Hyperemesis Gravidarum

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Hyperemesis Gravidarum

• Hyperemesis Gravidarum is from Greek word:

 Hyper: meaning excessive

 Emesis: meaning ,vomiting

 Gravidarum: meaning pregnant woman

• Excessive vomiting that occurs in pregnant women

 Severe enough to cause electrolyte, metabolic and nutritional imbalance.

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HEG…

Morning sickness: is the nausea felt by about 50% of pregnant women

on getting up in the morning.

Emesis Gravidarum: Actual vomiting in the morning

HEG: Vomiting is not confined to the morning but is repeated

throughout the day until it affects the general condition of the patient.

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Incidence…

• Hyperemesis affects between 0.3% and 2.3% of all pregnancies.

• It is now a rarity in hospital practice (less than 1 in 1000 pregnancies).

• Usually starts b/n the 4th & 6th weeks, peaks around the 9th week &
improves/disappears about the 20th week.

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Incidence…

• However, in up to 20% of cases, nausea and vomiting may continue

until delivery.

• Women who experienced hyperemesis in their first pregnancy have a

high risk for recurrence.

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Etiology & Risk Factors
• The cause of pregnancy-related nausea and vomiting is not clear. Several
theories have been proposed, although none have been definitively proven.
• This theories are:
1. hormonal
2. Psychogenic
3. Dietetic
4. Allergic or immunologic basis
5. Helicobacter pylori infection

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Theories…
1.Hormonal

A.Excess or higher biological activity of hCG is associated;

• High hCG stimulates the chemoreceptor trigger zone in the brain stem

including the vomiting center.

• This is proved by the frequency of vomiting at the peak level of hCG

and also the increased association with hydatidiform mole or multiple

pregnancy when the hCG titer is very much raised.

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Theories…
B. High serum level of estrogen
Production of nitric oxide via nitrogen oxidase synthetize
Female fetuses??
C. Progesterone excess
 Reduced gastrointestinal motility and retention of gastric fluids due
to impaired gastric motility.
Other hormones involved are: thyroxin, prolactin, leptin and
adrenocortical hormones.

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Theories…

2. Psychogenic

Due to psychological rejection of an unwanted pregnancy,

Fear of pregnancy or labor so it is more common in primigravida.

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Theories…

3. Dietetic Deficiency

 Probably due to low carbohydrate reserve, as it happens after a

night without food.

 Deficiency of vitamin B6, Vit. B1 and proteins

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Theories cont…

4. Helicobacter pylori infection

 Chronic infection with helicobacter pylori may also cause HEG.

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Etiology and risk factors…

Risk factors are:

 Multiple pregnancy,

 Null-parity,

 Metabolic disturbances,

 A history of HEG in a previous pregnancy,

 Trophoblastic disorders,

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Etiology and risk factors…

 Psychological disorders,

 Eating disorders such as anorexia nervosa,

 Women who did not take multivitamins,

 Daughters of women with hyperemesis.

 History of motion sickness or migraine

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Pathological Changes

These are the same as in the effects of prolonged starvation and severe
malnutrition:

√ Liver: There is centrilobular fatty infiltration without necrosis.

√ Kidney: fatty degeneration of the convoluted tubules; Which may be

related to acidosis.

√ Heart: small subendocardial and subpericardial haemorrhages.

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Pathological Changes…

√ Brain: congestion and petechial haemorrhages in the brain stem

resembling that of Wernicke’s encephalopathy.

√ Eye: optic neuritis and retinal haemorrhage.

√ Peripheral nerves: degeneration.

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Pathological Changes…

Blood:

• Hypovolemia and Hemoconcentration.

• Hyponatremia, Hypokalemia and Hypochloraemia.

• Increased blood urea.

• Hyperbilirubinemia (due to liver damage).

• Acidosis.
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Pathological Changes…

Urine:

• Oliguria.

• Increased specific gravity.

