System

Date: November 18, 2019

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Time: 10:50 pm

General Survey:

Received patient lying on bed with ongoing #2 IVF D5LR 1L @ 900 cc level x

30 gtts/ min patent and infusing well, hooked at right metacarpal vein. The patient is

conscious and coherent. She admits that she is experiencing severe nausea and vomiting

during this past few weeks.

Skin/Hair/Nails:

The patient denies of having rashes, lumps, sores, and itchiness of the skin, and

also denies of having dandruff and lice.

Head:

The patient denies having any head injury, but the patient claimed she

experienced headache this past few days.

Eyes:

The patient denies of having blurry of vision, trauma, pain, history of glaucoma

and cataracts. She denied using grade glasses.

Ears:
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The patient denied having hearing loss or ear pain. She also stated that she

cleans her ears using cotton buds for at least 3 times a week.

Nose:

The patient denies loss of smell, but she admits that this past few days she

doesn’t want to smell strong scents such as dried fish and denied nose injury and

epistaxis.

Mouth and throat:

The patient denies of having sore throat or pain in the mouth or throat. But

she admitted dryness of throat and mouth.

Neck:

The patient denies of having history of goiter, and stiffness of the neck.

Abdomen:

The patient denies abdominal pain and itching.

Respiratory system:

The patient denies of having a cough. .

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Cardiovascular system:

The patient denies of having chest pain and palpitations.

Musculoskeletal:

The patient denies having joint stiffness but claims, back pain and fatigue..

Gastrointestinal system:

The patient denies having constipation or diarrhea but she experience

severe nausea and vomiting.

Endocrine system:

The patient denies having enlargement of the thyroid gland or

inflammation of lymph nodes. .

Breast:

The patient denies having breast sore, and denies of having history of

breast cancer

Genitourinary:

The patient claims of having difficulty or pain during urination because of

her UTI.

Hematology:

The patient denies looking cyanotic these past few days.

Psychiatric:
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The patient claims that she is irritable these past few days because she was

not able to eat or drink because she knows that if she’ll eat, she’ll vomit.

Physical Assessment
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Date: November 18, 2019

Time: 10:50 pm

General Survey:

Received patient lying on bed with ongoing #2 IVF D5LR 1L @ 900 cc

level x 30 gtts/ min patent and infusing well, hooked at right metacarpal vein . The

patient is conscious and coherent. She admits that she is experiencing severe nausea and

vomiting during this past few weeks.

Vital signs:

BP:110/80mmHg TEMP:38.5 ℃ PR:93 bpm RR:20 cpm

Head/Hair/Scalp:

Inspection: The head is proportional to the body and skull is round, symmetrical

to the body, no dandruff noted, hair is long and evenly distributed and black in color. No

lesions noted.

Palpation: no tenderness and masses noted.

Face:

Inspection: the face is symmetrical, skin is brown in complexion. No pimples

noted. No scars and edema noted.

Palpation: there is no masses and tenderness noted. Skin is smooth.

Eyes:

Inspection: the eye is symmetrical, and eyebrow is black in color and its evenly

distributed, eyelid are able to close completely. Eyelashes directed outward and intact.

Pupils are equals in size, round in shape and reacts to light and accommodation.
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Conjunctiva is pinkish in color, sclera is well lubricated, whitish in color, the cornea is

clear and transparent, iris is black in color. There is no difficulty in eye movement.

Nose:

Inspection: the external nose is symmetrical, align at the midline, mucosa is

moist, nasal septum is intact, no lesions and nose deformities noted. Presence of

blackheads noted.

Palpation: there is no tenderness noted.

Ears:

Inspection: ears are symmetrical, normal in size with equal color to the body

complexion, no lesions noted, auricle is aligned to the outer canthus of the eye, pinna

recoils when folded.

Palpation: no tenderness or enlargement of lymph nodes noted.

