HYPEREMESIS GRAVIDARUM

INTRODUCTION

  • Definition of Terms:
    • Hyper: Excessive
    • Emesis: Vomit
    • Gravidarum: Pregnancy
  • Nausea and vomiting of moderate intensity are especially common until around 16 weeks of pregnancy.
  • Hyperemesis gravidarum (HCG) is a condition in early pregnancy characterized by intractable vomiting, leading to fluid and electrolyte imbalances and nutritional deficiencies.
  • Women with this condition typically require hospitalization.

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 in her day-to-day activities.

ETIOLOGY

  • Causes:
    • The exact cause of hyperemesis gravidarum is idiopathic; however, it is closely related to hormonal changes.
    • Key Hormonal Influence:
    • High levels of human chorionic gonadotropin (HCG) during pregnancy are associated with severe vomiting.
  • Other Risk Factors:
    • Overweight
    • Multiple pregnancies (twins, triplets, etc.)
    • Presence of trophoblastic disease (involves abnormal growth of cells in the uterus)
    • Psychological factors (e.g., stress, anxiety)

FURTHER ETIOLOGY

  • Hyperemesis gravidarum is often limited to the first trimester of pregnancy.
  • It is more common in first pregnancies and has a tendency to recur in subsequent pregnancies.
  • A familial history (mother and sisters suffering from similar manifestations) increases the risk.
  • It is more prevalent in conditions such as hydatidiform mole and multiple pregnancies.
  • Moreover, it is commonly seen in unplanned pregnancies.

RISK FACTORS

  • Demographics:
    • Age below 17 years and over 35 years
    • Primigravidae (first-time pregnant women)
  • Physical conditions:
    • Both underweight and obesity are risk factors.
  • Psychological Factors:
    • Situations such as unwanted pregnancy and marital problems can also be contributory.
  • Medical Factors:
    • The presence of trophoblastic disease.

PATHOPHYSIOLOGY OF HYPEREMESIS GRAVIDARUM

  1. Hormonal Factors:

    • High levels of HCG during pregnancies such as hydatidiform mole or in multiple pregnancies can exacerbate the condition.
    • Elevated levels of estrogen and progesterone cause the relaxation of the cardiac sphincter, leading to increased vomiting.
    • Other hormones involved include:
      • Thyroxin
      • Prolactin
      • Leptin
      • Adreno-cortical hormones

  2. Psychogenic Factors:

    • Psychological factors may aggravate nausea once it begins, triggering neurogenic elements that worsen the symptoms.

  3. Dietary Deficiency:

    • It may be due to low carbohydrate reserves, particularly after fasting overnight.
    • Deficiencies of vitamin B1, B6, and protein can manifest as effects rather than direct causes of hyperemesis gravidarum.

  4. Allergic or Immunologic Basis:

    • Some cases have an underlying allergic or immunological component contributing to symptoms.

  5. Decreased Gastric Motility:

    • Impaired gastric motility can lead to nausea and exacerbated symptoms of hyperemesis gravidarum.

CLINICAL COURSE

  • Early Stage:

    • Constant vomiting throughout the day, disrupting normal day-to-day activities.
    • Initially, there is often no evidence of dehydration or starvation.

  • Late Stage:

    • Evidence of dehydration and starvation may develop as the condition worsens.

SYMPTOMS

  • Persistent vomiting and retching throughout the day and night.
  • Associated symptoms may include:
    • Epigastric pain
    • Constipation
    • Ptyalism (excessive salivation)
    • Fatigue
    • Anorexia (loss of appetite)
  • Complications may arise if left untreated.

SIGNS

  • Signs indicating severe dehydration and ketoacidosis:
    • Dry, coated tongue
    • Sunken eyes
    • Acetone smell in breath
    • Tachycardia (rapid heart rate)
    • Postural hypotension (drop in blood pressure upon standing)
    • Elevated temperature
    • Jaundice in later stages
  • Confirmation of pregnancy and condition may involve vaginal examination and ultrasound (USG).

