presentation on symptoms and signs of pregnancy and hyperemesis gravidarum @ FTH Gombe, college of medical science GSU.

1. DEPARTMENT OF OBSTETRICS AND
GYNAECOLOGY
COLLEGE OF MEDICAL SCIENCES
GOMBE STATE UNIVERSITY
SYMPTOMS AND SIGNS OF
PREGNANCY/HYPEREMESIS GRAVIDARUM
BY
UG13/MDMD/1005
UG13/MDMD/1046

2. CONTENTS
• INTRODUCTION
• PRESUMPTIVE MANIFESTATION
• PROBABLE MANIFESTATION
• POSITIVE MANIFESTATION
• PREGNANCY TEST
• HYPEREMESIS GRAVIDARUM
– CAUSES
– CLINICAL FEATURES
– DIFFERENTIAL DIAGNOSIS
– COMPLICATION
– ASSESSEMENT
– MANAGEMENT
• REFERENCES

3. • Pregnancy is the state of having products of conception
implanted normally or abnormally in the uterus or
occasionally elsewhere. It is terminated by spontaneous
or elective abortion or by delivery.
• In a patient who has regular menstrual cycles and is
sexually active, a period delayed by more than a few
days to a week is suggestive of pregnancy. Even at this
early stage, patients may exhibit signs and symptoms
of pregnancy
• On physical examination, a variety of findings indicate
pregnancy.

4. PRESUMPTIVE MANIFESTATIONS
Symptoms
• Amenorrhea
Cessation of menses is caused by increasing estrogen
and progesterone levels produced by the corpus luteum
• Nausea and Vomiting
This common symptom occurs in approximately 50%
of pregnancies and is most marked at 2–12 weeks'
gestation. (morning sickness)
• Fatigue

5. Breasts
• Mastodynia, or breast
tenderness, may range from
tingling to frank pain
• Enlargement of Circumlacteal
Sebaceous Glands of the Areola
(Montgomery's Tubercles)
occurs at 6–8 weeks' gestation
and is a result of hormonal
stimulation.
• Colostrum Secretion: begin
after 16 weeks' gestation.
• Secondary Breasts: may
become more prominent both in
size and in coloration. These
occur along the nipple line.
Hypertrophy of axillary breast
tissue often causes a
symptomatic lump in the axilla.

6. Urinary Tract
• Bladder Irritability, Frequency, and Nocturia
• These conditions occur because of increased
bladder circulation and pressure from the
enlarging uterus
• Others
– Quickening: The first perception of fetal
movement occurs at 18–20 weeks in primigravidas
and at 14–16 weeks in multigravidas

7. Signs
• Increased Basal Body Temperature >3-wk period usually indicates
pregnancy.
• Skin
• Chloasma or the mask of pregnancy, is darkening of the skin over
the forehead, bridge of the nose, or cheekbones. It usually occurs
after 16 weeks' gestation and is intensified by exposure to sunlight.
• Linea Nigra: is darkening of the nipples and lower midline of the
abdomen from the umbilicus to the pubis (darkening of the linea
alba). The basis is stimulation of melanophores by an increase in
MSH.
• Stretch Marks or striae of the breast and abdomen, are caused by
separation of the underlying collagen tissue and appear as irregular
scars. This is probably an adrenocorticosteroid response. These
marks generally appear later in pregnancy when the skin is under
greater tension.
• Spider Telangiectases: are common skin lesions that result from
high levels of circulating estrogen. These vascular stellate marks
blanch when compressed. Palmar erythema is often an associated
sign. Both of these signs are also seen in patients with liver failure.

9. PROBABLE MANIFESTATIONS
Symptoms:
• are the same as those discussed under Presumptive Manifestations, above.
Signs
• Pelvic Organs
• Chadwick's Sign: Congestion of the pelvic vasculature causes bluish or
purplish discoloration of the vagina and cervix
• Vaginal sign: (a) Apart from the bluish discoloration of the anterior vaginal
wall
• (b) The walls become softened and (c) Copious non-irritating mucoid
discharge appears at 6th week (d) There is increased pulsation, felt through
the lateral fornices at 8th week called Osiander’s sign.
• Leukorrhea: An increase in vaginal discharge consisting of epithelial cells and
cervical mucus is due to hormone stimulation.
• Bones and Ligaments of Pelvis. There is slight but definite relaxation of the
joints, most pronounced at the pubic symphysis, which may separate to an
astonishing degree.