Lips and Mouth:

Inspection: lips is pale in color with dry texture, the tongue is pinkish in color

with white patches, mobile and positioned at the midline. No dentures noted with

incomplete set of teeth. Gums and mucosa is pink and no lesion noted. Tonsils are not

inflamed; uvula is bell in shape, pinkish in color, and at the midline.

Neck:

Inspection: jugular veins are not inflamed and no stiffness noted.

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Palpation: lymph nodes at the neck are not palpable. There is no enlargement of

thyroid gland upon palpation.

Breast:

Inspection: dark brown areola and nipple noted. The breast are slightly

asymmetrical.

Lungs:

Auscultation: breathing pattern is normal and no irregular rhythm noted. No

crackles or stridor noted.

Heart:

Auscultation: no abnormal sound noted. Rate is within normal range.

Abdomen:

Inspection: no scars noted upon inspection. striae gravidarum is not present in the

entire abdomen.

Auscultation: no abnormal sound noted.

Extremities:

Inspection: extremities are proportionate to the trunk; skin is brown in

complexion, symmetrical on both upper and lower extremities, no difficulties in

performing flexion and extension. Muscle has equal strength, able to grasp noted. No
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edema noted. There are scars from mosquito bites on her feet and a bit larger scar in her

right knee.

Skin:

Inspection: fair complexion, no lesion and hair is evenly distributed.

Palpation: no masses and tenderness noted. Warm to touch and has a smooth skin.

Nails:

Inspection: nails are pinkish in color, trimmed and no presence of dirt under nail

beds, capillary refill after 3 seconds.

TEXTBOOK DISCUSSION

COMPLETE DIAGNOSIS:
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Hyperemesis gravidarum is a condition characterized by

severe nausea, vomiting, weight loss, and electrolyte disturbance. Mild cases are treated

with dietary changes, rest, and antacids. It is believed that this severe nausea is caused by

a rise in hormone levels; however, the absolute cause is still unknown. The symptoms of

HG usually appear between 4-6 weeks of pregnancy and may peak between 9-13 weeks.

Most women receive some relief between weeks 14-20, although up to 20% of women

may require care for hyperemesis throughout the rest of their pregnancy (Kaledin, 2019).

Hyperemesis gravidarum (HG) is an extreme form of morning sickness

that causes severe nausea and vomiting during pregnancy. HG typically includes nausea

that doesn’t go away and severe vomiting that leads to severe dehydration. This doesn’t

allow you to keep any food or fluids down.The symptoms of HG begin within the first six

weeks of pregnancy. Nausea often doesn’t go away. HG can be extremely debilitating

and cause fatigue that lasts for weeks or months. Women with HG may experience a

complete loss of appetite. They may not be able to work or perform their normal daily

activities.HG can lead to dehydration and poor weight gain during pregnancy (Wilson,

2014).

Hyperemesis gravidarum (HG) is a rare disorder characterized by severe

and persistent nausea and vomiting during pregnancy that may necessitate

hospitalization. As a result of frequent nausea and vomiting, affected women experience

dehydration, vitamin and mineral deficit, and the loss of greater than five percent of their

original body weight. Nausea and vomiting of pregnancy (NVP), more widely known as

morning sickness, is a common condition of pregnancy. Many researchers believe that

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NVP should be regarded as a continuum of symptoms that may impact an affected

woman's physical, mental and social well-being to varying degrees. Hyperemesis

gravidarum represents the severe end of the continuum, (Fejzo, 2015).

UTI occurs when bacteria from somewhere outside of a woman’s body gets inside

her urethra (basically the urinary tract) and causes an infection.Women are more likely to

get UTIs than men. The female anatomy makes it easy for bacteria from the vagina or

rectal areas to get in the urinary tract because they are all close together. Hormones are

one reason. In pregnancy, they cause changes in the urinary tract, and that makes women

more likely to get infections.Also, your growing uterus presses on your bladder. That

makes it hard for you to let out all the urine in your bladder. Leftover urine can be a

source of infection (Bandukwala, 2019).

