COMPLICATION OF PREGNANCY DURING FIRST TRIMESTER Hyperemesis Gravidarum

1. MODULE 1
COMPLICATION OF
PREGNANCY:
FIRST
TRIMESTER
Lesson 1.
Hyperemesis
Gravidarum
By: Daren R. Goco, RM.

2. INTRODUCTION
Pregnancy ultimately builds up a woman. It is the highpoint of life
wherein women become more than just women; they become
mothers. The journey of pregnancy is also a hard one but is
meaningful and brilliant. The discomforts a woman would
experience are just bumps along the road of contentment once
she has delivered her child.
The first trimester although most women are pleased to be
pregnant, the symptoms of early pregnancy tend to cause
discomfort to a woman rather than provide evidence that she is
carrying a child. As such, a woman may become frustrated,
expecting pregnancy to be a time of glowing good health.
Providing empathetic and sound advice about measures to
relieve these discomforts helps promote overall health and well-
being. Although the symptoms discussed below are classified as
minor, they may not seem minor to a woman who wakes up
each morning feeling nauseated, wondering if she will ever feel
like herself again. Also, each of these symptoms has the potential
to lead to problems that are more serious (Pillitteri, 2007).

3. LESSON 1. HYPEREMESIS GRAVIDARUM
A Woman with Hyperemesis Gravidarum Hyperemesis
gravidarum (sometimes called pernicious vomiting) is
nausea and vomiting of pregnancy that is prolonged past
week 12 of pregnancy or is so severe that dehydration,
ketonuria, and significant weight loss occur within the first
12 weeks of pregnancy (Koren & Maltepe, as cited in
Pillitteri, 2007). It occurs at an incidence of 1 in 200 to 300
women. The cause is unknown, but women with the
disorder may have increased thyroid function due to the
thyroid-stimulating properties of human chorionic
gonadotropin. It is associated with Helicobacter pylori, the
same bacteria that causes peptic ulcers (Shirin et al., as
cited in Pillitteri, 2007).

4. CAUSES
The exact pathology of hyperemesis is not clearly understood. Based
on current studies, the following possible causes have been
proposed (Sia, 2006):
1. Elevated HCG: The most widely accepted cause is raised
concentrations of HCG in early pregnancy (Sia, 2006):
• HCG disrupts the normal activity of the GIT by causing
reverse peristalsis that result in nausea and vomiting. Using
electrograms to study the activity od the GIT, researchers
found that gastric dysrhythmias occur at the same time
that the woman experience nausea. They concluded that
this is due to HCG because normal gastric motility returns
after the first trimester when HCG level declines.
• Higher HCG level has been found in women pregnant with
female fetuses than male fetuses. In two studies, it was
found out that women experiencing hyperemesis
gravidarum have a higher incidence of female offspring.
• These results established a link between the hormonal
profile of women pregnant with female offspring and
women suffering from hyperemesis gravidarum. However,
elevated HCG cannot be used to predict the sex of the
fetus. (Asking et al, 1999 as cited in Sia 2006).

5. 2. Thyroid dysfunction: Thyroxine hormone has been found to be
elevated as many as 70%b of women suffering from
hyperemesis gravidarum. Yet these women do not suffer from
Grave’s disease. As an effect, of elevated thyroxine hormone.
This hormone is also elevated in molar pregnancy wherein
excessive nausea and vomiting is also found (Cafferty, 2000 as
cited in Sia, 2006).
3. Psychological stress: Another belief is that hyperemesis
gravidarum is due to psychological stress as some studies
point out n increased incidence of depression, anxiety, and
interpersonal problem in women with hyperemesis (O’bien nd
Naber, 1992 as cited in Sia, 2006).

6. ASSESSMENT (PILLITTERI, 2007)
1. Nausea and vomiting are so severe that she cannot maintain
her usual nutrition.
2. Elevated hematocrit concentration at her monthly prenatal
visit because her inability to retain fluid has resulted in
hemoconcentration.
3. Concentrations of sodium, potassium, and chloride may be
reduced from low intake, and hypokalemic alkalosis may
result if vomiting is severe during the day or persists for an
extended period.
4. In some women, polyneuritis, due to a deficiency of B
vitamins, develops.
5. Weight loss can be severe.

7. 6. Urine may test positive for ketones, evidence that a woman's
body is breaking down stored fat and protein for cell growth.
 If left untreated, the condition is associated with
intrauterine growth restriction or preterm birth if a woman
becomes dehydrated and can no longer provide a fetus
with essential nutrients for growth. Prolonged hospitalization
or home care with this disorder can result in social isolation.
 Always try to determine exactly how much nausea and
vomiting women are having during pregnancy, ask a
woman to describe the events of the day before if she says
it, was a typical day.
 How late into the day did the nausea last? How many
times did she vomit, and how much? What was the total
amount of food she was able to eat.