10. Uterine sign
• Hegar's Sign This is widening of
the softened area of the isthmus,
resulting in compressibility of the
isthmus on bimanual
examination. This occurs by 6–8
weeks
• There may be asymmetrical
enlargement of the uterus if
there is lateral implantation. This
is called Piskacek’s sign where
one half is more firm than the
other half. As pregnancy
advances, symmetry is restored.
The pregnant uterus feels soft
and elastic.
• Palmer’s sign

11. • Uterine Contractions
As the uterus enlarges, it becomes globular and often
rotates to the right. Painless uterine contractions
(Braxton Hicks contractions) are felt as tightening or
pressure. They usually begin at about 28 weeks'
gestation and increase in regularity. These contractions
usually disappear with walking or exercise, whereas
true labor contractions become more intense
• Cervical signs: (a) Cervix becomes soft as early as 6th
week (Goodell’s sign), a little earlier in multiparae.
The pregnant cervix feels like the lips of the mouth,
while in the non-pregnant state, like that of tip of the
nose. (b) On speculum examination, the bluish
discoloration of the cervix is visible. It is due to
increased vascularity

12. • Abdominal
Enlargement :There
is progressive
abdominal
enlargement from 7–
28 weeks. At 16–22
weeks, growth may
appear more rapid as
the uterus rises out of
the pelvis and into the
abdomen

13. POSITIVE MANIFESTATIONS
• Fetal Heart Tones (FHTs)
• It is possible to detect FHT by hand held Doppler as early as 10
weeks' gestation. The normal fetal heart rate is 120–160 beats per
minute. It may be detected by fetoscope by 18–20 weeks' gestation.
• Palpation of Fetus
• After 22 weeks, the fetal outline can be palpated through the
maternal abdominal wall. Fetal movements may be palpated after 18
weeks. This may be more easily accomplished by a vaginal
examination.
• Ultrasound Examination of Fetus
• Sonography is one of the most useful technical aids in diagnosing
and monitoring pregnancy. Cardiac activity is discernible at 5–6
weeks, limb buds at 7–8 weeks, and finger and limb movements at
9–10 weeks. At the end of the embryonic period (10 weeks by
LMP), the embryo has a human appearance. Fetal well-being can be
monitored by ultrasound as the pregnancy progresses

14. Pregnancy Tests
• Sensitive, early pregnancy tests measure
changes in levels of hCG. the β subunit of
hCG is measured. hCG is produced by the
syncytiotrophoblast 8 days after fertilization
and may be detected in the maternal serum
after implantation occurs, 8–11 days after
conception.

15. • Urine Pregnancy Test
• This is the most common method used. Using antibodies, the test
identifies the subunit of hCG, minimizing cross-reaction with
similarly structured hormones. The test is affordable, reliable and
fast (1–5 minutes to obtain results) tool to diagnose pregnancy in the
office. The urine pregnancy test is qualitative—positive or negative,
based on color change, with the level of hCG detection ranging
between 5 and 50 mIU/mL, depending on the kit used.
• Home Pregnancy Tests
• hCG is detected in a first-voided morning urine sample. A positive
test is indicated by a color change or confirmation mark in the test
well. Because the accuracy of the home pregnancy test depends on
technique and interpretation, it should always be repeated in the
office.
• Serum Pregnancy Test
• hCG can be detected in the serum as early as a week after
conception. The serum pregnancy test can be quantitative or
qualitative with a threshold as low as 2–4 mIU/mL, depending on
the technique used. The serum pregnancy test is a reliable method to
diagnose an early pregnancy; it is widely used in the evaluation of
threatened abortion, ectopic pregnancy, and other conditions

17. 1st
TRIMESTER
2nd
TRIMESTER
3rd
TRIMESTER
Amenorrhoea + + +
Morning sickness: ++ + -
Frequency of micturition ++ - +
Appetite changes and sleepiness. + - -
Breast sign + ++ +++
Uterine signs: + ++ +++
Cervix : soft, hypertrophied and
violet/bluish
+ ++
Vagina: violet/bluish, moist,
warm with increased acidity.
+ ++
Quickening - ++ +++
Abdominal enlargement. - ++ +++
Skin signs - + +++
Foetal signs: - ++ +++
lightening