Signs and symptoms

The defining symptoms of hyperemesis gravidarum are gastrointestinal in nature and

include nausea and vomiting. Other common symptoms include ptyalism (excessive

salivation), fatigue, weakness, and dizziness.

Patients may also experience the following:

● Sleep disturbance

● Hyperolfaction

● Dysgeusia
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● Decreased gustatory discernment

● Depression

● Anxiety

● Irritability

● Mood changes

● Decreased concentration

Diagnosis

Physical examination in women with suspected hyperemesis gravidarum is usually

unremarkable. Findings may be more helpful if the patient has unusual complaints

suggestive of other disorders (eg, bleeding, abdominal pain).

Examination includes the following:

● Vital signs, including standing and lying blood pressure and pulse

● Volume status (eg, mucous membrane condition, skin turgor, neck veins, mental

status)

● General appearance (eg, nutrition, weight)

● Thyroid evaluation

● Abdominal evaluation

● Cardiac evaluation
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● Neurologic evaluation

Laboratory tests

Initial laboratory studies used in the evaluation of women with hyperemesis gravidarum

should include the following:

● Urinalysis for ketones and specific gravity

● Serum levels of electrolytes and ketones

● Liver enzymes and bilirubin levels [2]

● Amylase/lipase levels

● Thyroid stimulating hormone, free thyroxine levels [3]

● Urine culture

● Calcium level

● Hematocrit level

● Hepatitis panel [1]

Imaging studies
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The following imaging studies may be used to assess women with hyperemesis

gravidarum:

● Obstetric ultrasonography: Usually warranted to evaluate for multiple gestations or

trophoblastic disease

● Upper abdominal ultrasonography: If clinically indicated, to evaluate the pancreas

and/or biliary tree

● Abdominal computed tomography scanning or magnetic resonance imaging: If

appendicitis is suspected as a cause of nausea and vomiting in pregnancy

Additional imaging studies may be warranted if the patient’s clinical presentation is

atypical (eg, nausea and/or vomiting beginning after 9-10 wk of gestation, nausea and/or

vomiting persisting after 20-22 wk, acute severe exacerbation) or if another disorder is

suggested based on the history or physical examination findings.

Procedures

In patients with abdominal pain or upper gastrointestinal bleeding, upper gastrointestinal

endoscopy appears to be safe in pregnancy, although careful monitoring is suggested.

Causes of Hyperemesis Gravidarum

The exact cause of hyperemesis gravidarum is not known. Some theories

concerning the cause of hyperemesis gravidarum include pregnancy hormone imbalances,

vitamin B deficiency; hyperthyroidism; gastroesophageal reflux occurring in association

with abnormalities in the electrical properties of muscles affecting the stomach (gastric
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dysrhythmias); Helicobacter Pylori infections; psychological factors; and disturbances in

carbohydrate metabolism.

Many of these theories are based on symptoms coexisting with hyperemesis

gravidarum that are just as likely to be caused by hyperemesis as they are to be causal.

For example, many affected women are unable to tolerate vitamins and normal nutrition

in pregnancy and therefore may develop vitamin deficiencies, thyroid, and other

metabolic disturbances. Additionally, while in the first half of the 1900s theories for

hyperemesis were dominated by far-fetched psychological proposals such as rejection of

pregnancy due to embarrassment about sexual relations or fear of childbirth and

motherhood, more recently, scientific studies have shown that 94% of women with

hyperemesis have no prior psychiatric history and although women may be depressed or

anxious during pregnancy when they are too nauseous to eat healthfully or care for their

families, they revert back to normal when their extreme physical symptoms subside.

Finally, many women with no or normal nausea in pregnancy have H. Pylori

infections and/or abnormally high levels of pregnancy hormones such as hCG and

estrogen. Thus, despite several clinical studies, researchers have been unable to

definitively determine why hyperemesis gravidarum occurs.

