HYPEREMESIS GRAVIDARUM

1. HYPEREMESIS
GRAVIDARUM
SUDHA
GAUTAM
ASSOCIATE PROFESSOR
M.SC. N (OBG)

2. DEFINITION
• Hyperemesis gravidarum or Pernicious Vomiting is extreme, persistent nausea and
vomiting during pregnancy which can lead to dehydration, weight loss, electrolyte
imbalances and may have adverse fetal consequences.
• It is a severe type of vomiting of pregnancy which has got deleterious effect on the
health of the patient and / or incapacitates her day to day activities.
- D. C.
Dutta
HYPER – INCREASED/ EXCESSIVE
EMESIS – VOMIT
GRAVIDARUM - PREGNANCY
• .

3. MORNING SICKNESS
• Morning sickness is mild nausea and vomiting that occurs
in early pregnancy and affects most women to some extent.
• Begins early in pregnancy , mostly between 4th and 7th week
and subsides by 12 to 14 weeks.
• Irrespective of the name it can occur during any time of the
day and night.

4. ETIOLOGY
• Abnormal upsurge in the pregnancy hormones – HCG
• Rise in Estrogen and Progesterone leading to nausea and digestive
issues.
• Family history
• Can reoccur in subsequent pregnancy if once she has suffered with the
problem.
• Hydatidiform mole / Molar pregnancy
• Multiple pregnancy
• More common in unplanned pregnancy

5. ETIOLOGY (CONTINUED)
• Early primigravida (age <17 years)
• Elderly primigravida (age >35 years)
• Psychological factors like marital problems or unmarried
mother or teenage pregnancy

6. SUGGESTED THEORIES FOR HG
A. HORMONAL THEORY:
 High levels of HCG – Molar pregnancy, multiple pregnancy
 Increased levels of Estrogen
 High progesterone which leads to relaxation of cardiac sphincter
 Other hormones: Thyroxine, Prolactin, Leptin, Adeno- cortisol
hormones.

7. THEORIES ( CONTINUED)
B. PSYCHOGENIC THEORY :
 Nausea gets aggravated once neurogenic elements are triggered.
C. DIETARY DEFICIENCY:
 When a woman stays a night without food, the low carbohydrate
reserve in her body and its increasing demand over time by her
body and the fetus can lead to HG.
 Deficiency of Vitamin B1, B6 and Protein may be the effect
rather than the cause.

8. THEORIES ( CONTINUED)
D. Allergic or Immunological Basis
E. Decrease gastric motility can lead to increased nausea.

9. CLINICAL COURSE
• EARLY – Vomiting through out the day
Daily activities are disturbed
No evidence of dehydration and starvation
 LATE – Evidenced by dehydration and starvation
Weight loss

10. SYMPTOMS
• Excess vomiting and retching day and night
• Epigastric pain
• Constipation
• Ptyalism
• Fatigue
• Anorexia
• Dehydration & Ketoacidosis

11. SYMPTOMS ( CONTINUED)
• Dry coated tongue
• Sunken eyes
• Acetone smell in breath
• Tachycardia
• Postural hypertension

12. LAB INVESTIGATION
• URINANALYSIS – For analysis of ketones and specific gravity ( a
sign of starvation, ketones may be harmful for fetal development and
high specific gravity occurs with volume depletion).
• SERUM ELECTROLYTES AND KETONES – To evaluate low
potassium or sodium or chloride (to identify hyperchloremic metabolic
alkalosis or acidosis and evaluate renal function and volume status).
• LIVER ENZYMES AND BILIRUBIN – Elevated liver enzymes as a
sign of underlying liver condition such as hepatitis, liver injury.
• AMYLASE/ LIPASE ESTIMATION, TSH AND FREE THYROXINE
may suggest overt hyperthyroidism which is often associated with
HG.
• OTHERS : Opthalmic examination for retinal detachment and ECG

13. DIAGNOSIS
• Pregnancy should be confirmed first.
• Differential Diagnosis should be done to find the associated
causes of vomiting like Gynecological or Medical Or
Surgical Causes.
• USG – Pregnancy, Multiple Pregnancy, Hydatidiform mole

14. COMPLICATIONS
• NEUROLOGICAL - Wernicke’s encephalopathy d/t thiamine def.
Peripheral Neuritis
Psychosis
Retinal Hemorrhage
Convulsion
Coma
• OTHER’S - Stress ulcer in stomach
Oesophageal Tear
Jaundice d/t Liver Damage

15. PREVENTION
• Although there are no known ways to completely prevent
hyperemesis gravidarum, the following measures might
help keep morning sickness from becoming severe:
• Eating small, frequent meals.
• Eating bland foods.
• Waiting until nausea has improved before taking iron
supplements

16. MANAGEMENT
• PRINCIPLES: To control vomiting
To correct fluid and electrolyte imbalance
To correct Metabolic disturbance
To prevent serious complication of severe
vomiting

17. HOSPITALIZATION
• Admit the patient
• Administer IV Fluids and electrolytes to correct the imbalances.
• Send for relevant investigations
• Maintain intake- output chart
• Monitor urine output ( catheterize the patient)
• Monitor the vitals.
• Periodical urine test should be done to check for presence and
concentration of ketone bodies.

18. FLUIDS
• Oral feeding is withheld for at least 24 hours after the cessation of
vomiting
• During this period, fluid given through IV drip method
• The amount of fluid to be infused in 24 hours is calculated as: total
amount of fluid approx. 3litres, of which half is 5% is dextrose and
half is Ringer’s solution.
• Extra amount of 5% dextrose equal to the amount of vomitus and
urine in 24 hours, is to be added.
• These measures help to correct dehydration, electrolyte imbalance and
keto-acidosis.

19. DRUGS
• Antiemetics such as:
 Vitamin B6 + Doxylamine
 Promethazine
 Prochlorperazine
 Chlorpromazine
 Triflupromazine
 Meclozine HCl
 Metoclopramide
 D2 Antagonist
 Given parenterally H1 Antihistaminics

20. DRUGS (CONTINUED)
• Vitamin supplements like Vitamin B1, Vitamin B6, Vitamin
C and Vitamin B12 may be given
• Hydrocortisone in cases of hypotension or intractable (hard
to heal) vomiting.
• Oral Prednisolone is also useful is severe cases.

21. NURSING CARE
• Sympathetic but firm handling of patient
• Daily monitoring of the patient
• Look for signs of improvement in the patient: subsidence of
vomiting, feeling hungry, better look, disappearance of
acetone from breath and urine, normal pulse and blood
pressure, normal urine output.

22. DIET
• Before IV fluids are omitted, food is given orally
• Small and frequent dry meals without fat
• Biscuit, bread and toast
• Ginger is helpful
• Gradually full diet is restored

23. REFERENCES
1. Williams Obstetrics, 24th Edition
2. DC Dutta’s Textbook of Obstetrics, 7th Edition

24. THANK YOU