18. • SUMMARY
• AT 6–8 WEEKS: Symptoms — Amenorrhea, morning sickness, frequency
of micturition, fatigue, breast discomfort.
• Signs: Breast enlargement, engorged veins visible under the skin; nipples
and areola more pigmented. Internal examination reveals — positive
Jacquemier’s sign, softening of the cervix, bluish discoloration of the
cervix and Osiander’s sign; positive Hegar’s and Palmer’s sign. Uterine
enlargement varies from hen’s egg to medium size orange. Immunological
tests will be positive. Sonographic evidence of gestational ring.
• AT 16TH WEEK: Symptoms — Except amenorrhea, all the previous
symptoms disappear.
• Signs: Breast changes — pigmentation of primary areola and prominence
of Montgomery’s tubercles, colostrum. Uterus midway between pubis
and umbilicus, Braxton-Hicks contractions, uterine souffle, internal
ballottement. X-ray shows fetal shadow. Sonographic diagnosis.
• AT 20TH WEEK: Symptoms — Amenorrhea, quickening (18th week).
• Signs: Appearance of secondary areola (20th week), linea nigra (20
weeks), uterus at the level of umbilicus at 24 weeks, Braxton-Hicks
contractions, external ballottement (20th week), fetal parts (20 weeks),
fetal movements (20 weeks), FHS (20weeks), internal ballottement (16–28
weeks). X-ray shows fetal shadow. Sonographic diagnosis

19. COMMON PROBLEMS OF PREGNANCY
• Back Pain
• Constipation
• Contractions
• Dehydration
• Edema
• Gastroesophageal Reflux Disease
• Hemorrhoids
• Pica
• Round Ligament Pain
• Varicose Veins
• Urinary Frequency

20. Hyperemesis gravidarum
Definition:
It is a severe type of vomiting of pregnancy which has got
deleterious effect on the health of the mother and/or
incapacitates her in day-to-day activities requiring hospital
admission and rehydration associated with adverse effects
such as dehydration, metabolic acidosis (from starvation) or
alkalosis (from loss of hydrochloric acid), electrolyte
imbalance (hypokalemia) and weight loss.

21. INCIDENCE
• There has been marked fall in the incidence
during the last 30 years. It is now a rarity in
hospital practice (less than 1 in 1000
pregnancies). The reasons are — (a) Better
application of family planning knowledge
which reduces the number of unplanned
pregnancies, (b) early visit to the antenatal
clinic and (c) potent antihistaminic, antiemetic
drugs.

22. Causes/Pathogenesis
• The etiology is obscure but the following are the known facts: (1)
It is mostly limited to the first trimester (2) It is more common in
first pregnancy, with a tendency to recur again in subsequent
pregnancies (3) It has got a familial history — mother and sisters
also suffer from the same manifestation (4) It is more prevalent in
hydatidiform mole and multiple pregnancy (5) It is more common in
unplanned pregnancies but much less amongst illegitimate ones.
 Hormonal—(a) Excess of chorionic gonadotropin or higher
biological activity of hCG is associated. This is proved by the
frequency of vomiting at the peak level of hCG and also the
increased association with hydatidiform mole or multiple
pregnancy when the hCG titer is very much raised (b) High serum
level of estrogen (c) Progesterone excess leading to relaxation of
the cardiac sphincter and simultaneous retention of gastric fluids
due to impaired gastric motility. Other hormones involved are:
thyroxin, prolactin, leptin and adrenocortical hormones

23.  Psychogenic: It probably aggravates the nausea once it
begins. But neurogenic element sometimes plays a
role, as evidenced by its subsidence after shifting the
patient from the home surroundings. Conversion
disorder, somatization, excess perception of sensations
by the mother are the other theories
 Dietetic deficiency: Probably due to low carbohydrate
reserve, as it happens after a night without food.
Deficiency of vitamin B6, Vit B1 and proteins may be
the effects rather than the cause.
Allergic or immunological basis.
Mechanical: There is a fall in lower oesophageal
pressure, decreased gastric peristalsis and gastric
emptying in pregnancy.

24. PATHOLOGY
• There is no specific morbid anatomical findings. The changes in the
various organs as described by Sheehan are the generalized
manifestations of starvation and severe malnutrition.
• Liver: There is centrilobular fatty infiltration without necrosis.
• Kidneys: Usually normal with occasional findings of fatty change in
the cells of first convoluted tubule, which may be related to
acidosis.
• Heart: A small heart is a constant finding. There may be
subendocardial hemorrhage.
• Brain: Small hemorrhages in the hypothalamic region giving the
manifestation of Wernicke’s encephalopathy. The lesion may be
related to vitamin B1 deficiency.

