This document discusses hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy. It begins by defining hyperemesis gravidarum and listing its risk factors, which include high levels of hCG and estrogen, primigravidity, and a history of this condition. The document then covers signs and symptoms, pathogenesis, diagnosis, and both outpatient and inpatient management. Outpatient management involves medications, dietary changes, and lifestyle adjustments while inpatient management focuses on IV rehydration and electrolyte replacement, antiemetics, and monitoring until discharge criteria are met. Complications are also outlined.

1. Course objective
At the end of this lesson the learner will be able to:
• Define hyperemesis gravidarum
• Identify the risk factors of hyperemesis gravidarum
• Manage hyperemesis
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2. Vomiting control centre
1. Vomiting centre
2. CTZ
3. Vestibular nuclei (VIII)
4. High brain centre
5. Vagus nerve (X)
Vomiting reflex
a. Relax Lower ES
b. Cont. abdominal and diaphragm (inc. IAP)
c. Act. ANS ( inc.HR, salivation, peristalsis)
d. Close epiglottis
Treatment
1. Histamine antagonist
2. Serotonin antagonist
3. Dopamine antagonist
4. Muscurinic antagonist 2

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4. Brainstorming Questions :
c/c: Arriving at emergency OPD, Mrs. SPH said, “I
have nausea and vomiting for the last three days”.
1. What are the possible hypothesis and why?
2. Describe your hypothesis as a mechanism leading
to her problem? Which
3. What aspects of history would you take that will
help you to modify your hypothesis?
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5. DDX of Nausea and vomiting
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6. Hyperemisis gravidarum
• Hyperemesis Gravidarum (HG) is the severe form of
nausea and vomiting during pregnancy resulting
electrolyte, metabolic and nutritional imbalance
• It is a rare case but can cause
– Dehydration
– Electrolyte imbalance (hypokalemia)
– Keto-acidosis
– Weight loss (5% prepregnancy weight)
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7. Hyperemesis gravidarum
Morning Sickness: Hyperemesis Gravidarum:
Nausea sometimes
accompanied by vomiting
Nausea accompanied by severe
vomiting
Nausea that subsides at 12wks
or soon after
Nausea that does not subside
Vomiting that does not cause
severe dehydration
Vomiting that causes severe
dehydration
Vomiting that allows you to
keep some food down
Vomiting that does not allow to
keep any food down
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8. Hyperemesis gravidarum
Incidence: 1 in 1000 pregnant women.
• The cause is unknown but can be associated with
condition of high HCG and estrogen level
– Multiple pregnancy
– Hydatidiform mole
– Vitamin B deficiency and psychological factors
Note: high recurrence in subsequent pregnancy
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9. Risk factors
• The cause is unknown but can be associated with condition of
high HCG and estrogen level
• high recurrence in subsequent pregnancy
 Primigravida, young age, overweight (?)
 Hyperthyroidism (due to hCG)
 Previous molar pregnancy
 Multiple pregnancy, diabetes, gastrointestinal illnesses
 Family or past history of this condition
 A female fetus increases the risk by 1.5 fold
 Vitamin B deficiency and psychological factors
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10. Determinants of hyperemesis gravidarum among pregnant
women attending health care service in public hospitals of
Southern Ethiopia 2021
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11. Pathogenesis
• Exaggerated nausea, excessive vomiting → cell
starvation→ ketone bodies are formed from
metabolism of fatty acids (acidosis) → ketone
bodies in the urine
• Alkalosis and hypokalemia develops from loss of
gastric HCl in the vomitus→RR increase to restore
the PH of blood
• Inadequate fluid intake and excessive vomiting result
in weight loss, dehydration & oliguria
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12. Sign and symptom of HEG
• Dehydration
• Headache /confusion
• weight loss
• The PR will be weak & rapid & the BP will be low.
• Urine will be scant & dark in color & contain acetone
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13. Hyperemesis gravidrum… cont’d
Laboratory & Diagnostic test
• Liver enzyme: elevation of (AST) & (ALT)
• CBC: elevated level of RBC & hematocrite
• Urine ketones: positive
• BUN: increase
• Urine specific gravity :grater than 1.025
• Serum electrolyte: decrease levels of K, Na, Cl
• Ultrasound :evaluation for molar or multi pregnancy
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14. Outpatient management
IV fluids:
1. Infuse 1L over 1-2hrs and then 1L over 4hrs
Medications:
1. Vitamin B6 (pyridoxine):-10–25mg PO BID-QID
and Meclizine 25 mg PO TID, or
2. Metoclopramide:- 5-10 mg PO TID, or
3. Promethazine:- 12.5-25 mg PO TID to QID, or
4. Ondansetron 4-8 mg PO TID, or
5. Chlorpromazine 12.5 mg IM BID
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15. Outpatient management
Dietary advice:
• Avoiding of empty stomach, intake of small and frequent diet
• Restriction of coffee, and spicy, odorous, high fat, acidic and
very sweet foods
• Counsel on preferably taking protein rich, salty (e.g. nuts), low
fat, tasteless and dry snacks/meals
• Encourage on fluid intake (better tolerated if cold, clear, and
carbonated or sour)
• Advise on taking peppermint containing products (e.g.