Several lines of evidence support a genetic predisposition to nausea and vomiting

in pregnancy. In a study of nausea and vomiting of pregnancy in twins, concordance rates

were more than twice as high for monozygotic compared to dizygotic twins. Studies

suggest familial aggregation of hyperemesis gravidarum as there is a remarkably high

prevalence of affected siblings and mothers of patients affected with nausea and vomiting

of pregnancy and hyperemesis gravidarum, and a significantly increased risk to daughters

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and sisters of women with a history of HG. Additionally, a biologic component to the

condition has been suggested from animal studies. There are also data suggestive of a

role for genetic predisposition in the development of nausea and vomiting of pregnancy.

However, the cause of hyperemesis gravidarum is currently unknown and the rationale

for maintenance of genes that predispose to dehydration and malnutrition in pregnancy

remains an evolutionary enigma. One would think that a condition that commonly

resulted in maternal and fetal death before the introduction of intra venous fluids in the

1950s would have been strongly selected against in nature.

Some researchers have reported that certain factors may be associated with an

increased risk of developing or increasing the duration of hyperemesis gravidarum

including a history of hyperemesis gravidarum in a previous pregnancy, a family history

of severe nausea/vomiting in pregnancy, younger maternal age, high body weight

(obesity), no previous completed pregnancies (nulliparity), carrying multiples, a first-time

pregnancy, allergies, and a restrictive diet.

Management

Initial management in pregnant women with hyperemesis gravidarum should be

conservative and may include reassurance, dietary recommendations, and support.

Alternative therapies may include acupressure and hypnosis. [4]

Pharmacotherapy

The only FDA-approved drug for treating nausea and vomiting in pregnancy is

doxylamine/pyridoxine. However, antihistamines, antiemetics of the phenothiazine class,

and promotility agents (eg, metoclopramide) have also been used to manage nausea and
 32

vomiting during pregnancy. In cases refractory to standard therapy, ondansetron and

steroids may be considered.

The following medications may be used in women with hyperemesis gravidarum:

● Vitamins (eg, pyridoxine)

● Herbal medications (eg, ginger)

● Antiemetics (eg, doxylamine-pyridoxine, prochlorperazine, promethazine,

chlorpromazine, trimethobenzamide, metoclopramide, ondansetron)

● corticosteroids (eg, methylprednisolone)

● Antihistamines (eg, meclizine, diphenhydramine)

Surgery

In some refractory severe cases of hyperemesis gravidarum, if maternal survival is

threatened, or if hyperemesis gravidarum is causing severe physical and psychological

burden, termination of the pregnancy should be considered.

HYPERMESIS GRAVIDARUM vs. MORNING SICKNESS

Morning sickness and HG are very different conditions. They have different

complications and side effects for each pregnant woman. It’s important to distinguish

between these two conditions to properly treat symptoms. Morning sickness typically

includes nausea that’s sometimes accompanied by vomiting. These two symptoms

usually disappear after 12 to 14 weeks. The vomiting doesn’t cause severe

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dehydration.Morning sickness typically begins in the first month of pregnancy. It usually

goes away by the third or fourth month. Pregnant women with morning sickness can get

fatigue and a slight loss of appetite. They may have difficulty performing their usual

daily activities.

Hyperemesis Gravidarum typically includes nausea that doesn’t go away and severe

vomiting that leads to severe dehydration. This doesn’t allow you to keep any food or

fluids down.The symptoms of HG begin within the first six weeks of pregnancy. Nausea

often doesn’t go away. HG can be extremely debilitating and cause fatigue that lasts for

weeks or months.HG can lead to dehydration and poor weight gain during pregnancy.

There’s no known way to prevent morning sickness or HG, but there are ways to manage

the symptoms.

Pathophysiology

The physiologic basis of hyperemesis gravidarum is controversial. Hyperemesis

gravidarum appears to occur as a complex interaction of biological, psychological, and

sociocultural factors. Several proposed theories are discussed below.

