HYPEREMESIS GRAVIDARUM for MBBS STUDENTS

1. T/Maj Dr Sumit Bidari
MBBS, MS
SHREE BIRENDRA HOSPITAL

3. ACOG 2015
 -persistent nausea and vomiting not caused by other underlying
medical conditions
 -ketonuria as a measure of acute starvation, and
 -at least a 5% weight loss from the pre-pregnancy weight.
Dutta
-severe type of vomiting of pregnancy which has got deleterious
effect on the health of the mother and/or incapacitates her in day to
day activities.
Other causes should be considered because hyperemesis gravidarum
is a diagnosis of exclusion (Benson, 2013). Williams 24TH Ed

4.  The incidence vary from 0.3 to 3 %.
 50% of pregnant women experience nausea and
vomiting,
 25% have nausea only, and
 25% are unaffected
 Recurrence with subsequent pregnancies ranges
from 15.2% to 81%.
 timing of the start of nausea or vomiting
 Symptoms almost always present before 9 weeks
of gestation
 When begins for the first time after 9 weeks, other
conditions should be considered
ACOG 2015
CREASY RESNIK’s

5. ETIOPATHOGENESIS
“ multifactorial and certainly enigmatic “
 1. high or rapidly rising serum levels of pregnancy-related
hormones
 human chorionic gonadotropin (hCG), estrogens, progesterone, leptin,
placental growth hormone, prolactin, thyroxine, and adrenocortical
hormones (Verberg, 2005).
 ghrelins, leptin, nesfatin-1, and PYY-3(Peptide YY-3) (Albayrak, 2013; Gungor,
2013).

6. 2. Biological and environmental factors
 more common in westernized industrialized societies and
urban areas than rural areas
3. An ethnic or familial predilection (Grjibovski, 2008)
 less common in American Indian and Eskimo populations, as
well as less common in African and some Asian populations
(but not industrialized Japan)

7. 4. Psychological components (a response to stress) play a major role
(Buckwalter, 2002; Christodoulou- Smith, 2011; McCarthy, 2011).
5. The vestibular system and olfactory system (Goodwin, 2008).
Hyperacuity of the olfactory system
Similarities to motion sickness
6. An association of Helicobacter pylori infection has also been proposed,
but evidence is not conclusive (Goldberg, 2007).
7. And for unknown reasons—perhaps estrogen-related—a female fetus
increases the risk by 1.5-fold (Schiff, 2004; Tan, 2006; Veenendaal, 2011).

8. RISK FACTORS
 hyperthyroid disorders
 psychiatric illnesses
 previous molar disease
 gastrointestinal disorders
 pregestational diabetes
 asthma
 female fetuses(1.5 fold)
 multiple fetuses
 maternal smoking
 older than 30 years
ACOG Practice Bulletin 2015
low to middle socioeconomic class
lower levels of education
previous pregnancies with nausea and
vomiting
first pregnancy
previous intolerance to oral
multiple-gestation pregnancies.
Ethnicity
occupational status
fetal anomalies
increased body weight
nausea and vomiting in a prior pregnancy
history of infertility
interpregnancy interval
corpus luteum in right ovary
prior intolerance to oral contraceptives

9. COMPLICATIONS
MATERNAL COMPLICATIONS
 Acute kidney injury—may require dialysis
 Depression—cause versus effect?
 Diaphragmatic rupture
 Esophageal rupture—Boerhaave syndrome
 Hypoprothrombinemia—vitamin K deficiency
 Hyperalimentation(artificial supply of nutrients,
typically intravenously) complications
 Mallory-Weiss tears—bleeding, pneumothorax,
pneumomediastinum, pneumopericardium
 Wernicke encephalopathy—thiamine deficiency
Williams 24TH Ed
FETAL
COMPLICATIONS
preterm labor
placental abruption
preeclampsia
Bolin and coworkers (2013)

10. PRESENTATION
 nausea and vomiting
 Other common symptoms include
 ptyalism (excessive salivation)
 fatigue, weakness, and dizziness.
 Sleep disturbance
 Hyperolfaction
 Dysgeusia (distortion of the sense of taste)
 Depression
 Anxiety
 Irritability
 Mood changes
 Decreased concentration
ACOG Practice Bulletin 2015

11. PHYSICAL EXAMINATION
 Vital signs, blood pressure and pulse
 volume status (eg mucous membrane
condition, skin turgor, neck veins, mental
status)
 general appearance (eg nutrition, weight)
 thyroid examination findings
 abdominal examination findings
 cardiac examination findings
 neurologic examination findings
ACOG Practice Bulletin 2015

12. DIFFERENTIAL
DIAGNOSIS
 Drug toxicity
 Eating disorders
 Gastroparesis
 Migraines
 Ovarian torsion
 Pseudotumor cerebri
 Psychological disorders
 Tumors of the central nervous
system
 Vestibular lesions
ACOG Practice Bulletin 2015
Acute intermittent porphyria
Acute Pancreatitis
Appendicitis
Biliary Disease
Diabetic Ketoacidosis
Esophagitis
Fatty Liver
Gastroenteritis
Gastroesophageal Reflux Disease
Hepatitis
Hyperparathyroidism
Hyperthyroidism and Thyrotoxicosis
Irritable Bowel Syndrome
Nephrolithiasis
Paralytic Ileus/Bowel Obstruction
Peptic Ulcer Disease
Preeclampsia

