Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy that can lead to serious health issues, including dehydration and adverse fetal outcomes. Its causes include hormonal changes, dietary deficiencies, and psychological factors, with various management strategies focusing on hydration, nutritional support, and medications. Prevention of its severity may involve dietary adjustments, and proper diagnosis and monitoring are essential for effective treatment.

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