25. Clinical features
The patient is usually a nullipara, in early pregnancy. The onset is
insidious.
• EARLY: Vomiting occurs throughout the day. Normal day-to-day
activities are curtailed. There is no evidence of dehydration or
starvation.
• LATE: (Evidences of dehydration and starvation are present).
– Symptoms: Vomiting is increased in frequency with retching. Urine
quantity is diminished even to the stage of oliguria. Epigastric pain,
constipation may occur. Complications may appear (see below) if not
treated.
– Signs: Features of dehydration and ketoacidosis: Dry coated tongue,
sunken eyes, acetone smell in breath, tachycardia, hypotension, rise in
temperature may be noted, jaundice is a late feature. Such late cases
are rarely seen these days. Vaginal examination and/or
ultrasonography is done to confirm the diagnosis of pregnancy.

26. • Risk factors
– Previous history of hyperemesis gravidarum
– Family history of hyperemesis gravidarum
– Overweight
– Primigravida
– Multiple pregnancy

27. Investigations
• Urinalysis: (1) Quantity—small (2) Dark color (3) High specific
gravity with acid reaction (4) Presence of acetone, occasional
presence of protein and rarely bile pigments (5) Diminished or even
absence of chloride.
• Biochemical and circulatory changes: The changes are
mentioned previously. Routine and periodic estimation of the
serum electrolytes (sodium, potassium and chloride) is helpful in the
management of the case.
• Ophthalmoscopic examination is required if the patient is
seriously ill. Retinal hemorrhage and detachment of the retina are
the most unfavorable signs.
• ECG when there is abnormal serum potassium level.
DIAGNOSIS: The pregnancy is to be confirmed first. Thereafter, all
the associated causes of vomiting (enumerated before) are to be
excluded. Ultrasonography is useful not only to confirm the
pregnancy but also to exclude other, obstetric (hydatidiform mole,
multiple pregnancy), gynecological, surgical or medical causes of
vomiting

28. DIFFERENTIAL DIAGNOSIS
• Multiple pregnancy
• Gastrointestinal (for example, infection
including Helicobacter pylori, reflux
oesophagitis, gastritis, cholecystitis, peptic
ulceration, hepatitis, appendicitis, pancreatitis,
complications after bariatric surgery)
• Neurological (for example, migraine, raised
Intracranial pressure, central nervous system
diseases)
• Molar pregnancy

29. • Ear, nose, and throat disease (for example, labyrinthitis,
Ménière’s disease, vestibular dysfunction)
• Drugs and supplements (such as opioids and iron- some
prenatal multivitamin preparations contain iron which
may exacerbate NVP)
• Metabolic and endocrine disorders (such as
hypercalcaemia, Addison’s disease, uremia, and
thyrotoxicosis)
• Persistent vomiting in diabetic women which may
suggest autonomic neuropathy
• Psychological disorders (such as eating disorders)
• Urinary tract infection

30. Maternal Complications
• Dehydration
– increases the risk of diabetic ketoacidosis in those with type 1
Diabetes
– increases the risk of thromboembolism along with
immobilisation
• Electrolyte disturbances as seen in any patient with persistent
vomiting – hypochloraemic alkalosis, hypokalaemia and
hyponatraemia
• Protein-calorie malnutrition
• Vitamin/mineral deficiencies and accompanying problems – e.g.
thiamine deficiency can cause Wernicke’s encephalopathy, a serious
neurological disorder associated with acute mental confusion, short
term memory loss, ataxia, ocular abnormalities such as nystagmus
and peripheral neuropathy. Wernicke’s encephalopathy can lead to
irreversible neurological impairment.
• Folate deficiency, leading to iron deficiency

31. • Thyroid dysfunction – e.g. “pseudo-thyrotoxicosis” –
suppressed TSH with high free thyroxine resulting from
thyroid stimulation by HCG
• Renal dysfunction – (reversible) elevated urea and
creatinine
• Hepatic dysfunction accompanying hyperemesis –
elevated ALT, AST, low albumin, elevated bilirubin,
due to malnutrition and catabolic changes
• Ulcerative oesophagitis
• Psychological morbidity e.g. post-traumatic stress
disorder, Depression
• Mallory –Weiss tears
• Cachexia
• Death

32. Fetal Complications
• Fetal loss as a result of maternal Wernicke’s
encephalopathy.
• Intrauterine growth restriction (IUGR) or small
for gestational age infants associated with
prolonged hyperemesis /multiple admissions
and loss of >5% body weight.
• Undernutrition in early pregnancy during fetal
programming increases risk of chronic illness
in adult life of the offspring.

