Definition Severe and unremitting nausea and vomiting that persist after the first trimester.

Usually occurs with the first pregnancy and commonly effects pregnant women with conditions that produce high levels of human chorionic gonadotropin (hCG), such as gestational trophoblastic disease or multiple gestations.

Pathophysiology
Exact cause is unknown, but it’s linked to trophoblastic activity, gonadotropin production, and psychological factors. Various possible causes: Hormonal changes Pancreatitis Biliary tract disease Decreased secretion of free hydrochloric acid in the stomach Urinary tract infection Gastroenteritis Drug induced vomiting Decreased gastric motility (slowed emptying of the stomach and intestines) Gastrointestinal dysfunction

Drug toxicity Vitamin deficiency (especially of B6) Multiple pregnancy Hydatidiform mole Diabetic ketoacidosis Vestibular and olfaction Hepatitis Bowel obstruction Hyperthyroid disorders Psychological factors (in some cases) Greater body weight Infection

Symptoms of hyperemesis gravidarum The following are the most common symptoms of hyperemesis gravidarum. However, each woman may experience symptoms differently. Symptoms may include: constant nausea, especially after the first trimester vomiting after eating or drinking vomiting not related to eating weight loss dehydration ptyalism (excessive salivation), fatigue, weakness, and dizziness.

When HG is severe and/or inadequately treated, it may result in: Loss of 5% or more of pre-pregnancy body weight Dehydration Nutritional deficiencies Metabolic imbalances Difficulty with daily activities Altered sense of taste Sensitivity of the brain to motion Food leaving the stomach more slowly Rapidly changing hormone levels during pregnancy Stomach contents moving back up from the stomach Physical and emotional stress of pregnancy on the body Physical and emotional stress on ones coworkers The popping of blood vessels in eyes. Hallucinations . The appearance of a blue aura around people.

Complications For the pregnant woman If inadequately treated, HG can cause renal failure, central pontine myelinolysis, coagulopathy, atrophy, Mallory-Weiss syndrome, hypoglycemia, jaundice, malnutrition, Wernicke's encephalopathy results from a deficiency of thiamine (vitamin B1) and is manifested by confusion, ophthalmoplegia (paralysis of the eye muscles), or convulsions , esophageal rupture, pneumomediastinum (presence of air or gas in the mediastinum), vasospasms of cerebral arteries, rhabdomyolysis (disintegration of striated muscle fibers with excretion of myoglobin in the urine), deconditioning, splenic avulsion, peripheral neuropathy due to vitamin B6 and B12 deficiency, and coagulopathy due to vitamin K deficiency. Depression is a common secondary complication of HG. There is also a side effect of constipation.

For the fetus No long-term follow-up studies have been conducted on children of hyperemetic women. Children born to hyperemetic women appear to have no greater risk of complications or birth defects than the general population. However, recent research in fetal programming indicates that prolonged stress, dehydration and malnutrition during pregnancy can put the fetus at risk for chronic disease, such as diabetes or heart disease, later in life, or neurobehaviorial issues from birth. This underscores the importance of aggressive treatment of the condition.

Diagnosis and investigations  The diagnosis of hyperemesis is only made after exclusion of other pathology • Obtain detailed history including any maternal disease or conditions related to nausea and vomiting • Clinical assessment for signs of dehydration • Exclude maternal disease, molar or multiple pregnancy

Investigations are required to determine the degree of physiological disturbance and to exclude significant pathology if indicated by history and examination. Ward urinalysis, microurine and culture Blood for urea, electrolytes and serum creatinine Blood sugar if diabetic Liver function tests (specific hepatitis serology if indicated) Thyroid stimulating hormone, free T4 level to exclude thyrotoxicosis Serum amylase if pancreatitis considered Obstetric ultrasound to confirm ongoing pregnancy and exclude multiple pregnancy or hydatidiform mole Abdominal erect and supine x-rays if suspected bowel obstruction

Exclusion of other pathology before diagnosis of hyperemesis gravidarum
Possible cause Urinary tract infection Gastroenteritis Drug induced vomiting Multiple pregnancy Hydatidiform mole Diabetic ketoacidosis Hepatitis Addison's disease Thyrotoxicosis Pancreatitis Bowel obstruction Raised intracranial pressure Investigations if indicated by history and examination Urinalysis, microurine, urine culture Stool culture Obstetric ultrasound Obstetric ultrasound Urinalysis, electrolytes, blood sugar level Liver function Specific hepatitis serology Electrolytes, creatinine Thyroid stimulating hormone, free T4 level Serum amylase Erect / supine abdominal X-ray with appropriate shielding MRI or CT head tests

Treatment Intravenous rehydration  Intravenous fluid replacement: usually 2 litres of sodium chloride 0.9 % with each litre given over 2 to 3 hours. This may be reduced but should not be exceeded according to assessment of fluid balance. Potassium containing fluids should be used depending on the most recent electrolyte measurement.  This is the most important component of management  Use electrolyte solutions containing sodium- and potassium to correct the hyponatremia + / - hypokalemia  It is recommended glucose is avoided as it may precipitate Wernicke's encephalopathy (Bergin 1992). If glucose is used, thiamine (100 mg once daily either orally or intravenous) should be given to prevent this.

Antiemetics Metoclopramide (Maxolon) - 10 mg tablets, one tablet taken three times a day. Side effects may include extrapyramidal signs and oculogyric crises Doxylamine (Restavit) - 25 mg tablets, one at night. Doxylamine with Vitamin B6 (Diclectin) is the only medication approved in Canada for nausea and vomiting in pregnancy (Category A) Promethazine theoclate (Avomine) - 25 mg morning and night. Side effects include sedation Prochlorperazine (Stemetil) - Suppositories, 25 mg once or twice daily for severe, persistent and uncontrolled hyperemesis gravidarum, not relieved by the above treatment Promethazine and prochlorperazine - Category C for use in pregnancy, as when used in large doses late in pregnancy, they have been associated with extrapyramidal side effects in the infants after birth

Vitamins  Studies report pyridoxine (vitamin B6) significantly reduces nausea, but there was no significant reduction in vomiting (Sahakian 1991;Vutyavanich 1995)  Pyridoxine - 25 mg tablets, one tablet taken three times a day Observations Temperature, pulse, respiratory rate and blood pressure on admission and every two hours during intravenous fluid treatment.

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