CASE REPORT

HYPEREMESIS GRAVIDARUM
Presented by :
Eva Faoziyah Saleh
12100116040
Supervised by :
dr. Hj. Hesty Duhita Permata, Sp.OG

Department of Obstetric and Gynecology

Faculty of Medicine Bandung Islamic University
RSUD R. Syamsudin, S.H., Sukabumi
 INTRODUCTION
Hyperemesis Gravidarum
Hyperemesis Gravidarum is a severe type of vomiting of pregnancy which has got
deleterious effect on the health of mother and/or incapacitates her in day-to-day
activities
According to the World Health Organization (WHO) 2014 the incidence of hyperemesis
gravidarum reaches 35.5% of the total number of Pregnancy in the world. Based on the
results of the DEPKES RI research in 2014 explained that more than 80% of pregnant
women experience nausea and vomiting. According in West Java, 25% of pregnant
women have hyperemesis gravidarum
Hyperemesis gravidarum is clinically classified as mild or severe, depending on
associated metabolic disturbances such as carbohydrate depletion, dehydration and
electrolyte imbalance
 IDENTITY
Name : Mrs. AK Husbands name : Mr.R
Age : 24 years old Age : 27 years old
Nationality : Indonesian Religion : Moslem
Address : Grya Karang Tengah Last Education : Senior High School
Marital status : Married Occupation : Entrepreneur
Occupation : Housewife
Religion : Moslem
Date of admision : August, 12th 2017
 HISTORY TAKING

nausea and
Chief vomitus 5 days
Complaint prior to
admission
 HISTORY OF PRESENT ILLNESS
5 days prior 3 days limp, and these
symptoms
to admission prior to interfered her daily
activities.
admission
She took Ranitidin 2
Nausea and vomitus, 6 times a day, and
until 7 times a day, that fever, the
temperature of her Paracetamol 3 times a
contained food with no day for 2 days.
blood. body could reach
38,5 C
Before this
headache and fever pregnancy, she had
headache, the were relieved for regular dietary
sensation is dizziness 2 days prior several hours but it habit. She ate 3
without spinning came again. times a day.
sensation.
to admission
Other symptoms like Epigastric pain
couldnt take any food or nausea, vomitus still was denied.
drink and she vomited all
felt the sourness
sensation in the persisted after Other abdominal
food or drink that she medications. pain was denied.
has taken. mouth.
HISTORY OF PAST ILNESS
History of gastritis or dyspepsia denied
History of diarrhea denied
History of allergy denied
History of diabetes mellitus denied
History of asthma denied
 FAMILY HISTORY

History of hypertension : denied

History of diabetes mellitus : denied
MENSTRUATION HISTORY

Menarche : 12 years old

regularly every 28-30 days, 6-7 days
duration and without history of
Menstrual cycle dysmenorrhea, menorraghia,
metrorraghia
2-3 normal pads / day ( 40-
Amount of menstrual blood 60 cc )

LMP June, 10th 2017

 HISTORY
Contraception History
injection contraception every 3 months for 17 months, stopped since last
year, no complaints while using this type of contraception and she
stopped using it because she wanted to have a child again.
Marital History
Married once, this marriage has been going on for 4 years.
Antenatal Care History
The patient has gone for 2 times antenatal cares routinely at midwife
 OBSTETRIC HISTORY

No Date Gestational Age Labor History Sex Birth Weight

1. 2014 Aterm Spontaneous Boy 2800 g

2. 2017 (this
pregnancy)
 moderately ill
General condition
appearance
Consciousness Compos Mentis

Blood pressure 100/60 mmHg

Heart rate 100 bpm

Physical Respiratory rate 21 times/minute
Examination
Temperature 36,8C

Weight 56 kg

Height 155 cm

BMI 23,31 kg/m2

 GENERAL EXAMINATION
Eyes: anemic conjunctiva -/-, icteric
sclera -/-
Mouth: dry oral mucosa membrane,
dry lips, smell of ketones (+)
Cor and Pulmo within normal limits
Mammae: nipple retraction -/-breast
milk -/-
Abdomen
Inspection: rounded shape
Auscultation: bowel sound +, 5 times
in a minute
Palpation: supple in all abdominal
region, tenderness -
Extremities: warm, edema -/-/-/-, CRT <
2 seconds, physiological reflex
++/++/++/++, pathological reflex --/--
 OBSTETRIC EXAMINATION
Inspection Convex
Estimated Due Date April, 17th 2018
Fundal height 1-2 fingers upper the symphysis
Fetal heart rate not performed
His (-)
Inspeculo not performed
Inspection not performed
Vaginal toucher not performed
 LABORATORY EXAMINATION
August, 12th 2017
Types Results Units Normal Value
Hemoglobin 12,2 g/dL 12 14
Hematocrit 36 % 37 47
Leucocytes 8.200 /uL 4000 10000
Erythrocyte 4,0 Millions/ uL 3.8-5.2
Platelets 227 thousands/uL 150-400
Quantitative Anti-HIV Non reactive Non reactive
MCV 91 fL 80-100
MCH 31 pg 26-34
MCHC 34 g/dL 32-36
 URINE LAB TEST
Chemistry Normal Value
Color Yellow Yellow
Clarity Turbid Clear
pH 6,0 4,6-8,0
Specific Gravity (SG) 1,030 1,005-1,03
Leucocytes Negative sel/uL Negative
Nitrite Negative Negative
Protein Negative mg/dL Negative
Glucose Negative mg/dL Negative
Ketones Positive +++ / 150 mg/dL Negative
Urobilinogen Normal mg/dL <1
Bilirubin Negative Negative
Erythrocytes Positive + / 10 cells/uL Negative
 URINE LAB TEST
Microcopic Normal Value

