Hyperemesis gravidarum: Excessive vomiting of Pregnancy, Causes, clinical features, pathophysiological changes and management.
• definition-(“from greek hyper and emesis and latin gravida; meaning “excessive vomiting of pregnant women”) .
• it is a severe type of vomiting of pregnancy which has got a deleterious effect on the health of mother and incapacitates her in day to day activities.
• also it is defined further as –
vomiting sufficiently severe to produce wt.loss ,dehydration, acidosis from starvation,alkalosis from loss of hcl in vomitus and hypokalaemia.
incidence: • 1 in 95 pregnant women admitted at NMCTH, Nepal
Distinguishing between morning sickness and hyperemesis gravidarum
morning sickness hyperemesis gravidarum
1• nausea sometimes 1 • nausea accompanied by
accompanied by vomiting severe vomiting.
2• nausea that subsides at 12 2 • nausea that doesn’t subsides
wks or soon after. .
3• vomiting that doesn’t cause 3• vomiting that causes severe
severe dehydration dehydration.
Etiology is unknown but the following are the known facts:
1.mostly limited to 1st trimester
2.most common in 1st pregnancy with tendency to reoccur again in subsequent pregnancy
3.has got a family history
4.more prevalent in h.mole & multiple pregnancy
a.excess of hcg or higher biological activity of hcg is associated.this is proved by freq. Of vomiting at the peak level of hcg &increased association with h.mole or multiple pregnancy.
b.progesterone excess leading to relaxation of the cardiac sphincter & simulteneous retention of gastric fluid due to impaired gastric motility
• the changes in the various organs as described by sheehan are the generalised manifestations of starvation & severe malnutrition
1.liver-centrilobular fatty infiltration without necrosis
2.kidneys-occasional findings of fatty change in the cell of first convoluted tubules which may be related to acidosis
3.small heart.may be subendocardial haemorrhage
4.brain-small haemorrages in the hypothalamic region
Severe vomiting +Inadequate intake of food leads to Glycogen depletion and Carbohydrate starvation.Fat broken down occurs and Incomplete oxidation of fat leads to Accumulation of ketone bodies in the blood. Thus,Acetone excreted through the kidneys & breath.
• loss of water & salts in the vomitus results in fall in plasma sodium,potassium &chlorides. Hepatic dysfunction results in acidosis& ketosis with rise in blood urea& uric acid; hypoglycemia, hypoproteinaemia, hypovitaminosis & rarely
• there is haemoconcentration leading to rise in hb%,rbc count&haematocrit
- • severe nausea and vomiting
- • food aversions
- • weight loss of 5% or more of pre-pregnancy weight
- • decrease in urination
- • dehydration
- • headaches
- • confusion
- • fainting
- • acetone smell in breath
- • jaundice
Complications: Read more….
- • women who are experiencing hyperemesis gravidarum often are dehydrated and losing weight despite efforts to eat. The nausea and vomiting begins in the first or second month of pregnancy. It is extreme and is not helped by normal measures.
- • vaginal examination or usg is done to confirm pregnancy.
- • usg is also helpful to exclude other obstetrics cause like h.mole,multiple pregnancy, gynaecological & surgical causes.
. Small quantity ,dark colour, high specific gravity with acidic reaction ,presence of acetone , diminished or absence of chloride
2.serum electrolytes- decreased sodium ,potassium & chloride
3.opthalmoscopic examination is required to r/u retinal haemorrhage & detachment.
4.ecg where there is abnormal serum potassium level.
• medical causes
- 1. intestinal infestations
- 2. uti
- 3. hepatitis
- 4. diabetic ketoacidosis
- 5. uraemia
. Surgical cause
- 1. appendicitis
- 2. peptic ulcer
- 3. intestinal obstruction
- 4. cholecystitis
- 1.twisted ovarian tumor
- 2.red degeneration of fibroid
- 1.hydatidiform mole
- 2.multiple pregnancy
1.to correct fluids , electrolytes & other metabolic changes promptly & effectively
2.to control vomiting
3.to prevent or to detect at the earliest, the ominous complications that may arise
2.patient kept npo
3.during this period fluids given through i.v. infusion.
• amount of fluid to be infused in 24hrs is calculated as total amount of fluid approx. 3 lits of which half is 10%dextrose &half is ringers lactate. Extra amount of 10%dextrose equals to the amount of vomitus & urine output in 24hrs.
• oral feeding is withheld for at least 24hrs after the cessation of vomiting
• serum electrolyte should be estimated & corrected if there is any abnormality
A.antiemetic drugs like
e.metoclopramide (blocks central &peripheral dopamine d2 receptors) stimulates gastric &intenstinal motility without stimulating secretions.
B.hydrocortisone 100mg i.v. is given in cases with hypotension or in intractable vomiting. oral prednisolone can be used.
5.nutritional support with vit. B1,b6,b12&vit.c
6.social & psychological support is essential
Other treatments may include:
• herbs – ginger or peppermint
• homeopathic remedies are a non-toxic system of
• hyperemesis progress chart is helpful
.daily record of vitals at least twice daily & intake-output charting. .urine for acetone & blood biochemistry & ecg(when serum potassium is abnormal)
.diet:before i.v. fluid is omitted food are given orally.at first dry carbohydrate foods like biscuits,bread,toast are given. Small but frequent foods are recommended. Gradually full diet is restored.
•termination of pregnancy is rarely indicated – intractable hyperemesis gravidarum
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