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
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
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
21.
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.
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