• Decreased chloride.

• Albuminuria.

• Ketonuria.
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Sign & Symptoms

Sign

 Manifestations of starvation & dehydration

• > 5% or 3 kg pre pregnancy weight Loss
• Sunken eyes
• Dry tongue & inelastic skin
• Rapid & weak pulse
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Sign and Symptoms…

• Low blood pressure

• Breath smells like Acetone

• Scant & dark urine due to acetone

• Tachycardia

• Rise in temperature may be noted

• Jaundice is a late feature.

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Signs and Symptoms…

Symptoms

• Can’t retain anything in her stomach, vomiting occurs through the day and
night even without eating.

• Thirst, constipation and oliguria.

• In severe cases, vomitus is bile and/ or blood stained.

• Finally, there is manifestations of Wernicke's encephalopathy as drowsiness,

nystagmus and loss of vision then coma.
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Signs and Symptoms…

• Sensitive to odors in there environment:

- Hyper olfaction

• Ptyalism

• Symptoms can be aggravated by hunger, fatigue, prenatal

vitamins( iron containing).

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Investigations/Evaluations

Measurement of;  U/S

 BUN
Weight  Creatinine
B/P  CBC
Heart rate  LFT
Respiratory rate  Thyroid function tests
 Serum electrolytes  Calcium level
 Urinalysis ECG
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Diagnosis

• The pregnancy is to be confirmed first. Thereafter, all the associated

causes of vomiting (enumerated before) are to be excluded.

• Ultrasonography is useful not only to confirm the pregnancy but also

to exclude other, obstetric (hydatidiform mole, multiple pregnancy),
gynecological, surgical or medical causes of vomiting.

• Sign and symptoms

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Management…

The principles in the management are:

• To control vomiting

• To correct the fluids and electrolytes imbalance

• To correct metabolic disturbances (acidosis or alkalosis)

• To prevent the serious complications of severe vomiting

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Management…

Depends upon the:

• Impact of her symptoms on her health and quality of life &

• The safety of treatment for the fetus

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Management…

 Initial approach

• Generally, treatment begins with:

 Advice about diet,
 Avoidance of triggers, and
 Non-pharmacologic interventions

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Management…

 Modalities

1. Non-pharmacological

2. Pharmacological

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Management…

1.Non-pharmacological
• Avoidance of triggers
• Behavioral modification/Psychological support/ counseling
• Diet

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Management...
2. Pharmacological
 Intravenous fluids:
• Re-hydrate with N/S, Ringers lactate, D/W, D/S 1000ml eight hourly.
• Supplementation of electrolytes
- sodium and potassium
• Supplementation for lost Vitamins
- Pyridoxine/ doxylamine, thiamine, folic acid…
• Glucose to correct Ketoacidosis's
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Management…
 Drugs:

• Calorie replacement: Add 40% Glucose 2 vials (40 ml) in each bag.

• Add Vit. B complex 2 ampoules in each bag.

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Management…

• Anti-emetic;

- Chlorpromazine, 12.5 - 25 mg IV or I.M. BID until vomiting is

controlled and then P.O.

- Metoclopromide, 10 mg IM BID.

- Pyridoxine hydrochloride, 20mg/day orally.

- 25 mg of promethazine given every 8 hours for 24 hours.

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Management…

• Vitamins:

- Pyridoxine 10 to 25 mg every 8 hours, and doxylamine, 25 mg at

bedtime and 12.5 mg each in the morning and afternoon.

- Thiamine (100 mg) for 3 days to prevent the possibility of

Wernicke’s encephalopathy.

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Management…

• Order urine test twice/ day for - specific gravity

- Measure intake & out put of fluid, including vomits

Note:
• If vomiting is ceased for 24 hrs oral fluid can be started & if this is
tolerated a high carbohydrate diet may follow
• Then normal food is gradually introduced & IV therapy will be
discontinued.

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THANK YOU!!!