HYPEREMESIS GRAVIDARUM

INTRODUCTION

  • Definitions of Terms:
    • HYPER: Excessive
    • EMESIS: Vomit
    • GRAVIDARUM: Pregnancy
  • Nausea and vomiting of moderate intensity are common until about 16 weeks of pregnancy.
  • Hyperemesis Gravidarum (HG) occurs when vomiting becomes intractable in early pregnancy, leading to:
    • Fluid and electrolyte imbalances
    • Nutritional deficiencies
    • Women may require hospitalization due to severity.

DEFINITION

  • Hyperemesis Gravidarum is defined as a severe type of vomiting during pregnancy that has deleterious effects on the health of the patient and/or incapacitates her day-to-day activities.

ETIOLOGY

  • General Causes:

    • The cause is typically idiopathic, but it is related to hormonal changes. When levels of Human Chorionic Gonadotropin (HCG) are elevated during pregnancy, severe vomiting can occur.

  • Risk Factors:

    • Overweight
    • Multiple pregnancies
    • Presence of trophoblastic disease
    • Abnormal growth of cells in the uterus
    • Psychological factors may also play a role.

RISK FACTORS

  • Factors that increase the likelihood of developing HG:
    • Age below 17 years and over 35 years
    • Primigravidae (first-time pregnancies)
    • Multiple pregnancies
    • Underweight and obesity
    • Psychological factors (e.g., unwanted pregnancy, marital problems)
    • Hyperemesis Gravidarum itself
    • Trophoblastic disease.

ADDITIONAL ETIOLOGICAL FACTORS

  • Hormonal Factors:

    • High levels of HCG in conditions like hydatidiform mole and multiple pregnancies, high levels of Estrogen, and high levels of progesterone (causing relaxation of the cardiac sphincter).
    • Other hormones involved:
    • Thyroxin
    • Prolactin
    • Leptin
    • Adreno-cortical hormones

  • Psychogenic Factors:

    • Psychological aspects may aggravate nausea; neurogenic elements can trigger symptoms once they begin.

  • Dietary Deficiencies:

    • Low carbohydrate reserves, particularly after prolonged periods without food, can heighten symptoms.
    • Deficiencies in vitamins B1, B6, and protein may cause symptoms as opposed to acting as initial triggers.

  • Allergic or Immunological Basis:

    • Chronic nausea may have an allergic or autoimmune component.

  • Decreased Gastric Motility:

    • Disruption in gastric motility may lead to an increased sensation of nausea.

CLINICAL COURSE

  • Early Stage:

    • Persistent vomiting throughout the day
    • Disturbance of normal daily activities
    • No evidence of dehydration or malnutrition.

  • Late Stage:

    • Development of dehydration and malnourishment symptoms.

SYMPTOMS

  • Symptoms associated with Hyperemesis Gravidarum:
    • Excess vomiting and retching, occurring both day and night.
    • Epigastric pain.
    • Constipation.
    • Ptyalism (excessive spitting).
    • Fatigue.
    • Anorexia.
    • Complications arise if untreated.

SIGNS

  • Physical signs to observe:
    • Evidence of dehydration and ketoacidosis, which may present as:
    • Dry, coated tongue
    • Sunken eyes
    • Acetone smell on breath
    • Tachycardia (increased heart rate)
    • Postural hypotension (a drop in blood pressure upon standing)
    • Elevated temperature
    • Jaundice (appearing in later stages)
  • Confirmation of pregnancy is often accomplished through vaginal examination and ultrasound (USG).

INVESTIGATION

  • Sterile Urinalysis:

    • Evaluation focuses on:
    • Quantity (for oliguria)
    • Color (dark due to concentration)
    • High specific gravity with acid reaction
    • Presence of acetone, occasional protein, and bile pigments
    • Diminished or absent chloride levels.

  • Biochemical and Circulatory Changes:

    • Serum electrolytes (Sodium, Potassium, and Chloride) must be assessed.

  • Ophthalmoscopic Examination:

    • Necessary if the patient is seriously ill, as retinal hemorrhage and detachment are significant unfavorable signs.

  • ECG Monitoring:

    • Conducted when serum potassium levels are abnormal.

DIAGNOSIS

  • Steps for diagnosis:
    • Confirm pregnancy first.
    • Exclude other causes of vomiting (gynecological, medical, or surgical).
    • Ultrasound for confirmation of pregnancy or to identify conditions such as hydatidiform mole or multiple pregnancies.

COMPLICATIONS

  • Possible complications of Hyperemesis Gravidarum include:
    • Stress ulcers in the stomach
    • Oesophageal tears
    • Jaundice resulting from liver damage.

PREVENTION

  • The only preventive strategy is effective management aimed at correcting mild vomiting experienced in pregnancy.

MANAGEMENT

  • Principles of Management:

    • Control vomiting.
    • Correct fluid and electrolyte imbalances.
    • Address metabolic disturbances.
    • Prevent serious complications associated with severe vomiting.

  • Hospitalization Protocol:

    • Admit the patient for observation and treatment.
    • Establish an open IV line to correct fluids.
    • Order relevant diagnostic investigations.
    • Maintain an intake-output chart.
    • Monitor urine output (consider catheterization).
    • Regularly monitor vital signs.
    • Periodically test urine for ketone bodies.

FLUID MANAGEMENT

  • Oral feeding is withheld for at least 24 hours after vomiting resolves.
  • During this abstinence, fluids are administered through IV drip.
  • Fluid calculation should approximate 3 liters over 24 hours, divided evenly between 5% dextrose and Ringer's solution.
  • Additional Fluid Needs:
    • Any amount of vomitus and urine output within that 24-hour period should be added as additional 5% dextrose.
  • This approach is vital for correcting dehydration, electrolyte imbalance, and ketoacidosis.
  • Nutritional support through a nasogastric tube may also be provided if necessary.

ANTIEMETIC DRUGS

  • Common medications:

    • Promethazine: 25 mg IM, BD or TDS
    • Trifluoperazine: 10 mg IM
    • Metoclopramide: 10 mg IM
    • Hydrocortisone: 100 mg IV in drip
    • Prednisolone: administered orally

  • Nutritional Support:

    • Vitamins B1, B6, B12, and C should be administered as part of supportive care.

NURSING CARE

  • Caring for the patient includes:
    • Providing sympathetic but firm handling.
    • Daily monitoring for signs of patient improvement, including:
    • Reduction of vomiting
    • Increase in hunger
    • General betterment in appearance
    • Disappearance of acetone odor from breath and urine
    • Normal pulse and blood pressure readings
    • Normal urine output.
    • Monitor lab results for dehydration and electrolyte status.
    • Assess fetal heart rate (FHR), fetal activity, and growth.
    • Encourage the patient to sit upright post-meal.
    • Suggest small and frequent meals to ease symptoms; liquids should be taken between meals to avoid distention and subsequent vomiting.

OBSTETRIC CARE

  • Therapeutic abortion is not indicated if the patient shows improvement with therapy.
  • Rarely prescribed in cases where pregnancy is associated with renal or neurological complications.

DIETARY MANAGEMENT

  • Before initiating IV fluid therapy, provide the patient with:
    • Small, frequent dry meals low in fat.
    • Begin with dry carbohydrates (e.g., biscuits, bread, toast).
    • Ginger may be a helpful adjunct in dietary management.
    • Gradually restore to a full diet as tolerated.