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Hyperemesis Gravidarum – Causes, Symptoms, Treatment

Hyperemesis Gravidarum (also known as HG) is a severe type of vomiting of pregnancy which has got deleterious effect on the health of mother and/or incapacitates her in day-to-day activities.

Triad of adverse effects:

  1. > 5% loss of pre- pregnancy weight
  2. Dehydration
  3. Electrolyte imbalance

Incidence:

There has been a marked fall in the incidence during last 30 years (less than 1 in 1,000 pregnancies) because:

Etiology:

High risk factors:–

  1. mostly limited to 1st trimester and resolve by 20 weeks (90%)
  2. more common in 1st pregnancy,
  3. Younger age
  4. Low body mass
  5. History of motion sickness or migraine
  6. Family history
  7. Women suffered nausea and vomiting while on COC’s.
  8. Unplanned pregnancy, multiple pregnancy, hydatidiform mole.

Theories:

1) Hormonal =

• excess of chorionic gonadotropin or higher biological activity of hcG. • high serum level of oestrogen. • excess of progesterone leading to relaxation of cardiac sphincter of retention of gastric fluids due to impaired gastric motility.

2) Psychogenic = aggravates nausea

3) Dietetic deficiency = low carbohydrate reserve decreases Vit B6, B1.

4) Allergic or immunological basis

5) Decreased gastric motility

Pathology:

Changes in various organs –

  • Liver = enzymes are elevated. There is centri-lobular fatty infiltration without necrosis.
  • Kidneys = usually normal with fatty change in the cells of first convoluted tubule.
  • Heart = small heart, subendocardial haemorrhage
  • Brain = small haemorrhage in hypothalamic region

Metabolic, Biochemical & Circulatory changes:

Hyperemesis Gravidarum

Due to the combined effect of dehydration and starvation due to protracted vomiting

METABOLIC :- For energy supply, fat reserve is broken down.

Fats [due to low carbohydrate] ➡️ Incomplete oxidation ➡️ ketone bodies in blood accumulates ➡️ acetone excreted through kidney and in breath.

BIOCHEMICAL :–

  • Loss of water and salt ➡️ decrease in plasma Na, K, chlorides
  • Starvation ➡️ metabolic acidosis
  • Loss of HCI & hypokalemia ➡️ alkalosis

CIRCULATORY :–

Hemoconcentration ➡️ Decrease in Hb%, RBC values, WBC, eosinophiles

Clinical Course:

Division:

▪ EARLY = no evidence of dehydration or starvation

▪ LATE = evidence of dehydration and starvation

Symptoms:

  1. Vomiting is increased in frequency with retching.
  2. Urine quantity increased.
  3. Epigastric pain
  4. Constipation may occur.

Signs:

Features of dehydration of ketoacidosis

{eg. dry coated tongue, sunken eyes, acetone smell in breath, rise in temp.}

Investigations:

  1. Urinalysis = small quantity, dark colour, high specific gravity with acid reaction, presence of acetone, diminished or absence of chloride.
  2. Biochemical & circulatory changes = LFTS are abnormal (40%) with rise in level transaminase & bilirubin.
  3. Serum TSH, T3 and free T4 = 60% may suffer from thyroid dysfunction.
  4. Ophthalmoscopic examination = if patient is seriously ill, retinal haemorrhage & detachment of retina.
  5. ECG = when there is abnormal serum potassium level.

Diagnosis:

• First confirm the pregnancy.

• USG – used to confirm pregnancy, also excludes other obstetric, gynaecological, or medical cause of vomiting.

Differential Diagnosis:

When vomiting is persistent in spite of usual treatment, other causes of severe vomiting should be considered and investigated.

Complications:

Maternal =

  1. Neurologic complications like Wernicke’s encephalopathy etc.
  2. Stress ulcer in stomach
  3. Jaundice, hepatic failure
  4. Convulsions & coma
  5. Renal failure

Foetal =

Foetus is usually unaffected but risk may be due to Low birth weight & preterm birth.

Prevention:

  1. Take small amount & at frequent intervals
  2. Drink fluids in between meals & not after the meals.
  3. Not to lie down immediately after meals.
  4. Avoid food that cause gastric irritation.
  5. Avoid high fat food and odors that trigger nausea and vomiting

Management:

Principles –

  • maintenance of hydration
  • control vomiting
  • correct fluid & electrolyte imbalance
  • prevent serious complications of secure vomiting
  • correct metabolic disturbances (acidosis or alkalosis)
  • care of pregnancy.
  • correct vitamin deficiencies.

HOSPITALIZATION:

In case of :- Protracted NVP (Nausea, vomiting in pregnancy) despite the use of oral anti-emetics, weight loss > 5%, presence of any comorbidity

FLUIDS:

After cessation of vomiting –

  1. Oral feeding is paused for atleast 24hrs
  2. Fluid is given through intravenous drip

➡️ Calculation of amount of fluid to be infused in 24 hours is:

Total fluid [3 litres]

  • 5% dextrose (1.5 litres)
  • Ringer’s solution (1.5 litres)

**Crystalloids (equal to the amount of vomitus and urine) is also added.

Drugs:

  1. Antiemetic drugs – • promethazine 25mg or prochlorperazine 5mg IM (twice or thrice daily) • metoclopramide (second line drug)
  2. Hydrocortisone 100 mg IV (in case of hypotension or intractable vomiting)
  3. Nutritional supplementation – Vit B, 100mg daily, Vit B6, Vit C, Vit B12
  4. Ondansetron – safe and effective

To Read, Antiemetic drugs in detail, CLICK HERE.

Nursing care:

  • Sympathetic but firm handling of patient.
  • Thiamine 100mg IV is injected to prevent Wernicke’s encephalopathy.
  • Stress ulcer by proton pump inhibitor (IV).
  • Hyperemesis progress chart – to assess progress of patient while in hospital.
  • Daily record of pulse, temp., B.P. (twice). ECG, urine.
  • Termination of pregnancy is rarely indicated.