nausea and vomiting during pregnancy.

1. Nausea And Vomiting During Pregnancy
Prepared By : Syed Hassnain Shah
Group # 02
Semester # 07
Submitted to : Dr. Kahkashan

2. When the symptom of nausea &/ or vomiting are
during early pregnancy where there is no other
causes, It is often called morning sickness’, but it can
occur at any time of the day or night.
Affect up to 80% of pregnant women1.
3% have sever nausea and vomiting of pregnancy
which is hyperemesis gravidarum.
It typically starts between 4th and 7th week of
pregnancy.
Peaks in approximately the 9th week and resolve by
20th week in approximately 90% of women.
In many cases it resolves by the end of the first
trimester.
7% have symptoms before the time of first missed
period.
20% continue to have symptom through out their
pregnancy.

3. Family history.
Female gender of fetus.
History of migraine.
Multiple gestation.
Down syndrome.
Molar gestation.

4.  Hyper means ‘over’, Emesis means
‘vomiting’ and Gravidarum means
‘pregnancy’.
 HG can be diagnosed when there is
protracted NVP with the triad of more than
5% prepregnancy weight loss, dehydration
and electrolyte imbalance.
 It affects ~ 1-3 % of pregnant woman.
 It occurs more in multiple and molar
pregnancy.

5. The pathogenesis is poorly understood and the
etiology is likely to be multifactorial
Hormonal effect: mainly hCG and to lesser extend
estradiol.
This is the most accepted theory and proved by the
higher frequency in the conditions where the hCG is
high, such as in:
I. Early in pregnancy.
II. Vesicular mole.
III. Multiple pregnancy.

6.  Cytokines: The consistent finding
has been an increased concentration
of TNF_α which is involved in
regulation of hCG production,
suggesting a possible link to hCG –
hormones hypothesis genetic factor:
 The siblings of patients affected by
NVP are ,more likely to be affected.
 Psychological factor may play a
role.

7. £ The patient cannot retain anything in her
stomach, vomiting occurs through the day and
night even without eating.
£ Thirst, constipation and infrequent urination.
£ In severe cases, vomitus is bile and/ or blood
stained.
£ Finally, there are manifestations of Werniche’s
encephalopathy as drowsiness, nystagmus and
loss of vision then coma.
£ A common associated symptom is Ptyalism- (the
inability to swallow saliva), an increased
olfactory and gustatory aversion and change in
the taste sensitivity.

8.  Manifestations of starvation and dehydration include:
 Loss of weight
 Sunken eyes
 Dry tongue dry mucous membranes, and inelastic skin
 Gums covered with sores
 Breath acetone smell
 Late, slight jaundice
 Pulse: rapid and weak
 Blood pressure: low
 Temperature: slight rise

9. ∞NVP begins before 9 -10 weeks’ gestation.
∞Symptoms that begin after this gestational age
are due to other causes.
∞Abdominal pain is not a prominent feature of
NVP.
∞Fever is not present in NVP, but is characteristic
of many other disease associated with nausea
and vomiting.

10. Fetal growth restriction.
Women with severe NVP or HG who have
continued symptoms into the late second or the
third trimester should be offered serial scans to
monitor fetal growth.
Maternal hyponatraemia leading to central
pontine myelinolysis.
Thiamine deficiency leading to Wernicke’s
encephalopathy.

11.  Pack cell volume (PCV):This may be elevated because
of volume depletion.
 General urine examination (GUE) including testing for
 Ketones and specific gravity.
 Serum electrolytes.
 Renal function test (RFT).
 Liver function test (LFT).
 Thyroid function test (TFT).
 Ultrasound to exclude molar or twin pregnancy.

12.  Other pathological causes should be excluded by
clinical history, focused examination and
investigations.
 Other pathological causes of nausea and
vomiting include peptic ulcers, cholecystitis,
gastroenteritis, hepatitis, pancreatitis,
genitourinary conditions such as urinary tract
infection or pyelonephritis, metabolic conditions,
neurological conditions and drug-induced nausea
and vomiting.

13.  The management of nausea and vomiting of
pregnancy depends on the severity of the symptoms.
 Treatment measures range from dietary changes to
more aggressive approaches involving hospitalization,
or even total parenteral nutrition (TPN).
 Most women with nausea and vomiting in pregnancy
can be successfully managed in primary care.
 Judicious assessment enables recognition of women
whose symptoms are severe and intractable despite
treatment with oral antiemetics, who are unable to
maintain oral hydration and have ketonuria, and who
therefore require referral to hospital.

14.  Exclude other causes of nausea and
vomiting:
Urinary tract infection
Thyrotoxicosis
Cholecystitis
Adequate rehydration (normal saline + K)
sufficient to correct tachycardia,
hypotension, ketonuria and return electrolyte
level to normal. This is the most important
component of management.

15.  Cyclizine.
 Stemetil 5 mg,8 hourly orally or 12.5 mg, 8 hourly IV, IM
 Metoclopramide 10 mg, 8 hourly orally, or 10 mg, 8
hourly IV, IM
 Promethazine.
 Combinations of different drugs should be used in
women who do not respond to a single antiemetic.
 For women with persistent or severe HG, the parenteral
or rectal route may be necessary and more effective than
an oral regimen.

16. Women should be asked about previous adverse reactions
to antiemetic therapies. Drug-induced extrapyramidal
symptoms and oculogyric crises can occur with the use of
phenothiazines and metoclopramide. If this occurs, there
should be prompt cessation of the medications.
Prophylactic thiamine: Oral → 25 - 50 mg, 8 hourlyIV →
100 mg in 100 ml N.S., 60 minSteroid treatment: For women
with severe hyperemesis gravidarum who do not improve
despite conventional treatment with IV fluid & regular
antiemetics, a trial of corticosteroid may be
considered.Ondansetron(5HT3 antagonist) may also have a
role in exceptional cases but clear evidence of safety in first
trimester is still awaited.