For medical students

1. Nausea and Vomiting in
Pregnancy
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2. Nausea
• Unpleasant sensation at back of throat
• Awareness of urge to vomit
• Often accompanied by
– cold sweat
– pallor
– salivation
– disinterest in surroundings
– loss of gastric tone
– duodenal contractions
– reflux of intestinal contents into stomach
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3. Retching
• Spasmodic, rhythmic contractions of respiratory
muscles:
– Diaphragm
– Chest wall
– Abdominal wall muscles
• Without expulsion of gastric contents
• Normally generates pressure gradient leading to
vomiting
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4. Vomiting (emesis)
• Forceful expulsion of gastric contents from the
mouth
• Caused by
– powerful sustained contraction of abdominal muscles
– descent of diaphragm
– opening of gastric cardia
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5. Epidemiology
Up to 90% of pregnant women have nausea
Up to 55% have vomiting
Occurs between 4-16 weeks
Usually mild, self-limited
5% are nauseated until delivery.
Nausea and vomiting are worse in morning.
May continue throughout the day.
Not disturb the patient's health or her pregnancy.
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6. Epidemiology
Primigravida
Young women
Obesity
History of motion sickness
Nausea/vomiting with oral contraceptives
Psychiatric issues
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7. Pathophysiology
Not fully understood
Correlated with increasing hCG .
Correlation with smooth muscle relaxation?
Correlation with thyroid, progesterone,
estrogen, adrenal hormones?
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8. I. During early pregnancy
A. Obstetric causes
◦ Vesicular mole.
◦ Multiple pregnancy.
◦ Hydramnios.
◦ Retroverted gravid uterus.
B. Non obstetric causes
1. Gastrointestinal causes
◦ Appendicitis.
◦ Cholecystitis.
◦ Peptic ulcers.
◦ Gastroenteritis.
◦ Intestinal obstruction.
◦ Hiatus hernia.
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Causes

9. Causes
I. During early pregnancy
B. Non obstetric causes ( continue)
2. Liver
◦ Viral hepatitis.
3. Pyelitis with pregnancy
4.Cerebral tumors.
5. Infectious fevers.
6. Red degeneration in a fibroid with pregnancy .
7. Torsion of ovarian cyst during pregnancy
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10. Causes
II. Persistent vomiting late in pregnancy
Pregnancy induced hypertension:
severe preeclampsia, eminent
eclampsia.
Abruptio placenta.
Other non obstetric causes of
vomiting.
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11. Treatment-Mild
Support and Reassurance
Avoidance of triggering foods and odors.
Frequent small meals
Eating dry toast or crackers before rising.
Drugs
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12. Prognosis
Generally excellent
Incidence of fetal demise is lower
Birth weight, congenital FD unchanged.
Untreated hyperemesis have high morbidity and mortality
HG is associated with decreased gestational age.
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13. Hyperemesis
Gravidarum
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14. Definition
Protracted and severe vomiting
before the 20th week of gestation
that affects the general condition of
patient and requires admission to
hospital .
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15. Epidemiology
Is the most severe manifestation of the spectrum of
nausea and vomiting of pregnancy.
It complicates 0.3 to 2% of all pregnancies.
Typically occurs in first trimester.
Vomiting with weight loss >5% of pre-pregnant weight.
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16. Epidemiology
Dehydration, electrolyte imbalance and acid base disturbances .
may lead to renal and hepatic injury .
At risk for growth restriction and fetal anomalies .
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17. Risk Factors for HG
Pgda
Multiple pregnancy.
Under the age of 24.
Past History of HG.
Obesity.
Female fetus.
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18. Causes of HG
Theories:
High levels of hCG (stim CRTZ, as in multiple – molar).
Increased estrogen levels & allergy.
Psychological factors.
High-fat diet.
Thyroid gland activation in early pregnancy.
Vitamin B6 deficiency.
PG.
Helicobacter pylori(HP) ???
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19. What is HP?
Is a spiral-shaped gram negative
rods found on gastric mucosa
particularly the antrum .
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20. Prevalence of HP
Very common all over the
world 55% .
90% In peptic ulcer.
60% - 80% in gastritis without
ulcer.
Developing > developed.
In Egypt very common at
young age .
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21. Transmission HP
Oral – Oral.
Faecal – Oral.
Vectorial.
Iatrogenic.
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22. Biochemical changes
◦ Electrolytes disturbances (decreased Na+, decreased Cl-).
◦ Hypovolemia.
◦ Hemoconcentration (increased viscosity).
◦ Oliguria. Starvation.
◦ Ketoacidosis.
◦ ketone bodies accumulation (Ketonuria).
◦ Vitamin deficiency (B6, B1).
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23. Clinical Picture
It starts as morning sickness that become aggravated gradually
1. Manifestations of dehydration as
◦ Sunken eyes.