Leucocytes 1-2 /LPB <6

Erythrocytes 0-2 /LPB <3

Epithelial cells 8-10 /LPK 1-15

Cylinder Negative /LPB Negative

Crystals Negative /LPB Negative

Bacteria Negative /LPK Negative

Others Negative Negative

BhCG Urine Positive

Types Results Units Normal Value
BT 1.3 Minute 13
CT 7,3 Minute 5 - 15
Random BG 94 mg/dL <140
Ureum 18 mg/dL 15-36
Creatinin 0.60 mg/dL 0,52-1,04
SGOT (AST) 23 U/L <31
SGPT (ALT) 11 U/L <32
Electrolytes
Sodium 144 mmol/L 137-150
Potassium 3,5 mmol/L 3,5-5,5
Calcium 10,6 mg/dL 8-10,4
Chloride 105 mmol/L 94-108
 USG

Interpretation USG : Single live intrauterine fetus, sac length 35.5 mm with
gestation age at 12 week, positive movement and pulsation of the fetus.
 WORKING DIAGNOSIS
Mrs. AK, G2P1A0, 24 years old, 11-12 weeks pregnancy, single
live fetus intra uterine with Hyperemesis Gravidarum level II
 MANAGEMENT
D5% 1850 cc / 24 hours
High Calories and High Protein Diet
Vitamin B6 3x10 mg
Ondansetron 2x4 mg iv
Ranitidine 2x150 mg
Education
FOLLOW UP
S O A P
Limp, General condition : moderate Mrs. AK, G2P1A0, 24 D5% : RL
nausea and ill apperance High Calories and High Protein
vomitus years old, 11-12 weeks
Level of consciousness : CM
Diet
BP: 100/60 mmHg
pregnancy, single live
Vitamin B6 3x10 mg
HR: 100x/minute fetus intra uterine with
Ondansetron 2x4 mg iv
RR : 21x/minute Hyperemesis Gravidarum
Temperatur : 36,8 C
Ranitidine 2x150 mg

Mouth : dry oral mucose Education

Abdomen:
I: convex
A: bowel sounds (+),
4x/minutes
P: supple, pain with palpation
(-)
Fundal height: 2 fingers upper
the symphysis
S O A P
Limp, but General condition : moderate Mrs. AK, G2P1A0, 24 D5% : RL
decreasing ill apperance High Calories and High Protein
in nausea years old, 11-12 weeks
Level of consciousness : CM
and vomitus pregnancy, single live Diet
BP: 110/70 mmHg
Vitamin B6 3x10 mg
HR: 82x/minute fetus intra uterine with
Ondansetron 2x4 mg iv
RR : 20x/minute Hyperemesis Gravidarum
Temperatur : 36,5 C
Ranitidine 2x150 mg

Mouth : wet oral mucose Education

Abdomen:
I: convex
A: bowel sounds (+),
4x/minutes
P: supple, pain with palpation
(-)
Fundal height: 2 fingers upper
the symphysis
S O A P
decreasing General condition : mild ill Mrs. AK, G2P1A0, 24 D5% : RL
in nausea apperance High Calories and High Protein
and vomitus years old, 11-12 weeks
Level of consciousness : CM
Diet
BP: 110/70 mmHg
pregnancy, single live
Vitamin B6 3x10 mg
HR: 82x/minute fetus intra uterine with
Ondansetron 2x4 mg iv
RR : 20x/minute Hyperemesis Gravidarum
Temperatur : 36,5 C
Ranitidine 2x150 mg