Hormonal changes

Women with hyperemesis gravidarum often have high hCG levels that cause

transient hyperthyroidism. hCG can physiologically stimulate the thyroid gland thyroid-

stimulating hormone (TSH) receptor. hCG levels peak in the first trimester. Some women

with hyperemesis gravidarum appear to have clinical hyperthyroidism. However, in a

larger portion (50-70%), TSH is transiently suppressed and the free thyroxine (T4) index
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is elevated (40-73%) with no clinical signs of hyperthyroidism, circulating thyroid

antibodies, or enlargement of the thyroid. In transient hyperthyroidism of hyperemesis

gravidarum, thyroid function normalizes by the middle of the second trimester without

antithyroid treatment. Clinically overt hyperthyroidism and thyroid antibodies are usually

absent.

A report on a unique family with recurrent gestational hyperthyroidism associated

with hyperemesis gravidarum showed a mutation in the extracellular domain of the TSH

receptor that made it responsive to normal levels of hCG. Thus, cases of hyperemesis

gravidarum with a normal hCG may be due to varying hCG isotypes.

A positive correlation between the serum hCG elevation level and free T4 levels has been

found, and the severity of nausea appears to be related to the degree of thyroid

stimulation. hCG may not be independently involved in the etiology of hyperemesis

gravidarum but may be indirectly involved by its ability to stimulate the thyroid. For

these patients, hCG levels were linked to increased levels of immunoglobulin M,

complement, and lymphocytes. Thus, an immune process may be responsible for

increased circulating hCG or isoforms of hCG with a higher activity for the thyroid.

Critics of this theory note that (1) nausea and vomiting are not usual symptoms of

hyperthyroidism, (2) signs of biochemical hyperthyroidism are not universal in cases of

hyperemesis gravidarum, and (3) some studies have failed to correlate the severity of

symptoms with biochemical abnormalities.

Some studies link high estradiol levels to the severity of nausea and vomiting in

patients who are pregnant, while others find no correlation between estrogen levels and

the severity of nausea and vomiting in pregnant women. Previous intolerance to oral
 35

contraceptives is associated with nausea and vomiting in pregnancy. Progesterone also

peaks in the first trimester and decreases smooth muscle activity; however, studies have

failed to show any connection between progesterone levels and symptoms of nausea and

vomiting in pregnant women. Lagiou et al studied prospectively 209 women with nausea

and vomiting who showed that estradiol levels were positively correlated while prolactin

levels were inversely associated with nausea and vomiting in pregnancy and no

correlation existed with estriol, progesterone, or sex-hormone binding globulin.

Gastrointestinal dysfunction

The stomach pacemaker causes rhythmic peristaltic contractions of the stomach.

Abnormal myoelectric activity may cause a variety of gastric dysrhythmias, including

tachygastrias and bradygastrias. Gastric dysrhythmias have been associated with morning

sickness. The presence of dysrhythmias was associated with nausea while normal

myoelectrical activity was present in the absence of nausea. Mechanisms that cause

gastric dysrhythmias include elevated estrogen or progesterone levels, thyroid disorders,

abnormalities in vagal and sympathetic tone, and vasopressin secretion in response to

intravascular volume perturbation. Many of these factors are present in early pregnancy.

These pathophysiologic factors are hypothesized to be more severe or the gastrointestinal

tract more sensitive to the neural/humoral changes in those who develop hyperemesis

gravidarum.

Levels of the plasma gut satiety hormones peptide YY (PYY) and pancreatic

polypeptide (PP) may play a role in hyperemesis gravidarum and pregnancy-related

 36

weight changes. In a prospective case-control study of 60 women (30 women with

hyperemesis gravidarum, 30 control women), Köşüş et al found that affected women had

significantly elevated plasma PYY and PP levels relative to the control group, and that

PP levels were the the most important diagnostic and prognostic factors of hyperemesis

gravidarum. [19]

Hepatic dysfunction

Abnormal liver function studies are noted in approximately 3% of pregnancies,

and pregnancy-related diseases are the most frequent causes of liver dysfunction during

pregnancy. There appears to be a trimester-specific occurrence of liver disease during

pregnancy.