13. LABORATORY STUDIES
 Urinalysis for ketones and specific gravity
 Serum electrolytes
 Liver enzymes and bilirubin
 Amylase/lipase
 TSH, free thyroxine
 Urine culture
 Calcium level
 Hematocrit
 Hepatitis panel

14. IMAGING STUDIES
 Ultrasonography
 evaluate for multiple gestations or trophoblastic disease.
 upper abdominal ultrasonography to evaluate the pancreas and/or biliary tree
 Other imaging modalities
 upper gastrointestinal endoscopy
 abdominal computed tomography (CT) scanning or even magnetic resonance
imaging (MRI) may be indicated

15. TREATMENT
Primarily supportive
 symptoms usually resolve by mid pregnancy regardless of therapy

16. FLUIDS AND NUTRITION
Many patients respond to
I.V hydration and a short period of gut rest, followed by
reintroduction of oral intake.
IV hydration often includes supplementation of electrolytes as persistent
vomiting frequently leads to a deficiency
Likewise supplementation for lost thiamine (Vitamin B1) must be
considered to reduce the risk of Wernicke's encephalopathy
(100 mg intravenously daily for two or three days)
After IV rehydration is completed, patients generally progress to frequent
small liquid or bland meals

17. Patients whose symptoms are related to delayed gastric emptying
should do better with a diet comprised of liquids and low fat solids

18. NONPHARMACOLOGIC
INTERVENTIONS
 Triggers — The cornerstone
 Supplements containing iron should be avoided
 Dietary changes
 frequent high carbohydrate, low fat, small meals.
 Dietary manipulations, such as eliminating spicy foods
 Fluids are better tolerated if cold, clear, and
carbonated or sour (eg, ginger ale, lemonade) and if
taken in small amounts between meals

19.  Psychotherapy can also be a useful adjunctive therapy,
particularly if psychological sources of anxiety are identified
and can be ameliorated
TRADITIONAL WAYS

20. PHARMACOLOGIC TREATMENT
 begin therapy with agents that appear to be effective and have shown
minimal side effects
 if these are ineffective, substitute other drugs in a step-wise progression

22. PYRIDOXINE AND DOXYLAMINE SUCCINATE
 Pyridoxine (vitamin B6) (10 to 25 mg orally three or four times per
day) improves mild to moderate nausea, but does not significantly
reduce vomiting .
 Doxylamine succinate is an antihistamine that is usually taken with
pyridoxine. The combination appears to improve efficacy

23.  Antiemetic drugs, especially ondansetron (Zofran), are effective
in many women
 The major drawback of ondansetron has been its cost.
 Metoclopramide is sometimes used in conjunction with
antiemetic drugs; however, it has a somewhat higher incidence
of side effects.
 Antihistamines (H1 antagonists) —promethazine (12.5 to 25
mg every four hours orally, I.M, or P.R) for the initial choice of
antiemetic in women who do not respond to VitB6
 Antacids — Pregnant women often develop gastroesophageal
reflux (heartburn), which can worsen nausea and vomiting.

24. IF ALL FAILED !!!

25. CORTICOSTEROIDS
 have been used in women with severe and refractory hyperemesis,
although the mechanism of action is not well understood
 Most obstetricians avoid chronic administration
 increased risk of preterm premature rupture of membranes (PPROM)
 increased risk of oral clefts when the drugs are administered before 10
weeks of gestation

26.  [If administered after 10 weeks (when the palate has formed), the
usual dose is
 Methylprednisolone 16 mg orally
or
 intravenously every eight hours for three days
 The drug can be :
 stopped abruptly if there is no response,
 tapered over two weeks in women who do have relief of symptoms.

27. OUTCOME AND PROGNOSIS
 the availability of I.V.F and parenteral nutrition has greatly reduced
morbidity, and mortality is virtually nonexistent in patients who are
treated
 If left untreated, micronutrient deficiency, Wernicke encephalopathy
(from deficiency of vitamin B1), and sequelae of malnutrition
(immunosuppression, poor wound healing) have been reported
 Esophageal tears and rupture are other rare complications

28.  Adverse outcomes for women with hyperemesis and low maternal
weight gain compared with those for patients without hyperemesis
include higher rates of small-for-gestational-age fetuses, low birth
weight, prematurity, and 5-minute Apgar scores less than 7
 Among women who experienced hyperemesis gravidarum in their first
gestation, 15% to 19% will be affected in the second pregnancy
CREASY & RESNIK’s 7th Edition

29. References
 1. William’s OBSTETRICS 24th Edition
 2. Creasy & Resnik's Maternal Fetal Medicine 7th Edition
 3. ACOG Revised practice bulletin for Hyperemesis Gravidarum
2015
Pictures
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30. AU REVOIR