Mouth : wet oral mucose Education

Abdomen:
I: convex
A: bowel sounds (+),
4x/minutes
P: supple, pain with palpation
(-)
Fundal height: 2 fingers upper
the symphysis
 Take Home Medicines
Vitamin B6 3x10 mg
Ondansetron 2x4 mg
Ranitidine 2x150 mg
Education
 PROGNOSIS
Quo ad vitam : dubia ad bonam
Quo ad functionam : bonam
Quo ad sanationam : dubia ad bonam
CASE ANALYSIS
 How to diagnosed this patient?
Theory Case
Anamnesis Diagnosis Hyperemesis gravidarum Patient came to the hospital 11-
begins with a first diagnosis of 12 weeks pregnant by USG and
pregnancy that can be found. In the complaining to have nausea and
history of amenorrhoea complaint, as vomitus 5 days prior to
well as nausea and severe vomiting admission, 6-7 times a day. She
that interfere their daily activities. felt limp and interfere her daily
activities 2 days prior to
admission. She couldnt take any
food or drink.
 Theory Case

Risk factors - Young maternal age Risk factors present in

- Diabetes before onset of this case is young
pregnancy maternal age.
- Depression
- Psychiatric illness
- Gastrointestinal disorder
- Asthma
- Multiple birth
 Theory Case

Physical Dehidration as a sign of Increasing of heart rate,

Hyperemesis Gravidarum decreasing of blood
examinations
pressure,

Laboratory Ketosis Ketones in Urine +++

studies
 Theory Case

Classification a) Hyperemesis Gravidarum level I : In this case, Hyperemesis

nausea and vomiting, weakness, Gravidarum level II.
decreased appetite, weight loss, and Patient complaining to have nausea
epigastric pain. Maternal pulse rate and vomitus 5 days prior to
usually rises to 100x / min, systolic admission, 6-7 times a day. She
blood pressure decreased, decreased felt limp and interfere her daily
skin turgor, tongue seemingly activities 2 days prior to
seemingly dry and sunken eyes. admission. She couldnt take any
food or drink.
Theory Case
Vital sign :
b) Hyperemesis Gravidarum level II : mother General condition : moderately ill
remains weak, tongue dry and dirty, weak and appearance
rapid pulse palpable, sometimes the body Consciousness:Compos Mentis
temperature rises, and slightly jaundiced eye. Blood pressure:100/60
Maternal weight down, raised hypotension, Heart rate:100xbpm
Respiratory rate : 21x/minute
hemoconcentration,oliguria, constipation and
Temperature:36,8C
bad breath acetone.
Weigh:56 kg
Height: 155 cm
BMI: 23,31 kg/m2
Sometimes temperature slightly : 38.5
PE (Mouth) : dry oral mucosa membrane, dry
lips, smell of ketones (+)
Theory Case

c) Hyperemesis Gravidarum level III including

decreased maternal awareness of somnolence

to coma, vomiting stops, rapid pulse and small,

the temperature increases and decreases blood

pressure.
 Hows the management of this patient?
Theory Case

Hospitalization Management for this patient was correctly.

Management
Fluid She was hospitalization to improves her
During this period, fluid : intravenous drip, condition better rapidly.
to be infused in 24 hours is calculated as She was given D5% : RL = 800cc : 800cc
follows: The total amount of fluid to treat dehydration and maintanance body
approximates 3 liters, of which half is 5% fluid,
dextrose and half is Ringers solution.
 Theory Case

Drugs She was given high calories and high

Management A. Antiemetic drugs promethazine 25 mg or
protein diet to complete nutrition,
prochlorperazine 5 mg or triflupromazine
vitamin B6 3x10 mg for nutritional
10 mg may be administered 2x1 i.m .
supplementation, ondansetron 2x4 mg iv
Trifluoperazine 1 mg 2x1 i.m is a potent
for vomitus, ranitidine 2x150 mg is a
antiemetic therapy. Vitamin B6 and
antihistamin to reduce gastric juice
doxylamine are also safe and effective.
Metoclopramide stimulates gastric and
intestinal motility without stimulating the
secretions. It is found useful.
Theory Case

B. Hydrocortisone 100 mg IV in the drip She take care education to

is given in a case with hypotension or in rest and avoid stimulating
intractable vomiting. Oral method foods, such as spicy foods,
prednisolone is also used in severe cases. fatty foods, or iron
C. Nutritional supplementation with supplements. Simple diet
vitamin B1 (100 mg daily), vitamin B6, changes, foods and beverages
vitamin C and vitamin B12 are given. in small portions but often.
 Conclusion
1. Diagnosis hyperemesis
gravidarum :
COMPLAINING : nausea and
vomiting 5 days , 6-7 time a
day. Interfere her daily
activities.
RF : young maternal age
PE : hipotension, takikardia,
sometimes temperatur
slightly increased.
Smell of keton (+)
LAB : keton urine +++
2. Management for this patient
was correctly .
hospitalization to improves her
condition better rapidly.
She was given D5%
Vitamin B6
Ondansetron
Ranitidine
Education patient to rest and
avoid stimulating foods, such
as spicy foods, fatty foods, or
iron supplements
THANK YOU