Liver disease, usually consisting of mild serum transaminase elevation, occurs in

almost 50% of patients with hyperemesis gravidarum. Impairment of mitochondrial fatty

acid oxidation (FAO) has been hypothesized to play a role in the pathogenesis of

maternal liver disease associated with hyperemesis gravidarum. It has been suggested that

women heterozygous for FAO defects develop hyperemesis gravidarum associated with

liver disease while carrying fetuses with FAO defects due to accumulation of fatty acids

in the placenta and subsequent generation of reactive oxygen species. Alternatively, it is

possible that starvation leading to peripheral lipolysis and increased load of fatty acids in

maternal-fetal circulation, combined with reduced capacity of the mitochondria to oxidize

fatty acids in mothers heterozygous for FAO defects, can also cause hyperemesis

gravidarum and liver injury while carrying nonaffected fetuses.

 37

LABORATORY RESULTS

HEMATOLOGY

Diagnostic test: HEMATOLOGY is practiced by specialists in the field who deal

with the diagnosis, treatment and overall management of people with blood disorders

ranging from anemia to blood cancer.

Complete Blood Count - The complete blood count (CBC) is one of the most

commonly ordered blood tests. The complete blood count is the calculation of the cellular

(formed elements) of blood. These calculations are generally determined by special

machines that analyze the different components of blood in less than a minute. A major

portion of the complete blood count is the measure of the concentration of white blood

cells, red blood cells, and platelets in the blood component.

 38

Components Result Normal value Interpretation Nursing

responsibility

Hemoglobin 79 g/L 120-140g/L Normal Health Teaching

Segmenters 0.74 0.54-0.64 Increased Increase fluid

intake.

White Blood cell 11.60 x10⁹/L 4.4-11.3x10⁹/L Normal Minimize risk of

count infection

Lymphocytes 0.18 0.29-0.39 Decreased Health Teaching

Eosinophils 0.01 0.02-0.06 Normal Health Teaching

Monocyte 0.06 0.04-0.09 Normal Health Teaching

Hematocrit 0.38 0.35-0.44 Normal Health Teaching

Platelet count 324x10⁹/L 150x450x10⁹/L Normal Health Teaching

 39

Electrolytes

The electrolyte panel is used to identify an electrolyte, fluid, or pH imbalance

(acidosis or alkalosis). It is frequently ordered as part of a routine health exam. It may be

ordered by itself or as a component of a basic metabolic panel (BMP) or a comprehensive

metabolic panel (CMP). These panels can include other tests such as BUN, creatinine,

and glucose. Electrolyte measurements may be used to help investigate conditions that

cause electrolyte imbalances such as dehydration, kidney disease, lung diseases, or heart

conditions. A series of electrolyte panels may also be used to monitor treatment of the

condition causing the imbalance.

Components Result Normal value Interpretation Nursing

responsibility
 40

Sodium 106 mmol/L 135.0-148.0 Decreased Health Teaching

mmol/L

Potassium 7.03 mmol/L 3.50-5.30 mmol/L Increased Health Teaching

Calcium, ionized 1.18 mmol/L 1.15-1.33 mmol/L Normal Health Teaching

Urinalysis

A urinalysis is a group of physical, chemical, and microscopic tests. The tests

detect and/or measure several substances in the urine, such as byproducts of normal and

abnormal metabolism, cells, cellular fragments, and bacteria.

Urine is produced by the kidneys, two fist-sized organs located on either side of

the spine at the bottom of the ribcage. The kidneys filter wastes out of the blood, help

regulate the amount of water in the body, and conserve proteins, electrolytes, and other

compounds that the body can reuse. Anything that is not needed is eliminated in the

urine, traveling from the kidneys through ureters to the bladder and then through

the urethra and out of the body. Urine is generally yellow and relatively clear, but each
 41

time a person urinates, the color, quantity, concentration, and content of the urine will be

slightly different because of varying constituents.