◦ Dry tongue.
◦ Dry wrinkled skin.
◦ Oliguria.
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24. Clinical Picture
2. Manifestations of starvation as:
Emaciation.
Loss of weight.
3. General Examination:
Vital signs :decreased blood pressure, tachycardia, and subnormal
temperature.
Jaundice in severe cases
Urine: Oliguria in late cases
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25. Clinical Picture
4. Nervous manifestations in severe cases.
Peripheral neuritis resulting in pain & tingling sensation.
Wernicke's encephalopathy (nystagmus, optic neuritis & diplopia).
Korsakoff's syndrome (confusion & loss of memory for recent events).
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26. Investigations
1. Sonar: to exclude multiple pregnancy & exclude vesicular mole.
2. Serum electrolytes (decreased of Na & Cl)
3. Renal function tests.
4. Liver function test.
5. Urine analysis.
6. Complete blood count.
7. Ophthalmic examination .
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27. Treatment
Hospitalization
IV hydration with electrolytes and
vitamins
Brief gut rest, then high carb, low fat diet
Pharmacotherapy
Enteral feeding if all other methods fail
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28. I. Treatment of Mild Cases
1. Reassurance and isolation from stressful home environment
by hospitalization
2. Diet :small, frequent, semisolid, rich in carbohydrate, poor in
fat and proteins.
3. Treatment of dehydration by ample fluids intake .
4. Drugs:
Antiemetics: cortigen B6, metclopramide (primperan and plasil).
Antihistaminic
Corticosteroids in resistant cases.
Vitamin B1 and B6
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29. II. Treatment of Severe cases
1. Hospitalization & isolation of the patient in a
single room, & no visitors are allowed.
2. IV fluids (glucose 5%, normal saline
3. Drugs
Antiemetics (metclopramide, antihistaminic).
Antacids.
Vitamin B6 & B1.
Sedatives.
Hydrocortisone.
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30. II. Treatment of Severe cases
4. Follow up of maternal & fetal conditions:
Maternal
◦ Vital signs twice /day: for hypotension and tachycardia.
◦ Urine analysis for acetone and chloride.
◦ Frequency, amount & characters of vomiting.
◦ Daily fluid chart for fluid input & output. Serum electrolytes daily
(Na+, Cl-, K+).
◦ Examination of the fundus oculi/week.
◦ Liver function tests weekly .
◦ Renal function tests weekly.
Fetal observation by serial sonography.
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31. II. Treatment of Severe cases
5. Termination of pregnancy :
1. Severe persistent vomiting unresponsive to all measures.
2. Jaundice.
3. High blood urea, oliguria or anuria.
4. Wernicke's encephalopathy.
5. Retinal hemorrhages.
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32. Complementary & Alternative Therapies
Acupuncture/acupressure, at wrist .
Nerve stimulation at wrist.
Herbal remedies:
◦ Ginger, 1 gm powder daily (ACOG)
◦ Peppermint leaf
◦ Chamomile
Vitamin supplements- B6.
Hypnosis
32
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33. The location of pericardium P6 point (Neiguan): Is three
fingers breadth (patient`s fingers) about 5 cm proximal to
the proximal flexor palmar crease, about 1 cm deep
between the tendons of flexor carpi radialis and palmaris
Neiguan (P. 6)
Tendon of musculus
flexor carpi radialis
Tendon of musculus
palmaris longus
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34. A The location of pericardium P6 point (Neiguan): Is three fingers breadth (patient`s fingers) about
5 cm proximal to the proximal flexor palmar crease, about 1 cm deep between the tendons of flexor
carpi radialis and palmaris longus .
B Active acupressure: An elastic wristband with a pressure stud, a small button the size of
a pea (7mm) Seaband (SeaBand®, UK Ltd., Leicestershire, England) was placed bilateral before
anaesthesia over the P6 point.
C The location of a non-acupoint. A point on the dorsal side of the forearms, four fingers breadth
(patient`s fingers) proximal to the flexor palmar crease was used for stimulation.
D Pressure on a non-acupoint: Seabands was placed bilateral before anaesthesia over the non-
acupoints described under C.
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35. ACUPUNCTURE AND ACUPRESSURE
Stimulation of the P6 (Neiguan) point,
located three-fingers’ breadth proximal
to the wrist, has been used for
thousands of years by acupuncturists to
treat nausea and vomiting from a
variety of causes.
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36. ACOG Recommendations
Level A
◦ Multivitamin use at conception reduces N/V
◦ B6 with or without doxylamine is 1st line therapy
Level B
◦ Ginger appears to be beneficial
◦ Antihistamines, Phenothiazines, Benz amides
◦ Methylprednisolone may be a last resort
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37. BVWALIKA 37