Hyperemesis gravidarum is severe nausea and vomiting during pregnancy that requires hospitalization. It is diagnosed after ruling out other causes and is characterized by dehydration, weight loss, and an inability to keep food or fluids down. Treatment involves hospitalization, IV rehydration, electrolyte and nutritional supplementation, antiemetic medications, and monitoring for complications of dehydration and malnutrition. The goals are to rehydrate the mother and prevent risks to her and fetal health.

1. MANAGEMENT OF HYPEREMESIS
GRAVIDARUM
WELCOME

2. DEFINITION
Hyperemesis gravidarum is defined as
unexplained intractable nausea, retching, or
vomiting beginning in the first trimester,
incapacitates her in day-to-day activities or
sufficient to warrant hospital admission
resulting in dehydration, ketonuria, and
typically a weight loss of more than 5% of
prepregnancy weight.

3. DIAGNOSIS:
• The pregnancy is to be confirmed first.
• Exclusion of other causes of vomiting
• Proper history taking
• Clinical examination
• Relevant investigation

4. HISTORY and PATIENT PROFILE
First trimester
First pregnancy
Familial history
Younger mother
Unplanned pregnancies
Hydatidiform mole and multiple pregnancy
Motion sickness, migraines, oral contraceptives
Helicobacter pylori

5. CLINICAL FEATURE
Symptoms:
• Vomiting is increased in frequency with retching.
• Urine quantity is diminished even to the stage of
oliguria.
• Epigastric pain
• Constipation
• Complications may appear if not treated.
• Result in frequently social isolation and negative
impacts on relationships with family and friends.
• Excess salivation (ptyalism)

6. Signs:
Features of dehydration and ketoacidosis:

7. INVESTIGATIONS
Hyperemesis gravidarum is a diagnosis of
exclusion
investigations are performed for
• Conformation of pregnancy
• Exclusion of common and serious causes of
vomiting
• Evaluating the extent of complication

8. • Urinalysis
• Biochemical
serum electrolytes
Sodium- hyponatremia
Potassium- hypokalemia
chloride
• Ophthalmoscopic examination

9. • ECG
• Biochemical hyperthyroidism
• Abnormal LFTs
• Hemoconcentration leading to rise in
Hemoglobin %
RBC count
Hematocrit values

10. Imaging Studies
1.Ultrasound
To confirm pregnancy
To establish the number of fetuses
To exclude hydatidiform mole
To exclude other conditions such as
• Pancreatitis
• Cholecystitis
• intracranial lesions

11. COMPLICATIONS:
Maternal and Fetal Risks
Maternal Risks
(1) Neurologic complications —
(a) Wernicke’s encephalopathy
(b) Pontine myelinolysis
(c) Peripheral neuritis
(d) Korsakoff’s psychos
(2) Stress ulcer in stomach
(3) Mallory-Weiss syndrome

12. (4) Jaundice
(5) Convulsions
(6)Coma
(7) Renal failure /acute tubular necrosis
(8) Pneumomediastinum/ pneumothorax
(9) Splenic avulsion
(10) Psychological burden- depression, anxiety,
lost work
(11) Anemia
(12)Hyponatremia (plasma sodium < 120
mmol/L) can cause confusion, seizures, and
respiratory arrest.
(13)Deep venous thrombosis /thromboembolism

13. Fetal Risks
• No fetal complications
• Women with HEG who gain <7 kg during the
entire pregnancy have a slightly higher risk of
Low birth weight / small for gestational age/ IUGR
Preterm birth / born before 37 weeks’ gestation
• If the mother develops Wernicke’s
encephalopathy- chance of IUD

14. MANAGEMENT
Prince WiIliam and Duchess Kate when they left the
King Edward VII hospital in central London in 2012,
the last time Kate was treated for hyperemesis

15. Hospitalization:
Whenever a patient is diagnosed as a case of
hyperemesis gravidarum, she is admitted

16. Fluids: Rehydration
Fluid replacement therapy should be with eithe
Normal saline
Hartmann’s solution
Dextrose-containing fluids should not be used

17. Double-strength saline
Potassium supplements
Thiamine supplements
Enteral - nasogastric tube
Parenteral feeding

18. Monitoring
Urine output
Ketonuria- dipsticks
Body weight

19. Drugs:
(a)Antiemetic drugs
CAT GROUP EXAMPLE DOSE
B H 1
ANTIHISTAMINES
Meclizine
Doxylamine-
pyridoxine
12.5 to 25 mg
PO four times a
day
SUBSTITUTED
BENZAMIDES
Metoclopramide 10 mg PO four
times a day
5-HT3 receptor
blockers
Ondansetron 8 mg PO two
times a day
ANTICHOLINERGIC Dicyclomine
C PHENOTHIAZINES Promethazine 25 mg PO or
rectally every 4
to 6 hours
prochlorperazine

20. Efficacy of antiemetic drug

21. (b) Hydrocortisone
• Severe and resistant symptoms
• Unable to tolerate fluids
Intravenous hydrocortisone 100 mg three times a
day
Prednisolone 40 mg once daily

22. (c) Nutritional support
• Vit B1
• Vit B6
• Vit B12
• Vit C

23. Diet:
At first, dry carbohydrate foods
• Biscuits
• bread
• toast
Small but frequent feeds are recommended
Spicy food should be avoided

24. Other Treatment Options
While they are inpatients
Thromboembolic deterrent stockings
Thromboprophylaxis such as enoxaparine 40 mg
daily

25. Nonpharmacologic measures
Acupuncture
Acupressure
Hypnotherapy
Herbal teas
Ginger/ ginger tea

26. Termination of pregnancy
Rarely indicated
• Intractable hyperemesis gravidarum inspite of
therapy
• Wernicke’s encephalopathy
• Jaundice
• Persistant CVS change