NORMAL

COMPONENTS RESULT VALUES INTERPRETATIO Nursing

N Responsibility

Colour Dark Yellow Pale Not normal Health

yellow- Teaching

yellow

Reaction 6.0 4.5-8 Increased Health

Teaching

Specific Gravity 1.030 1.001-1.030 Normal Health

Teaching

Transperancy Slightly hazy Clear or Not Normal Health

cloudy Teaching

Sugar Negative Negative Normal Health

Teaching

Albumin Trace /HPF Normal Health

Teaching

Pus Cells 7-10/HPF 0-5/HPF Increased Health

Teaching

RBC 5-8/ HPF 0-5/ HPF Increased Health

Teaching

Epithelial Cells Moderate /HPF Normal Health

 42

Teaching

List of Drugs

o Cefuroxime

o Paracetamol

o Omeprazole
 43

LIST OF PRIORITIZED NURSING PROBLEM

1.Deficient fluid volume to active fluid volume loss secondary to hyperemesis

gravidarum.

2. Hyperthermia related to dehydration secondary to hyperemsis gravidarum

3. Imbalanced nutrition less than body requirements related to inability to ingest food

secondary to hyperemesis gravidarum

4. Activity Intolerance related to generalized weakness secondary to Hyperemesis

Gravidarum.

5. Disturbed sleep pattern related to environmental barrier.

 44

PROGNOSIS

Prognosis Good Fair Poor Justification

Onset of Patient claimed that she is experienci

illness nausea and vomiting for 5 days along

with fever. The symptoms of HG beg

within the first six weeks of pregnanc

Nausea often doesn't go away. HG ca

✔
extremely debilitating and cause fatig
 45

that lasts for weeks or months (Wilso

2014).

Patient stayed at the hospital for three

Duration of days at OB Ward. According to the

illness McMeachan, Preganant women

✔
experience nausea during pregnancy

complete relief by about 14 week wit

treatment.

Hygiene Patient can perform simple task witho

depending on her family and nurse.

✔

Diet Patient knows the right food to decre

vomiting like plain crackers which is

really helpful in treating her vomiting

✔

After she was given medications, t

Performanc patient is now able to work without

e Level assistance.
✔
 46

Age Patient is 14 years old . According to

recent study of the age group that are

high-risk patient and being pregnant a

✔
young age increases your risk of havi

HG.

Willingness Patient shows willingness to undergo

✔
to undergo treatment to treat the pain she is

the experiencing.

treatment

Family The family of the patient does not ful

support show support to the patient because a

a few days she was left the hospital a

alone. As evidence by participation o

✔
 47

family in the hospital will be effectiv

parents and relatives are adequately

informed about patients’ condition an

appropriately educated by medical an

nursing staff, in order to provide their

patients with effective psychological

support ( Bellou, 2019).

Good – 5/8 × 100% = 75%

Fair – 0/8 × 100% = 0%

Poor – 2/8 ×100% = 25%

Remarks:

Prognosis shows the patient’s condition in getting well is good because most of

the criteria has good remarks

 48

REFERENCES:

CDC. (2018). National Vital Statistics. (2018). Retrieved from:

https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_05.pdf

Funai, E., Norwitz, E. (2019). Management of hyperemesis gravidarum. Retrieved from:

https://www.uptodate.com/contents/management-of-hyperemesis gravidarum/print

Female Reproductive System. Retrieved from:

https://courses.lumenlearning.com/boundless-ap/chapter/the-female-reproductive-system/

Milton,S. (2019). URINARY TRACT INFECTION. Retrieved from:

https://emedicine.medscape.com/article/260036-overview

Maternal Changes during pregnancy, First trimester. Retrived from:

https://opentextbc.ca/anatomyandphysiology/chapter/28-4-maternal-changes-during-

pregnancy /
 49

Urinary tract infection diagnosis. Delivery.Retrieved from:

https://www.healthline.com/health/pregnancy/urinary tract infection.com #1

Stoppler, M. (2019). 10 Early signs and symptoms. Retrieved from:

https://www.medicinenet.com/early_signs_and_symptoms_of_labor/article.htm