2. HYPEREMESIS GRAVIDARUM
• Severe nausea and intractable vomiting sufficient to interfere with maternal
nutrition causing deleterious effect on her health.
• Incidence: 0.8-1.6%
vomiting in pregnancy(70%)
3. ETIOLOGY/ THEORIES:
1. Endocrine factors: hCG , estrogen , progesterone, thyroxine
2. Infection: helicobactor pylori (gram negative)
3. Upper GI dysmotility due to progesterone
4. Dietary deficiency: B1 & B6
5. Genetic: familial tendency
6. Psychological : conversion disorder, chances of recurrence in subsequent
pregnancies
7. Liver dysfunction
5. PATHOLOGY
1.Metabolic changes:
Depletion of glycogen stores and mobilization of fat
increased ketone bodies
Increased tissue protein metabolism
increased BUN
Hypoglycemia, hypoproteinemia, ketoacidosis, hypovitaminosis
Severe cases- hepatic dysfunction and hyperbilirubinemia
6. 2.Biochemical changes:Alkalosis ( ph- 7.35- 7.45 )
Hyponatremia (135-143meq/l)
Hypokalemia (3.5- 5meq/l)
Hypochloremia (97-107meq/l)
• Brain: small haemorrhages in hypothalamus due to vit B1 deficiency
(Wernicke’s encephalopathy)
7. • Kidneys: acute renal failure due to severe dehydration
• Vascular changes:
Hemoconcentration with rise in hemoglobin level, red cell count and
hematocrit
Mild leucocytosis with eosinophilia
8. CLINICAL FEATURES
SYMPTOMS:
Nausea & vomiting begins at 4-6wks, peaks at 8-12 wks and usually resolves by
20wks
Strong aversion for food and ptyalism ( saliva)
SIGNS:
Signs of dehydration and ketoacidosis – sunken eyes, dry tongue, anxious look,
ketotic odour of breath, loss of skin elasticity, tachycardia, hypotension
9. COMPLICATIONS:
• Fetal complications include FGR in 1/3rd of cases
• Maternal complications include-
- mild electrolyte imbalance hypokalemia, hyponatremia.
11. MANAGEMENT OF MILD/ MODERATE CASE
WITHOUT DEHYDRATION
• Preconceptional multivitamin
• Reassurance and support
• Frequent small meals
• Vitamin B6 with or without doxylamine 10-30mg every 8hourly
12. • Antiemetics- Promethazine 25mg/prochlorperazine 5mg/ triflupromazine
10mg may be given intramuscularly twice or thrice daily
• Metochlopramide 10mg 8-12 hourly oral/ IV
• Serotonin antagonist ondansetron8-12mg oral/ IV (cat C)
13. LATE HYPEREMESIS WITH DEHYDRATION
• Hospitalization
• IV fluids- 3L in 24 hours : half D5%, half RL
• Electrolyte correction
• Intravenous thiamine- 100mg in 100ml NS over 30 min
• Vitamin B6, Vit C and B12.
• Hydrocortisone 100mg IV
14. • Severe cases – oral methyl prednisolone 15mg tid can be given
• Supportive psychotherapy
• Total Parenteral Nutrition in sick pts
• Diet modifications- frequent small meals with high proteins, low carbs and
low fat.
• Termination of pregnancy very rarely required.
15. OTHER AILMENTS OF PREGNANCY
• Acute abdominal pain
• Heartburn
• Fever
• Trauma
• Venous thromboembolism in pregnancy
17. FEVER IN PREGNANCY (>38 degree)
• Fever is not an illness but response to toxins
COMMON CAUSES OF FEVER:
1.Viral infections (common cold, influenza, rubella, varicella, mumps,
measles, chicken pox)
