1. DR. MEENAKSHI SHARMA
DR. SHARDA JAIN
DR. JYOTI BHASKAR
DR. JYOTI AGARWAL
MANAGEMENT OF
HYPEREMESIS GRAVIDARUM
LATEST GUIDELINES UPDATE

2. 2015
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3. Review this Lecture and others at:
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MANAGEMENT OF
HYPEREMESIS GRAVIDARUM
LATEST GUIDELINES UPDATE

4. Dr Meenakshi Sharma
Dr. Sharda Jain
Dr. Jyoti Bhaskar
Dr. Jyoti Agarwal
NICE 2013
ACOG 2010
SOGC 2002

5. HYPEREMESIS GRAVIDARUM
Severe nausea & intractable
vomiting
Affects - 0.3-2% of pregnancies

6.  Pathophysiology – multifactorial
 HCG– increased levels in pts with HG as HCG
stimulates secretions in upper GIT
 Estrogen- positive assoc b/w NVP and maternal
serum E2 level. Increased E2 causes a decrease
in GI motility and gastric emptying altering GI
pH and encourages subclinical H pylori
infection
 Thyroid hormone- physiological gestational
transient thyrotoxicosis. Raised FT3 & low TSH
found in 66% HG

7. Symptoms
 Nausea
 Vomiting
 Enhanced olfactory senses
 Food and/or fluid intolerance
 Lethargy
HYPEREMESIS GRAVIDARUMHYPEREMESIS GRAVIDARUM

8. Signs
 Dehydration
 Weight loss
 Ketonuria
 Anaemia
 Tachycardia
HYPEREMESIS GRAVIDARUMHYPEREMESIS GRAVIDARUM

9.  Initial Investigations
 Urea and Electrolytes
 LFT
 CBC
 Urinalysis
 USG-multiple/molar pregnancies
 Additional investigations
 Calcium
 Blood sugar
 TSH
HYPEREMESIS GRAVIDARUMHYPEREMESIS GRAVIDARUM

10. COMPLICATIONS
 Maternal
 Hypokalemia
 Hyponatremia and central pontine myelinosis
 Wernickie’s encephalopathy
 Vitamin B6/B12 deficiency
 Malnutrition
 Mallory- Weiss esophageal tears
 Venous thromboembolism
 Psychological morbidity
 Fetal
 Growth restriction
 Wernicke’s encephalopathy is associated with 40%
fetal death
COMPLICATIONS

11.  Hyponatremia (Na<120 mmol/l) - anorexia,
headache, nausea, vomiting and lethargy
 Severe hyponatremia may lead to central
pontine myelinolysis (osmotic demyeliniation)
 Pyramidal tract signs
 Spastic quadriparesis
 Pseudobulbar palsy
 Altered sensorium
 Ataxia and convulsion

12.  It is medical emergency
 Should be managed appropriately by
skilled personnel
 As treatment may be potentially as
dangerous as the condition itself

13.  Vitamin B1 deficiency precipitated by IV fluid
containing high concentration of dextrose
 Ophthalmoplegia (typically sixth nerve palsy, diploia),
 Ataxia
 Altered sensorium
 Diagnosis confirmed by low red cell transketolase, a
thiamine dependent enzyme
 MRI - symmetrical lesion around the aqueduct and
fourth ventricle, which resolve after treatment with
thiamine

14. TREATMENT
 Thiamine replacement may improve the
symptoms of Wernicke’s encephalopathy
 if associated with Korsakoff psychosis (retrograde
amnesia, impaired ability to learn and confabulation)
the recovery rate is only about 50%
 40% incidence of fetal death

15. Differential Diagnosis
System
Diagnosis
Genitourinary UTI
Uraemia
Molar pregnancy
Gastrointestinal Gastritis/ peptic ulcer
Reflux/ oesophagitis
Pancreatitis
Bowel obstruction
Endocrine Addison’s disease
Hyperthyroidism
Diabetes ketoacidosis
CNS Intracranial tumours
Vestibular disease

16.  Correction of dehydration and electrolyte
imbalance
 Prophylaxis against recognized complications
 Provision of symptomatic relief
 Admit if :
 Symptom are severe despite 24 hrs of medication
 Evidence of dehydration and ketosis
 Admit earlier if coexisting conditions eg diabetes

17.  IV fluid- NS and Hartmann’s solution
preferrable if ketotic or fluid intolerant
Avoid dextrose solution as
 can’t correct commonly associated
hyponatraemia
 High conc of dextrose solution precipitate
Wernicke’s encephalopathy
 Avoid double strength saline even in cases
of severe hyponatraemia

18.  Antiemetics are safe and recommended
liberally in HG
 Pts on antiemetic -better pregnancy outcome
due to better nutrition
REMEMBER !!!!! MEDICATION TO BE KEPT TO MINIMUM

