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Excessive vomiting in Pregnancy:Hyperemesis Gravidarum


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

• theories:

1.hormonal-

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

2.psychogenic.


Pathology

• 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


Metabolic changes

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.

Biochemical changes

• 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

hyperbillirubinaemia

Circulatory changes

• there is haemoconcentration leading to rise in hb%,rbc count&haematocrit


Clinical features

  1. • severe nausea and vomiting
  2. • food aversions
  3. • weight loss of 5% or more of pre-pregnancy weight
  4. • decrease in urination
  5. • dehydration
  6. • headaches
  7. • confusion
  8. • fainting
  9. • acetone smell in breath
  10. • jaundice

Complications: Read more….

Diagnosis

  • • 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.

Investigations

1.urine analysis-
. 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.

Differential diagnosis

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

Gynaecological cause

  • 1.twisted ovarian tumor
  • 2.red degeneration of fibroid

Obstetrical causes

  • 1.hydatidiform mole
  • 2.multiple pregnancy

Management

• principles

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


T/t-

1.hospitalisation

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

4.drugs-

A.antiemetic drugs like

a.promethazine 25mg

b.prochlorperazine 5mg

c.triflupromazine 10mg

d.trifluoperazine 1mg

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:

• acupressure.

• herbs – ginger or peppermint

• homeopathic remedies are a non-toxic system of

medicines.

• hypnosis

• 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

Presentation paper

Download Presentation at:

link: http://www.mediafire.com/file/t0dyrayonto/Final HYPEREMESIS GRAVIDARUM BY SUJIT.pptx

Password: medchrome.comhyperemesis

Tags: Excessive vomiting, Hyperemesis Gravidarum, ketoacedotic poison, ketoacidosis, korsakoff syndrome, mallory weiss tear, Pregnancy, wernicke's encephalopathy


Last updated: June 5, 2013



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4 Comments

  • MRS F BANDIPO says:

    I observed that my daughter who had moderate hyperemesis in three previous pregnancies had only a very mild one with the fourth.Could it be because she had to breastfeed in that pregnancy as it came unexpected

    • Mrs Bandipo,

      Some authors claim that “unquestionably” there is a link to psychological factors such as “lack of communication with husband,” and “stress and doubts about pregnancy.” can Cause Hyperemesis.
      So Unexpected pregnancy excludes stress of pregnancy. This may be one reason.

      There is no relation between Hyperemesis and Breast feeding

      But for your clarification, It has bee seen that:

      Fitzgerald followed 159 women who had HG in their first pregnancy. 56 of these women then had another pregnancy that was recorded by Fitzgerald, and 19 women had two subsequent pregnancies recorded by Fitzgerald.

      • 27 of the 56 women had HG in their second pregnancy.
      • 7 of 19 women had HG in their third pregnancy.

      So it is likely to recur but not 100% recurrence has been recorded by study
      Hope it answers your query.

      • Catherine says:

        I know this is an old thread, and I realize that the admin is loosely quoting what “some authors” claim, but I feel compelled to comment nontheless. I had HG with both of my pregnancies. I simply cannot understand how anyone can say it is remotely psychological. I was SO physically sick. Both of my pregnancies were very wanted and my husband was the epitomy of support. In fact, though pregnancy was a time of physical hell for me, when I look back now I respect and love my husband all the more for the tireless care he took of me and for the way he NEVER questioned whether I was “really sick.” Only someone who’s had HG can understand. (Now I don’t contest that HG can mess you up psychologically – try riding in a car if you get carsick for 9 months – you’d be pretty miserable – but it is the hormones, pure and simple that cause it.)

  • haider says:

    My wife also suffers with somewhat this. And she ends up having an iv/ with inj gravinate to stop the damn vomiting. I think there must be some herbal cure to this. Since its some harmones I guess which activate and sruff.

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This entry was posted by on June 12, 2010 at 6:14 pm and filed under Gynae/Obstr category.

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