Hyperemesis Gravidarum
HYPEREMESIS GRAVIDARUM
INTRODUCTION
Definitions of Terms:
HYPER: Excessive
EMESIS: Vomit
GRAVIDARUM: Pregnancy
Nausea/Vomiting in Early Pregnancy:
Moderate intensity nausea/vomiting is common until about 16 weeks of gestation.
HCG:
Hyperemesis gravidarum (HCG) occurs when vomiting becomes intractable in early pregnancy, leading to:
Fluid and electrolyte imbalances.
Nutritional deficiencies.
Hospitalization:
Women with severe HCG usually require hospitalization.
DEFINITION
Hyperemesis gravidarum is defined as:
A severe type of vomiting in pregnancy that has deleterious effects on the patient's health.
Incapacitates her day-to-day activities.
ETIOLOGY
General Overview:
The cause is primarily idiopathic; however, it is related to hormonal changes. Severe vomiting often occurs when the level of HCG is high during pregnancy.
Risk Factors:
Overweight status.
Multiple pregnancies.
Presence of trophoblastic disease:
This involves abnormal growth of cells in the uterus.
Psychological factors.
ETIOLOGY CONTINUED
Temporal Characteristics:
Limited to the first trimester.
More common in first pregnancies.
Tendency to recur in subsequent pregnancies.
Familial History:
Increased incidence in mothers and sisters.
Associated Conditions:
Prevalence is higher in hydatidiform mole and multiple pregnancies.
More common in unplanned pregnancies.
RISK FACTORS
Age:
Below 17 years and over 35 years.
Pregnancy Status:
Primigravidae (first-time pregnant women).
Multiple pregnancies.
Weight Issues:
Underweight and obesity.
Psychological Factors:
Issues such as unwanted pregnancy and marital problems.
Medical Conditions:
Presence of trophoblastic disease.
HORMONAL FACTORS
Primary Hormones Involved:
High levels of HCG (also associated with hydatidiform mole, multiple pregnancies).
High levels of estrogen.
High levels of progesterone leading to relaxation of the cardiac sphincter.
Other Hormones Contributing:
Thyroxin, prolactin, leptin, and adreno-cortisol hormones.
PSYCHOGENIC FACTORS
Psychological factors may aggravate nausea:
Once nausea begins, it may trigger neurogenic elements that worsen the condition.
DIETARY DEFICIENCY
Possible Causes:
Low carbohydrate reserves, particularly after not eating for a night.
Deficiencies of vitamin B1, B6, and protein are likely effects rather than initial causes of hyperemesis.
OTHER POTENTIAL CAUSES
Allergic or Immunological Basis:
Potential involvement in hyperemesis gravidarum.
Gastric Motility:
Decreased gastric motility observed in some cases may lead to increased nausea.
CLINICAL COURSE
Early Phase:
Vomiting occurs throughout the day, disrupting normal daily activities.
There may be no evidence of dehydration or starvation.
Late Phase:
Evidence of dehydration and starvation may appear if untreated.
SYMPTOMS
Common Symptoms:
Excessive vomiting and retching day and night.
Epigastric pain.
Constipation.
Ptyalism (excessive saliva production).
Fatigue.
Anorexia.
Complications:
Complications may arise if hyperemesis is not treated.
SIGNS
Signs Associated with Dehydration:
Dry, coated tongue.
Sunken eyes.
Acetone odor in breath.
Tachycardia (increased heart rate).
Postural hypotension (drop in blood pressure upon standing).
Fever.
Jaundice observed in later stages.
Diagnostic Procedures:
Vaginal examination and ultrasound (USG) performed to confirm pregnancy.
INVESTIGATIONS
Urinalysis:
Important parameters include:
Quantity for oliguria.
Dark color indicating concentration.
High specific gravity with acid reaction.
Potential presence of acetone, occasional protein, and bile pigments.
Diminished or absence of chloride.
Biochemical and Circulatory Changes:
Serum electrolytes including sodium, potassium, and chloride.
Opthalmoscopic Examination:
Required if patient is seriously ill.
Key signs include retinal hemorrhage and detachment, which are unfavorable indicators.
ECG:
Conducted when serum potassium levels are abnormal.
DIAGNOSIS
Steps to Diagnose:
Confirm pregnancy first.
Exclude other associated causes of vomiting:
Gynecological, medical, or surgical causes.
Utilize USG to check for:
Pregnancy, hydatidiform mole, multiple pregnancy.
OTHER COMPLICATIONS
Possible complications if left untreated:
Stress ulcers in the stomach.
Esophageal tears.
Jaundice due to liver damage.
PREVENTION
Primary Prevention Strategy:
Effective management of simple vomiting of pregnancy is critical to prevent hyperemesis gravidarum.
MANAGEMENT
Principles of Management
Goals:
Control vomiting.
Correct fluid and electrolyte imbalances.
Address metabolic disturbances.
Prevent serious complications stemming from severe vomiting.
HOSPITALIZATION
Initial Steps:
Admit the patient.
Establish an open IV line to correct fluids.
Order pertinent investigations.
Maintain an intake-output chart.
Monitor urine output, potentially including catheterization.
Monitor vital signs.
Periodic urine tests for ketone bodies.
FLUID MANAGEMENT
Protocol:
Oral feeding withheld for at least 24 hours after vomiting cessation.
IV fluids administered during this time.
Total approximate fluid requirement: 3 liters.
Half as 5% dextrose.
Half as Ringer's solution.
Additional 5% dextrose should equal the volume of vomitus and urine excreted within 24 hours. This helps address:
Dehydration.
Electrolyte imbalance.
Ketoacidosis.
Nasogastric tube feeding may also be employed.
ANTIEMETIC DRUGS
Commonly used medications include:
Promethazine: 25 mg IM twice or thrice a day.
Trifluopromazine: 10 mg IM.
Metoclopramide: 10 mg IM.
Hydrocortisone: 100 mg IV in drip.
Prednisolone: Oral administration.
NUTRITIONAL SUPPORT
Supplementation:
Vitamin B1, B6, B12, and C are important.
NURSING CARE
Best Practices:
Sympathetic yet firm handling of the patient.
Daily monitoring of progress:
Signs of improvement include:
Reduced vomiting.
Increased appetite.
Improved appearance.
Disappearance of acetone breath and urine symptoms.
Normal pulse and blood pressure.
Normal urine output.
Monitor lab results for dehydration status.
Assess fetal heart rate (FHR), fetal activity, and growth rates.
Encourage positioning upright post-meal and small, frequent meals to avoid distention triggering more vomiting.
OBSTETRIC CARE
Therapeutic Abortion:
Rarely indicated if the patient improves with therapy.
Generally not recommended in cases with renal or neurological complications.
DIETARY MANAGEMENT
Initial dietary strategy before initiating IV fluids:
Small and frequent dry meals avoiding fats.
Start with dry carbohydrates such as biscuits, bread, or toast.
Ginger intake may be beneficial.
Gradually restore a full diet after stabilization of the patient's condition.