Hyperemesis gravidum


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Hyperemesis gravidum

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Hyperemesis gravidum

  1. 1. Hyperemesis gravidarum (HG) is a severe form of morning sickness, during pregnancy in which excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids.<br /><ul><li>Hyperemesis is considered a rare complication of pregnancy, with difficult to differentiate between common morning sickness and hyper emesis.</li></ul>(Hyper-, meaning excessive, and emesis, meaning vomiting,, gravida, meaning pregnant Therefore, hyperemesis gravidarum means " excessive vomiting in pregnancy)<br />Cause:-<br />The cause of HG is unknown. In particular Hyper emesis may be due to raised levels of beta HCG (human chorionic gonadotrophin) as it is more common in multiple pregnancies and in gestational trophoblastic disease. This theory would also explain why hyperemesis gravidarum is most frequently encountered in first trimester (often around 8 - 12 weeks of gestation), as HCG levels are highest at that time and decline afterwards.<br />-Additional theories point to high levels of estrogen and progesterone<br />(Historically, HG was blamed upon a psychological condition of the pregnant women. Medical professionals believed it was a reaction to an unwanted pregnancy or some other emotional or psychological problem).<br />-There may be a genetic component.<br />Symptoms:-<br />When HG is severe and/or inadequately treated, it may result in:<br /><ul><li>Loss of 5% or more of pre-pregnancy body weight
  2. 2. Dehydration, which may causing ketosis and constipation
  3. 3. Nutritional deficiencies
  4. 4. Metabolic imbalances
  5. 5. Altered taste sense
  6. 6. motion sickness
  7. 7. Food leaving the stomach more slowly
  8. 8. Rapidly changing hormone levels during pregnancy
  9. 9. regurgitation of food
  10. 10. Physical and emotional stress of pregnancy on the body
  11. 11. Subconjunctival hemorrhage (broken blood vessels in the eyes)
  12. 12. Difficulty with daily activities
  13. 13. Hallucinations
  14. 14. Some women with HG lose as much as 20% of their body weight. Many women of HG are extremely sensitive to odors in their environment, certain smells may exacerbate symptoms. This is known as hyperolfaction. Ptyalism, or hypersalivation, is another symptom experienced by some women suffering from HG.</li></ul>-As compared to morning sickness, HG tends to begin little earlier in the pregnancy and last significantly longer. While most women will experience near-complete relief of morning sickness symptoms near the beginning of their second trimester, some sufferers of HG will experience severe symptoms until they birth their baby, and sometimes after birthing.<br />Complications:-<br /> For the pregnant woman<br />If inadequately treated, HG can cause renal failure, central pontine myelinolysis (serious brain injury), coagulopathy, atrophy, Mallory-Weiss syndrome, hypoglycemia, jaundice, malnutrition, Wernicke's encephalopathy, pneumomediastinum, rhabdomyolysis, deconditioning, splenic avulsion, and vasospasms of cerebral arteries.<br /><ul><li>Depression is a common secondary complication of HG.</li></ul>For the fetus<br /> Recent research in fetal programming indicates that prolonged stress, dehydration and malnutrition during pregnancy can put the fetus at risk for chronic disease, such as diabetes or heart disease, later in life, or neurobehavioral issues from birth. This underscores the importance of aggressive treatment of the condition.<br /> Diagnosis :-<br />Women who are experiencing hyper emesis 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. (Not simple vomiting, anorexia of pregnancy)<br />Fever, abdominal pain, or late onset of nausea and vomiting usually indicate another condition must be evaluated, such as appendicitis, gallbladder disorders, gastritis, hepatitis, or infection.<br />Because a self-report of this condition can be used to conceal an eating disorder, the presence of conditions such as bulimia nervosa and purging disorder must be appropriately evaluated. Key feature is,HG causes constant nausea and the vomiting is involuntary.<br />Treatment:-<br />Because of the potential for severe dehydration and other complications, HG is generally treated as a medical emergency. Treatment of HG may include antiemetic medications and intravenous rehydration. Nutritional support may be required.<br />Management of HG can be complicated because not all women respond to treatment. Coping strategies for uncomplicated morning sickness, which may include eating a bland diet, eating before rising in the morning, may be of some assistance but are unlikely to resolve the disorder on their own; this is generally ineffective in cases of HG.<br />IV hydration<br />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. A and B vitamins are depleted within two weeks, so extended malnutrition indicates a need for evaluation and supplementation. Additionally, mineral levels should be monitored and supplemented, particularly sodium and potassium.<br />After IV rehydration is completed, patients generally progress to frequent small liquid or bland meals. After rehydration, treatment focuses on managing symptoms to allow normal intake of food. However, cycles of hydration and dehydration can occur, making continuing care necessary. <br />Home care is available in the form of a PICC line(Peripherally inserted central catheter) for hydration and nutrition (total parenteral nutrition). Home treatment is often less expensive than long-term and/or repeated hospital stays.<br />Medications<br />While no medication is considered completely risk-free for use during pregnancy, there are several which are commonly used to treat HG and are believed to be safe.<br />The standard treatment in most of the world is a combination of doxylamine succinate and vitamin B6. (Doxylamine succinate is the active ingredient in many sleep medications), some doctors will recommend this treatment to their patients.<br />Antiemetic drugs, especially ondansetron , are effective in many women. The major drawback of ondansetron has been its cost. Promethazine (Phenergan) has been shown to be safe, at least in rats and may be used during pregnancy with minimal/no side effects.Metoclopramide is sometimes used in conjunction with antiemetic drugs; however, it has a somewhat higher incidence of side effects. Other medications less commonly used to treat HG include, corticosteroids and antihistamines.<br />Practice in United Kingdom<br />The practice in the United Kingdom, following the thalidomide tragedy, is to generally use older drugs for which there has been a greater experience of use in pregnancy. Hence the first choice drug is promethazine with second choice being either metoclopramide or prochlorperazine; with the administration of thiamine strongly recommended.<br />Nutritional support:-<br />Women who do not respond to IV rehydration and medication may require nutritional support. Patients might receive parenteral nutrition (intravenous feeding via a PICC line) or enteral nutrition (via a nasogastric tube or a nasojejunum tube).<br />Support<br />It is very important that women get early and aggressive care during pregnancy. This can help limit the complications of HG. Also, because depression can be a secondary condition of HG, emotional support, and sometimes even counseling, can be of benefit.<br /> It is very important, however, that women not be stigmatized by the suggestion that the disease is being caused by psychological issues.<br />