HYPEREMESIS GRAVIDARUM

INTRODUCTION

  • HYPER: Means excessive
  • EMESIS: Means vomit
  • GRAVIDARUM: Relates to pregnancy
  • Nausea and vomiting of moderate intensity commonly occur until about 16 weeks of pregnancy.
  • Hyperemesis gravidarum (HCG) is a condition where vomiting becomes intractable in early pregnancy, leading to fluid and electrolyte imbalances, as well as nutritional deficiencies.
    • Women with this condition usually require hospitalization.

DEFINITION

  • Hyperemesis gravidarum is defined as a severe type of vomiting during pregnancy that has detrimental effects on the health of the affected individual and/or incapacitates her ability to perform day-to-day activities.

ETIOLOGY

  • The exact cause of hyperemesis gravidarum is idiopathic but is closely related to hormonal changes.
    • Severe vomiting occurs when the levels of Human Chorionic Gonadotropin (HCG) are notably high during pregnancy.
  • Other significant risk factors include:
    • Overweight women
    • Multiple pregnancy scenarios
    • Presence of trophoblastic disease (abnormal cell growth in the uterus)
    • Psychological factors may also exacerbate the condition.

ETIOLOGY (Continued)

  • Additional Characteristics:
    • Limited primarily to the first trimester of pregnancy.
    • More prevalent in first pregnancies.
    • Exhibits a tendency to recur in subsequent pregnancies.
    • A familial history of hyperemesis gravidarum (e.g., mother and sisters suffering from the same condition) increases risk.
    • More prevalent in molar pregnancies (hydatidiform mole) and multiple pregnancies.
    • Commonly reported in unplanned pregnancies.

RISK FACTORS

  • Age demographics:
    • Below 17 years old and over 35 years old.
  • First-time mothers (primigravidae).
  • Multiple pregnancies.
  • Body weight issues: underweight and obesity.
  • Psychological stressors such as unwanted pregnancy or marital issues.
  • Trophoblastic diseases contribute as a significant risk factor for hyperemesis gravidarum.

CAUSES OF HYPEREMESIS GRAVIDARUM

  1. HORMONAL FACTORS:

    • High levels of HCG associated with conditions like hydatidiform mole and multiple pregnancies.
    • High levels of estrogen and progesterone - progesterone may relax the cardiac sphincter, contributing to symptoms.
    • Involvement of other hormones:
    • Thyroxine
    • Prolactin
    • Leptin
    • Adreno-cortical hormones.

  2. PSYCHOGENIC FACTORS:

    • Psychological stress may aggravate nausea; once it initiates, it can trigger neurogenic components that worsen the symptoms.

  3. DIETARY DEFICIENCIES:

    • Potentially due to low carbohydrate reserves, as symptoms often arise after prolonged periods without food.
    • Deficiencies in vitamins B1, B6, and protein may be effects rather than immediate causes of this condition.

  4. OTHER FACTORS:

    • The condition may be influenced by allergic or immunological origins.
    • Decreased gastric motility is found to exacerbate nausea.

CLINICAL COURSE

  • Early:

    • Patients may experience vomiting throughout the day, disrupting normal day-to-day activities.
    • Evidence of dehydration and starvation is generally absent at this stage.

  • Late:

    • Evidence of dehydration and starvation may be evident.

SYMPTOMS

  • Excessive vomiting and retching day and night.
  • Epigastric pain.
  • Constipation.
  • Ptyalism (excessive saliva production).
  • Fatigue.
  • Anorexia.
  • Complications arise if untreated.

SIGNS

  • Signs of dehydration and ketoacidosis include:

    • Dry coated tongue.
    • Sunken eyes.
    • Acetone smell in breath.
    • Tachycardia.
    • Postural hypotension.
    • Temperature increase.
    • Jaundice may appear in later stages.

  • Diagnostic procedures: Vaginal examination and ultrasound (USG) are utilized to confirm pregnancy.