INVESTIGATIONS

  1. Urinalysis:

    • Assessment of urine quantity (to check for oliguria).
    • Dark-colored urine due to concentration of solutes.
    • High specific gravity with acidic reaction.
    • Presence of acetone (indicative of starvation), occasional protein, and bile pigments.
    • Diminished or absent chloride levels.

  2. Biochemical and Circulatory Changes:

    • Serum electrolyte analysis (Sodium, Potassium, and Chloride).

  3. Ophthalmoscopic Examination:

    • Conducted if the patient is severely ill.
    • Retinal hemorrhages and detachment are unfavorable signs.

  4. ECG:

    • Performed when abnormal serum potassium levels are detected.

DIAGNOSIS

  • Confirmation of pregnancy is the first step in diagnosis.
  • Associated causes of vomiting must be excluded (gynecological, medical, or surgical causes).
  • Ultrasound findings may involve confirmation of pregnancy type (hydatidiform mole or multiple pregnancies).

OTHER COMPLICATIONS

  • Potential complications if hyperemesis gravidarum is untreated may include:
    • Stress ulcers in the stomach
    • Oesophageal tears
    • Jaundice secondary to liver damage.

PREVENTION

  • The only effective prevention strategy involves managing and correcting simple vomiting associated with pregnancy effectively.

MANAGEMENT PRINCIPLES

  1. Control vomiting.
  2. Correct fluid and electrolyte imbalances.
  3. Address metabolic disturbances.
  4. Prevent severe complications stemming from excessive vomiting.

HOSPITALIZATION CARE

  • Ensure hospitalization of the patient, with careful monitoring and management.
  • Key steps include:
    • Admit patient
    • Establish open IV line for fluid correction
    • Conduct relevant investigations
    • Maintain intake-output chart
    • Monitor urine output (may require catheterization)
    • Monitor vital signs consistently
    • Test urine periodically for ketone bodies to assess metabolic status.

FLUID MANAGEMENT

  • Oral feeding is withheld for at least 24 hours after cessation of vomiting.
  • Fluids administered via IV drip during this period.
  • Total amount of fluids calculated to be approximately 3 litres per 24 hours.
    • Half of the fluid will be 5% dextrose and half Ringer's solution.
    • Additional dextrose equal to total vomitus and urine output in the preceding 24 hours should be added to correct dehydration, electrolyte imbalance, and ketoacidosis.
  • Nutritional support via nasogastric tube may also be required.

ANTIEMETIC DRUGS

  • Medications for treatment may include:
    • Promethazine: 25 mg IM twice or thrice daily
    • Trifluoperazine: 10 mg IM
    • Metoclopramide: 10 mg IM
    • Hydrocortisone: 100 mg IV in drip
    • Prednisolone: Oral dosage as needed.
  • Nutritional support should include vitamins B1, B6, B12, and C to aid recovery and maternal health.

NURSING CARE

  • Provide empathetic yet firm care to the patient.
  • Perform daily monitoring and observe for improvement in symptoms:
    • Reduction of vomiting
    • Increased hunger
    • Improvement in appearance
    • Disappearance of acetone in breath and urine
    • Stabilization of pulse and blood pressure
    • Normal urine output.
  • Monitor laboratory results for dehydration levels.
  • Keep track of fetal heart rate (FHR), fetal activity, and growth.
  • Encourage upright positioning after meals and recommend small, frequent meals.
  • Suggest liquids be consumed between meals to avoid distension of stomach, which can trigger vomiting.

OBSTETRIC CARE

  • Therapeutic abortion is not indicated if the patient shows improvement on therapy.
  • Abortion is infrequently indicated in cases associated with severe renal or neurological complications due to hyperemesis gravidarum.

DIETARY MANAGEMENT

  • Initially, provide small, frequent dry meals without fat, post-IV fluids.
    • Starting with dry carbohydrates like biscuits, bread, and toast.
  • Ginger may be used to help alleviate nausea.
  • Gradually progress to a full diet as tolerated.

CONCLUSION

  • A comprehensive understanding and management of hyperemesis gravidarum are crucial to ensure the health and well-being of both the mother and fetus.
  • Effective management strategies can significantly alleviate symptoms and improve outcomes for pregnant women affected by this condition.
Thank You!