2. Bacterial infections (TB, typhoid, UTI)
3. Pneumonitis
4.Autoimmune
5. Neoplastic etiology
6. Malaria
18. FEVER- WHY A CONCERN ?
• Hyperthermia causes 2 fold increase in neural tube defects in women
during early pregnancy
• Excessive core temperature causes malformations
• Rubella and varicella may directly affect embryogenesis/ organogenesis
19. • Excessive risk of malformations has been shown to decrease with intake of
antipyretics
COMMON COLD:
Requires treatment if >100 degree temperature
Paracetamol safest; 4-6th hourly; upto 4gm/24hour
Symptomatic treatment- antihistaminics (safe in pregnancy)
20. INFLUENZA (H1N1)
• Most have mild illness, 1% may need hospitalizations
• Complications include- pneumonia, bacterial ci-infection, myocarditis, seisures,
encephalitis and altered sensorium
• Mortality - 6 %
• Can result in premature delivery
• Starting antiviral within 48hr of illness reduces risk of severity
• Influenza vaccine (inactivated) can be given in all 3 trimesters
21. TYPHOID
• Cause- Salmonella typhi, faeco-oral transmission by contaminated food or
water
• C/F: Persistent fever, abdominal pain, severe anorexia, mild diarrhoea or
constipation &delirium
• 10-15% develop severe disease with complications like GI bleed, intestinal
perforation & typhoid encephalopathy
22. DIAGNOSIS:
• Blood culture is confirmatory
• Widal test measures agglutinating antibodies ( positive only after 10days)
widal may be negative in 30% of cases
TREATMENT:
3rd gen cephalosporins
23. MALARIA IN PREGNANCY
• Severe malaria common in pregnancy due to immunosuppression
• Complications: pulmonary edema, hypoglycemia and severe anemia
• Severe p. falciparum infection may cause cerebral malaria, abortion &
IUFD.
• Perinatal effect : FGR, LBW, Preterm delivery, still birth and congenital
malaria
• DIAGNOSIS: peripheral smear (gold std)
24. Treatment of malaria in pregnancy:
• Treatment of choice- chloroquine
Dosage- 4 tab pf 150mg stat f/b 2 tab after 6 hrs and then 2 tabs once a day
for 2 days (total 10 tabs)
• Pyrimethamine (25mg) can be given in chloroquine resistant cases of
p.falciparum with folic acid
• Pyrimethamine can cause hemolytic anemia in fetus
• Mefloquine in chloroquine resistant cases
• Severe/ complicated cases- quinine can be given oral/ parenteral 10mg/kg
25. TRAUMA IN PREGNANCY
• CAUSES: motor vehicle accidents, fall, domestic violence & assault
• Fetal mortality mostly due to placental abruption, maternal shock & death
• Note: 1st trimester- uterus is intrapelvic and well protected in
2nd trimester- uterus is thick and muscular & fetus is cushioned in amniotic cavity
3rd trimester- uterus is more vulnerable
26. PRIMARY ASSESSMENT
• Posture of the gravida during resuscitation
• ABC – AIRWAY, BREATHING CIRCULATION
• Blood volume replaced quickly to prevent hypoxic injury to fetus, kidneys
& other organs
• Oxygen administration
• Coagulation profile to R/O DIC
27. SECONDARY ASSESMENT
• Assess type and severity of maternal injuries
• Manage non obstetric injuries
• Obstetric examination includes- fundal height, uterine irritability, fetal
movements & FHS
• To note bleeding / leak PV
• Gestational age is critical to decide further management
• Continuous electronic fetal monitoring
28. DIAGNOSTIC IMAGING
• USG can diagnose GA, placental localisation, FHR, AFI
• USG misses abruption in > half cases
• Radiological investigations - concern of exposure to fetus
• GA 2-7 weeks is major period of organogenesis with increased risk of
teratogenesis, mental retardation, growth restriction and childhood cancers
• Exposure below0.05 Gy (5rads) doesn’t increase the risk
29. OTHER TYPES OF INJURIES
• Blunt trauma abdomen:
- may cause abruption / rupture uterus
- intraperitoneal haemorrhage can be managed by direct peritoneal lavage
• Penetrating abdominal injury: common forms are gunshots, stab injuries
-selective laparotomy can be performed
30. • Electrical injury: High voltage current like in lightening results in loss of
pregnancy due to abortion/ still birth
- electric shock due to home appliances have no adverse affect
Electroconvulsive therapy is safe in pregnancy (all trimesters)
31. PERIMORTEM CAESAREAN SECTION
• Caesarean section concurrent with cardiopulmonary resuscitation
• Done when resuscitation is unsuccessful
• Baby should be delivered within 5min to maximise chances of fetal
survival without neurological sequalae
• It may improve chances of maternal survival with better and easier
resuscitation
32. VENOUS THROMBOEMBOLISM IN
PREGNANCY
• RISK FACTORS:
• Age >35
• parity >3
• Obesity (BMI >30)
• Previous VTE
• Family history
• Hyperhomocysteinemia
• Protein C & S deficiency
• APLA
• Immobilization
• Pre-eclampsia
• Diabetes
• Anemia
• Major blood loss
• Caesarean section
• Dehydration (HEG)
