Hyperemesis gravidarum is severe nausea and vomiting during pregnancy that can lead to dehydration and weight loss. The document discusses the epidemiology, risk factors, clinical presentation, diagnosis, and management of hyperemesis gravidarum. Treatment involves intravenous rehydration, nutritional supplementation, antiemetic medications like pyridoxine and doxylamine, and hospital admission for severe cases. Outcomes of untreated hyperemesis gravidarum can include complications like esophageal rupture, Wernicke's encephalopathy, and maternal mortality in rare cases.
4. Introduction
Nausea and vomiting in pregnancy is extremely
common.
The nausea and vomiting associated with
pregnancy usually begins by 9-10 weeks of
gestation, peaks at 11-13 weeks, and resolves in
most cases by 12-14 weeks.
Normal nausea and vomiting may be an
protective mechanism—it may protect the
pregnant woman and her embryo from harmful
substances in food.
5. Definitions
Motion sickness:
Nausea felt by pregnant woman on getting up in
the morning.
Emesis gravidarum:
actual vomiting in the morning.
Hyperemesis gravidarum:
Vomiting not confined to morning but repeated
throughout the day until it affect the general
condition of the patient.
6. Epidemiology
Incidence:
Of all pregnancies, 0.3-2% are affected with HEG .
more common in westernized industrialized
societies and urban areas than rural areas.
Race: No clear racial predominance is noted for
HEG
7. Risk factors
Previous pregnancies with HEG
Greater body weight
Multiple gestations
Trophoblastic disease
Nulliparity
The risk of HEG appears to decrease with
advanced maternal age.
Cigarette smoking is associated with a
decreased risk for HEG.
9. Aetiology cont.
Hormonal:
Women with hyperemesis gravidarum often have
high hCG levels that cause transient
hyperthyroidism.
High human chorionic gonado trophin (hCG)
stimulate the chemo receptor trigger zone in the
brain stem including vomiting center.
Evidence by High hCG in :
Early pregnancy.
Vesicular mole.
Multiple pregnancy.
10. Aetiology cont.
H . pylori infection:
1-The incidence of H.pylori sero positive in
patients with hyperemesis gravidarum (HG) is
high in comparison with non-HG pregnant
women .
ive
t
ni
efi ion
o d lat
no one was able to demonstrate correlation
or
t
N re
cH. pylori and the
between seropositivity for
fa
or
c
le
time of onset or tduration of HG symptoms.
l ip
Although H.M u
pylori infection may be an
importantm factor in exacerbating HG, it may
not represent the sole cause of the disease.
18. Investigations
Urinalysis: for ketones and specific gravity .
Serum electrolytes :
-low Na or K.
-hyperchloremic metabolic alkalosis or acidosis.
LFT: Elevated transaminase levels .
TSH,free thyroxine :HEG is associated with
hyperthyroidism
19. Investigations cont
Urine culture: UTI can be associated with
nausea and vomiting.
Hematocrit: This may be elevated.
Hepatitis screening: hepatitis A, B, or C may be
confused with HEG.
20. Investigations cont
Imaging Studies:
Obstetric ultrasonography : evaluate for multiple
gestations or trophoblastic disease.
upper abdominal ultrasonography to evaluate the
pancreas and/or biliary tree
In rare cases, abdominal CT scan may be
indicated if appendicitis is under consideration.
21.
22. Management
1-Admission:
2-Intravenous Fluids:
Normal saline or lactated Ringer’s solution is the
mainstay of intravenous fluid therapy.
It should be given by infusion over 2-3 hours.
thiamine (vitaminB1).
3-Enteral or Parenteral Nutrition.
23. Management cont
DIETARY AND LIFESTYLE CHANGES
Separating solids and liquids.
Eating small, frequent meals consisting of bland
foods.
Avoiding fatty foods such as potato chips.
Avoiding drinking cold or sweet beverages.
Eliminate pills with iron
High protein snacks are helpful.
24. Management cont
5 - PHARMACOLOGICAL THERAPIES:
Vitamins Pyridoxine (Nestrex)
Essential for normal DNA synthesis and play a
role in various metabolic processes
(Diclectin) combination of doxylamine with of
pyridoxine (vitamin B6)
A - Safe in pregnancy
at a dose of 10-12.5 mg PO qd/bid.
25. Management cont
Antiemetics :
a.DOPAMINE ANTAGONISTS:
Useful in the treatment of symptomatic nausea
- phenothiazines (i.e., chlorpromazine,
perphenazine, prochlorperazine, promethazine,
trifluoperazine)
- blocking postsynaptic mesolimbic dopamine
receptors through anticholinergic effects and
depressing reticular activating system
- C - Safety for use during pregnancy has not been
established.
26. Management cont
Metoclopramide:is an upper gastrointestinal
motility stimulant.
Blocks dopamine receptors and (when given in
higher doses) also blocks serotonin receptors in
chemoreceptor trigger zone of the CNS
Metoclopramide is safe to be used for
management of NVP, although evidence for
efficacy is more limited
B - Usually safe but benefits must outweigh the
risks
27. Management cont
SEROTONIN 5-HT3 ANTAGONISTS.
Ondansetron (Zofran) :
blocking serotonin, both peripherally on vagal
nerve terminals and centrally in the
chemoreceptor trigger zone
In general, 5-HT3 antagonists may be safe to use
during the first trimester, but the data are scant.
28. Management cont
Antihistamines :
Meclizine (Antivert) , Diphenhydramine
(Benadryl)
Appears to be as efficacious as pyridoxine
Causes sedation; caution must be used in
performing tasks which require alertness
30. Management cont
A doxylamine/ pyridoxine combination should be
the standard of care since it has the greatest
evidence to support its efficacy and safety.
Other drugs may also be used, primarily
dimenhydrinate, in conjunction with the
doxylamine/pyridoxine combination.
If possible, corticosteroid use should be avoided
in the first 10 weeks .
31. Management cont
Other modalities:
(antidepressent):
- Selective serotonin re-uptake inhibitors
- Tricyclic antidepressants (TCAs)
Helicobacter pylori eradication.
ACUPUNCTURE.
Stimulation of the P6 point, located three-fingers’
breadth proximal to the wrist, has been used for
treat nausea and vomiting
Ginger (Zingiber officinale)
32.
33. outcomes
Esophageal rupture or perforation
Pneumothorax and pneumomediastinum
Wernicke encephalopathy or blindness
Hepatic disease
Seizures, coma, or death
HEG is self-limited and, in most cases, improves
by the end of the first trimester. However,
symptoms may persist through 20-22 weeks of
gestation and, in some cases, until delivery.
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