chewing gum, candy) to reduce postprandial nausea
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16. Outpatient management
• drugs that may cause nausea and vomiting should be
temporarily discontinued e.g. iron supplement
• Advise on taking ginger or ginger containing
preparations
• Counsel on avoiding of environmental triggers: -
stuffy rooms, strong odors (e.g. perfume, chemicals,
food, smoke), heat, humidity, noise, and visual or
physical motion (e.g. flickering lights, driving)
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17. In patient management
Indications for admission:
1. Weight loss > 5% from pre-pregnancy
2. Ketonuria above +2
3. Electrolyte imbalance
4. Deranged renal and liver function tests
5. Persistent vomiting / failed OPD management
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18. In patient management
Fluid management:
 Oral feeding withheld for 24 to 48 hrs
 Give 1-2L of isotonic N/S or RL within 1-2hrs
 Continue 1-2L over the next 2-3 hrs until the clinical signs of
hypovolemia improves
 Avoid dextrose containing fluid until thiamine is supplemented
with the initial rehydration fluid
 Give maintenance fluid after deficit is corrected:-
4 ml / kg / hr- for the first 10 hrs
2 ml / kg / hr for the next 10 hrs
1 ml / kg / hr for the rest
 In addition replace ongoing loss
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20. In patient management
Vitamins:
Thiamine (vitamin B1):
• Give 100 mg IV with the initial rehydration fluids before
administration of dextrose containing fluids and another
100 mg daily for the next two or three days i.e. 10
ampoules of Vita. B complex containing 10 mg of
thiamine per 24 hrs (3 ampoules / liter).
Vitamin B6:
• Give 10-25 mg in every liter (i.e. at least 5 ampoules of
vitamin B complex containing 2 mg of vitamin B-6 in
each bag of fluid).
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21. In patient management
Electrolyte management:
For mild to moderate hypokalemia (serum potassium 2.5-
3.5 meq)
Give potassium - 20-80 meq / 24 hrrs
Add 1vial of KCL in each bag of maintenance fluid
For severe hypokalemia (serum potassium <2.5 meq/l) or
symptomatic hypokalemia
Give potassium – 20 meq/2-3 hrs with careful
monitoring every 2-4 hrs
Add 2-3 vials of KCL (40-60 meq) in each bag of
maintenance fluid
Adjust the amount based on the serum potassium level
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22. In patient management
Antiemetics:
First line
• Meclizine 25mg IV TID, or
• Metoclopramide-5–10mg IV TID,or
• Promethazine 5-10mg IM every 6-8
hrs
Second line:
• Serotonin antagonists -Ondansetron
4-8 mg IV or PO, TID
Third line: Chlorpromazine 25mg IV
or IM QID.
Diet:
PO diet can be resumed after a
short period of gut rest.
Adjunctive treatment:
• If the patient has acid reflux
or PUD administer anti-acid
suspensions or H2 receptor
blockers as needed.
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23. In patient management
Follow up:
• Vital signs (twice daily)
• Weight (at presentation, then daily)
• Features of dehydration
• Input & out put
• Urine ketone (daily)
• Appetite
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24. In patient management
Criteria for Discharge
• Improvement of ketone level in the urine
• Tolerating oral fluids and possibly food for at least 24 hrs
hours after urine is free for ketone and with PO antiemetic.
• Appropriate anti-emetic to be taken at home:-
• Vitamin B6 (pyridoxine):- 10–25 mg PO BID-QID PLUS
Meclizine 25 mg PO TID or Promethazine 12.5-25 mg every 6
hours OR
• Metoclopramide 10 mg every 6-8 hours, OR Ondansetron 4-8
mg PO TID.
NOTE: Antiemetic should be taken for at least one week and
with proper advice
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25. Complications
Maternal
• Esophageal tear or
rupture
• Peripheral neuropathy
due to B6 and B12
deficiency
• Wernicke's
encephalopathy
• Liver and renal failure
Fetal
• Preterm deliveries
• Stillbirths
• Miscarriages
• Fetal growth retardation
• Fetal death
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