8. THERAPEUTIC MANAGEMENT
1. Differential Diagnosis: Hyperemesis have symptoms similar to
other medical conditions such as hyperthyroidism,
gastroenteritis, pyelonephritis, molar pregnancy, pancreatitis,
and appendicitis. As such, it is important to rule out other
causes. Diagnostic tests would include liver and thyroid
function studies, urinalysis, and a white blood cell count (Sia,
2006).
2. Conservative management: When a pregnant patient report
excessive nausea and vomiting but she does not suffer from
dehydration, the initial intervention would be carried out at
home. The following health instruction are given to the patient
(Sia, 2006):
a. Have dry, low fat, high carbohydrate and bland diet.
 Take dry crackers.
 Small frequent feedings and sips of water to avoid
gastric distention which could trigger vomiting reflex.
 Avoid very hot and very cold food beverages.

9. b. Avoid noxious stimuli that may precipitate nausea
• Motion and pressure around the stomach such as light
waistbands.
• Temporary cessation of iron supplement id it contributes to
gastric upset.
• Avoid highly seasoned and spicy food.
• Avoid strong odors such as perfumes.
• Avoid loud noises, bright and blinking lights.
c. Take vitamin supplement to correct nutritional
deficiencies from decreased food intake.
d. . Have enough relaxation and rest.
e. Take prescribed medications to relieve symptoms:
• Promethazine (Phergan)
• Prochlorperazine (Compazine)
• Ondansetron (Zofran)
• Droperidol (Inapsine)
• Metoclopramide (Reglan)
• Diphenhydramine (Benadryl)
• Meclizine (Antivent)

10. 3. Hospitalization: When a pregnant woman suffers from
severe nausea and vomiting and shows signs of
dehydration, hospitalization is necessary. This is to
correct dehydration and fluid and electrolyte
imbalance (Sia, 2006)
a. The patient is provided with IV fluids to correct
dehydration and replace electrolytes. The usual IV given
first is lactated ringers. Warm the first liter of fluid first
before administration as dehydrated patients often feel
cold as their limited blood volume is shunted to vital
organs away from peripheral blood vessels.
b. Vitamin supplementation may also be ordered
depending on the nutritional status of the patient.
c. Patient is placed on NPO for 24 to 48 hours until nausea
subsides to rest the GIT.
d. Oral intake is started after the patient is properly
hydrated and nausea has subsided.

11. e. When patient begins oral intake of food:
4. An emesis basin is an important piece of equipment for
a woman who is vomiting. While she is hospitalized, put
it out of sight and not on the bed-side table, however,
so she is not constantly re-minded of vomiting (Sia,
2006).
5. Parenteral and enteral therapies: complementary
therapies are becoming increasingly popular for relief
of pregnancy discomforts as more and more women
are satisfies by their effects and it appeals to many
women who are hesitant of taking medications during
pregnancy because of the possibility of teratogenicity.
Complementary therapies like acupuncture, massage,
therapeutic touch, diet fads, herbal remedies,
homeopathy, reflexology, and color therapy are safe,
natural and inexpensive (Sia, 2006).

12. a. Acupuncture: according to acupuncture therapist, applying
pressure on the Neiguan point (pericardium 6 or P6) relieves nausea.
b. Herbal remedy: The most popular and readily available herbal
remedy for nausea is ginger. Its carminative effects (expels flatus or
gas from the GIT) and aroma relieves nausea.
c. Vitamin Supplementation: Pyridoxine deficiency has been related to
the development of hyperemesis. Supplementation helps relieve
symptoms in women who have Pyridoxine deficiency.
6. Provide emotional support (Sia, 2006):
a. Show sincere concern for the women’s welfare.
b. The difficulties of a woman suffering from hyperemesis may
be compounded by lack of understanding about her
condition. Patients may experience sense of losing control as
the excessive nausea and vomiting she experiences disrupts
her daily functioning and makes even the simplest task doe
difficult to accomplish. Providing reassurance about
pregnancy outcomes and information about the plan of
care will give patients a better understanding of
hyperemesis gravidarum and a sense of control.
Empowering patients with knowledge and encouragement
is one of the most important functions that nurse/midwife
can provide. With this knowledge, the woman realizes that
hyperemesis gravidarum need not disrupt her life if properly
managed.

13. c. Provide necessary referrals such as counseling as
necessary.
Some women have such extreme symptoms
that vomiting recurs with the introduction of food. To
maintain adequate nutrition to support fetal growth, a
woman may need to be maintained on total parenteral
nutrition or enteral feedings. While she is receiving total
parenteral nutrition at home, instruct her to check her
urine for glucose and ketones twice daily. If there is
glucose in the urine, this suggests that the infusion
solution contains more glucose than the body's
metabolism can use. Ketones in the urine mean that the
body is not receiving enough nutrients and it is breaking
down protein. If either of these findings is positive, she
should telephone her health care provider because she
needs a nutrition reassessment. Fortunately, despite its
extreme symptoms, excessive vomiting during pregnancy
rarely leads to pregnancy loss or low-birthweight
newborns when it is properly treated (SoItani & Taylor, as
cited in Pillitteri 2007).

14. THANK YOU!