19. Class of drugs Antiemetic
Phenothiazine Prochlorperazine (stemetil/
buccastem)
Chlorpromazine
Dopamine antagonists Metoclopramide
Domperidone
5-HT3 (serotonin) antagonist Ondansetron
Antihistamines
(H1 receptor antagonist)
Cyclizine
Promethazine (phenergan)
Meclozine

20. Group One Dose Route
First line Cyclizine 50 mg t.d.s. PO, IM or IV
Second line Prochlorperazine
(Stemetil)
12.5 mg t.d.s.
3-6 mg b.d
IM
sublingual
Third line Metoclopramide 10 mg t.d.s. PO, IM or IV
Group two:
Promethazine
(phenergan)
25 mg a day IM/oral
Chlorpromazine 10-25 mg t.d.s.
25 mg t.d.s.
PO
Domperidone 20 mg qds
30-60 mg qds
PO
PR

21.  Steroids should be used for intractable
hyperemesis which is not responding to
above management
 I/V Hydrocortisone 100 mg BD for 48 hrs
 Oral prednisolone 30 – 40 mg/day -1 week
then tapered gradually 5mg reduction every
week

22.  Increased risk of VTE due to dehydration
and immobilization in hospitalized pts.
 LMWH should be given if the risk factor score
for VTE is 3 or more

23. Pre-existing risk factors Score
Previous recurrent VTE 3
Previous unprovoked or
estrogen related
3
Previous VTE provoked 2
Family history of VTE 1
Known thrombophilia 2
Medical comorbidity 2
Age (> 35 years) 1
Obesity 1 or 2 *
Parity (≥ 3) 1
Smoker 1
Gross varicose vein 1
Obstetric risk factors 1
Pre-eclampsia 1
Dehydration/ Hyperemesis/
OHSS
1
Multiple pregnancy or ART 1
Transient risk factors
Current systemic infection 1
Immobility 1
Surgical procedure in
pregnancy
2
Total score
Risk assessment for
Venous
Thromboembolism
(VTE)
*Score 1 for BMI >30
*Score 2 for BMI >40

24. Prolonged nausea &
vomiting
Intolerable to fluid
and/or food
Clinical dehydration
Ketouria
Weight loss
Nausea & vomiting
History of other medical
condition e.g diabetes,
Summary for Management of Hyperemesis
Gravidarum-NHS 2013
Admission

25. Admission
Initial assessment
Temp, Pulse, Resp, BP, Body
weight
U&E
LFT
Urinalysis/ MSU
USS
Additional investigations
FBC (full blood count)
Blood glucose
TFT (thyroid function test)
Calcium
Diagnosis

26. Treatment
Fluid & electrolyte
replacement
Normal saline/
Hartmann’s
3 litres/day
KCl (potassium/ about 100
mmol/24 hr)
All hyperemesis
Pabrinex 250 mg thiamine
per pair weekly if oral
thiamine is not tolerated.
Clexane (as per protocol)
Antiemetics (1st group)
1st line: Cyclizine 50 mg t.d.s.
PO, IM or IV
2nd line: Prochlorperazine
12.5mg t.d.s. IM
Buccastem 3-6mg bd
sublingually
Third line: Metoclopramide 10
mg t.d.s. PO IM or IV
Subsequent assessment
Fluid intake output chart
U&E (urea and electrolytes),
LFT (liver function test
Alternate day if initial results were normal, daily
if the results were abnormal

27. Intractable vomiting
Antiemetics (2nd group)
Promethazine (phenergan)
25 mg a day IM/oral
Chlorpromazine 10-25 mg
t.d.s. PO
25 mg t.d.s. IM
Domperidone 10 mg q.d.s PO
30-60 mg b.d PR
With consultant decision
Ondansetron 4-8 mg b.d. PO,
IM or IV
Hydrocortisone 100 mg b.d. IV
for 48 hr followed by:
Prednisolone 30-40 mg o.d. PO
for one week then reduce the
dose by 5 mg/week

28. Other supportive
treatment
•Diet & lifestyle (small
frequent dry meal, learn to
avoid certain scents which
make the patient
intolerable)
•Ginger
•Acupressure/acupuncture
The options for severe
hyperemesis who failed to
response to above measures
•Enteral nutrition
•Parenteral nutrition (TPN)
•Termination of pregnancy

29.  A doxylamine/pyridoxine combination should
be the standard of care, since it has the
greatest evidence to support its efficacy and
safety. (I-A)
 H1 receptor antagonists should be considered
in the management of acute or breakthrough
episodes of NVP. (I-A)
 Pyridoxine monotherapy supplementation may
be considered as an adjuvant measure. (I-A)
 Phenothiazines are safe and effective for
severe NVP. (I-A)
SOGC 2002, ACOG 2010

30.  Metoclopramide is safe to be used for
management of NVP, although evidence for
efficacy is more limited. (II-2D)
 Corticosteroids should be avoided during the
first trimester because of possible increased
risk of oral clefting and should be restricted
to refractory cases. (I-B)
 When NVP is refractory to initial
pharmacotherapy, investigation of other
potential causes should be undertaken. (III-A)
SOGC 2002, ACOG 2010

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