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1. Hyperemesis Gravidarum
Dejene Edosa (BSc, MSc in CMw)
Jaaury 2021

2. HYPEREMESIS GRAVIDARUM (HEG)
• is persistent severe nausea and vomiting.
• May cause lose of more than 5% of their pre-
pregnancy body weight, and ketoneuria, electrolyte
abnormalities (hypokalemia), and
• In most cases, women with hyperemesis
gravidarum will have blood and urine tests that
show evidence of dehydration.
• Incidence: from 0.3 to 2% of pregnancies.
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3. Definition….
• Commonly occur b/n 5 and 18wks of Px.
• HEG may cause to vomit multiple times throughout
the day, lose weight, and usually requires Rx in the
hospital.
Morning sickness versus hyperemesis
"Morning sickness" is mild nausea and vomiting while
"hyperemesis gravidarum" is the term used to describe
a more severe condition.
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4. Etiology and risk factors
• Hormonal: Excess hcG, hyper-thyroidism, hyper-
progesteronism, hyper-estrogenism.
• Psychogenic:-
• Unwanted Px, uninformed mothers ( no ANC ).
• Dietary deficiencies: Low carbohydrate reserves,
deficiency of B-complex vitamins.
• Non-pregnant women who experience nausea and
vomiting related to estrogen–based medication & who
had motion sickness.
• Multiple Px & hydatidiform mole px.
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5. Pathogenesis
• The pathogenesis of nausea and vomiting in Px is unknown
( Predominant theories.)
• Psychological factors - a response to stress.
• A feeling of ambivalence about the Px.
• Psychological makeup of pts with hyperemesis gravidarum
differs from those without the disorder.
• The woman’s psychological response to persistent N & V
may exacerbate her symptoms as a result of conditioning.
• Hormonal changes - Elevated estrogen & progesterone.
• These hormones relax smooth muscle and thus slow
gastrointestinal transient time and may alter gastric
emptying.
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6. Pathogenesis….
• Helicobacter pylori
• The infection may play a role in pathogenesis of
disease in some women (in severe disease).
• Abnormal gastrointestinal motility
• gastric motility may be abnormal (delayed or
dysrhythmic) HEG.
The lower esophageal sphincter is relaxed in
pregnancy, leading to an increase in gastro-
esophageal reflux.
• Gastro-esophageal reflux results in heartburn and, in
some individuals, nausea.
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7. DIAGNOSIS AND CLINICAL COURSE
• The mean onset of symptoms is at 5-6wks of
gestation, peaking at about 9 wks, and usually
abating/reduced by 16-20 wks.
• Common criteria for diagnosis of hyperemesis :
• Pregnancy-related persistent vomiting accompanied
by weight loss >3kg or >5% of pre-Px body wt.
• Ketonuria unrelated to other causes.
• Hypersalivate (ptyalism)
• Increased vomiting
• Oliguria
• Epigastric pain
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8. EVALUATION
• Laboratory tests and imaging
• Laboratory evaluation is indicated in women with
persistent nausea and vomiting to determine the
severity of disease and to exclude other diagnoses
that could account for the symptoms.
• The standard initial evaluation: measurement of
weight, orthostatic BP, HR, serum electrolytes, and
urine ketones.
• An obstetrical U/S: to look for gestational
trophoblastic disease and multiple gestation
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9. Clinical features
• General examination
• Progressive emaciation with weight loss
• Anxious look with sunken eyes
• Icterus /yellowish eye, skin and membrane.
• Dry, coated tongue
• Teeth covered with sordid/dirty
• Acetone smell in breath
• Tachycardia
• Hypotension 9

10. Investigations
Blood
• Complete blood count (CBC).
Urine
• Specific gravity – kidney’s ability to concentrate urine.
• Urine culture
• Urine acetone or ketones.
Ophthalmic examination
• Retinal hemorrhage, rarely retinal detachment
USG
• To rule out molar pregnancy, multiple Px.
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11. MANAGEMENT OF HEG
Non-pharmacologic interventions
 Avoidance of triggers - Stuffy rooms, odors (eg,
perfume, chemicals, food, smoke), Heat, Humidity,
noise, visual or physical motion (eg, flickering
lights, driving).
• Quickly changing position and not getting enough
rest, particularly after eating, may also aggravate
symptoms.
• Lying down soon after eating and lying on the left
side are additional potentially aggravating factors
because these actions may delay gastric emptying.
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12. Management…
• Cold solid foods are tolerated better than hot solid
foods because they have less odor and require less
preparation time (ie, shorter exposure to the trigger if
the woman is preparing her own meal).
• Brushing teeth after a meal, spitting out saliva, and
frequently washing out the mouth can be helpful.
• Counseling may be helpful for women with anxiety.
• Ginger - Powdered ginger may help to relieve
nausea and vomiting in some women.
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13. Pharmacologic Management HEG
• Hospitalization and Fluid management
• Fast hydration first then based on the output (loss) &
as maintenance.
• Fluid requirement – 1.5 Lit 5% dextrose, 1.5 lit. DNS and 5%
dextrose equal to vomitus and in last 24hrs (usually 1 lit.)
• Drip rate =no. of lit. to be infused in 24 hours multiplied by 12.
Drugs – used in order to tide over the situation fast & prevent
complications:
• Metoclopramide-10 mg IM TID/BID, then PO when able to
tolerate.
• Promethazine–12.5 - 25 mg IM/PR TID/BID, then 25mg PO BID
• Chlorpromazine – 12.5 - 25 mg IM TID/BID, then PO.
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14. Management..…
• Vitamins - daily IM injection containing Vitamin B1,
Vitamin B6 and Vitamin C.
• Vitamin B6 50-100 mg PO daily may be used when able to
tolerate.
• Vitamin B complex may also be used with hydration
crystalloid by adding an ampoule in 1000 ml of fluid.
• Corticosteroids -methylprednisolone 10mg TID for 2 days
with rapid taper over 2wks in resistant cases.
• Accurate maintenance of input/output chart, vital sign chart,
weight chart.
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15. Diet
• Started before the IV fluid therapy is omitted in the form of
dry carbohydrate rich foods like biscuit, toasts, etc.
• Role of termination of pregnancy – very rarely indicated
and a very last option:
• Hemodynamic instability due to intractable vomiting in
spite of adequate and appropriate treatment
• Hepatic failure and renal failure
• Neurological complications
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16. .
GALATOOMAA!
ANY QUESTION?
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