INVESTIGATIONS

  1. Urinalysis:

    • Quantitative analysis for oliguria.
    • Assessment of colour (dark due to concentration).
    • High specific gravity with acid reactions.
    • Presence of acetone, with occasional protein and bile pigments.
    • Diminished chlorides or even absence thereof.

  2. Serum Biochemical and Circulatory Changes:

    • Measurement of serum electrolytes including sodium, potassium, and chloride.

  3. Ophthalmoscopic Examination:

    • Necessary if the patient is seriously ill.
    • Retinal haemorrhage and detachment of the retina represent unfavorable signs.

  4. Electrocardiogram (ECG):

    • Conducted when there are abnormal serum potassium levels.

DIAGNOSIS

  • Confirmation of pregnancy is the first step.
  • Exclusion of other causes of vomiting, which could be gynecological, medical, or surgical.
  • Ultrasound assessment for pregnancy confirmation, hydatidiform mole, or multiple pregnancies.

OTHER COMPLICATIONS

  • Possible development of:
    • Stress ulcers in the stomach.
    • Oesophageal tears.
    • Jaundice due to liver damage.

PREVENTION

  • The only preventative measure is efficient management to correct simple vomiting experienced during pregnancy.

MANAGEMENT

Principles
  • Goals include:
    • Controlling vomiting.
    • Correcting fluid and electrolyte imbalances.
    • Addressing metabolic disturbances.
    • Preventing serious complications due to severe vomiting.
HOSPITALIZATION
  • Recommended steps:
    • Patient admission.
    • Establish an open IV line for fluid correction.
    • Conduct relevant investigations.
    • Maintain an intake-output chart.
    • Monitor urine output, consider catheterization if necessary.
    • Continuously monitor vital signs.
    • Regularly test urine for ketone bodies.
FLUID MANAGEMENT
  • Oral feeding should be withheld for a minimum of 24 hours post cessation of vomiting.
  • During this time, administer fluid via IV drip.
  • Total fluid volume for 24 hours calculated as:
    • Approximately 3 litres, half as 5% dextrose and the other half as Ringer's solution.
  • Additional amounts of 5% dextrose equal to the volume of vomitus and urine produced in 24 hours are to be incorporated.
  • These steps aim to address dehydration, electrolyte imbalances, and ketoacidosis.
  • Nutritional needs may be met via a nasogastric tube if necessary.
ANTIEMETIC DRUGS
  • Prescribed medications include:
    • Promethazine: 25mg IM BD or TDS.
    • Trifluoperazine: 10mg IM.
    • Metoclopramide: 10mg IM.
    • Hydrocortisone: 100mg IV in drip.
    • Prednisolone administered orally.
NUTRITIONAL SUPPORT
  • Vitamin supplementation is crucial, including:
    • B1, B6, B12, and C.
NURSING CARE
  • Sympathetically yet firmly handle patient interactions.
  • Daily monitoring is essential.
    • Look for signs of improvement, including: subsiding vomiting, increased hunger, better overall appearance, elimination of acetone in breath and urine, normalized pulse and blood pressure, and appropriate urine output.
  • Monitor lab results for dehydration.
  • Regularly assess fetal heart rate (FHR), fetal activity, and growth patterns.
  • Encourage patients to sit upright post-meals and take small, frequent meals.
    • Liquids should ideally be ingested between meals to prevent stomach distension and subsequent vomiting triggers.
OBSTETRIC CARE
  • Therapeutic abortion is not typically indicated if the patient shows improvement from treatment.
  • Abortion may be necessary in pregnancy complicated by renal or neurological issues; however, such instances are rare.
DIETARY MANAGEMENT
  • Initial oral administration of small, frequent dry meals without fats is suggested before IV fluids are initiated.
    • Starting with dry carbohydrates (e.g., biscuits, bread, toast).
    • Ginger may also be beneficial.
  • Gradually increase to a full diet as tolerated.

Thank You