33. Management
• The principles in the management are:
• To control vomiting
• To correct the fluids and electrolytes imbalance
• To correct metabolic disturbances (acidosis or alkalosis)
• To prevent the serious complications of severe
vomiting Case of pregnancy.
• Hospitalization: Whenever a patient is diagnosed as a
case of hyperemesis gravidarum, she is admitted.
Surprisingly, with the same diet and drugs used at
home, the patient improves rapidly. The relatives may
be too sympathetic or too indifferent

34. • Fluids: Oral feeding is withheld for at least 24 hours after the cessation of
vomiting. During this period, fluid is given through intravenous drip method. The
amount of fluid to be infused in 24 hours is calculated as follows: The total
amount of fluid approximates 3 liters, of which half is 5% 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. With this regime — dehydration,
ketoacidosis, water and electrolyte imbalance are likely to be rectified. Serum
electrolyte should be estimated and corrected if there is any abnormality. Enteral
nutrition through nasogastric tube may also be given.
• Drugs:
• (a) Antiemetic drugs promethazine (Phenergan) 25 mg or prochlorperazine
(Stemetil) 5 mg or trifluopromazine (Siquil) 10 mg may be administered twice or
thrice daily intramuscularly. Trifluoperazine (Espazine) 1 mg twice daily
intramuscularly is a potent antiemetic therapy. Vitamin B6 and doxylamine are also
safe and effective. Metoclopramide stimulates gastric and intestinal motility
without stimulating the secretions. It is found useful. (b) Hydrocortisone 100 mg
IV in the drip is given in a case with hypotension or in intractable vomiting. Oral
method prednisolone is also used in severe cases. (c) Nutritional support — with
vitamin B1, Vit B6, Vit C and Vit B12 are given. Nursing care: Sympathetic but
firm handling of the patient is essential. Social and psychological support should
be extended.

35. • Hyperemesis progress chart is helpful to assess the
progress of patient while in hospital. Daily record of pulse,
temperature, blood pressure at least twice daily, intake-
output, urine for acetone, protein, bile, blood
biochemistry and ECG (when serum potassium is abnormal)
are important.
• Clinical features of improvement are evidenced by — (a)
subsidence of vomiting (b) feeling of hunger (c) better look
(d) disappearance of acetone from the breath and urine (e)
normal pulse and blood pressure and (f) normal urine
output.
• Diet: Before the intravenous fluid is omitted, the foods are
given orally. At first, dry carbohydrate foods like biscuits,
bread and toast are given. Small but frequent feeds are
recommended. Gradually full diet is restored.
• Termination of pregnancy is rarely indicated. Intractable
hyperemesis gravidarum inspite of therapy is rare these
days.

36. REFERENCES
1) Alan H. DeCherney, Lauren Nathan, T. Murphy Goodwin, Neri Laufer, “Current
Diagnosis & Treatment Obstetrics & Gynecology”, Tenth Edition 2007. The
McGraw-Hill Companies, Inc
2) Kevin P. Hanretty “Obstetrics Illustrated” 6th Edition 2003. Churchill Livingstone
3) Diaa M. EI-Mowafi, “Obstetrics Simplified” First edition 1997. Burg Abu-Samra
,El-Happy Land Square, El-Mansoura ,Egypt.
4) “GYNECOLOGY AND OBSTETRICS CLINICAL PROTOCOLS & TREATMENT
GUIDELINES” MINISTRY OF HEALTH P. O. Box 84 Kigali, Rwanda.
www.moh.gov.rw
5) CLINICAL PRACTICE GUIDELINE HYPEREMESIS AND NAUSEA/VOMITING IN
PREGNANCY Institute of Obstetricians and Gynaecologists, Royal College of
Physicians of Ireland and the Clinical Strategy and Programmes Division, Health
Service Executive. Version 1.0 Publication date: Nov 2015 Guideline No: 12
6) Tamara A. Callahan, Aaron B. Caughey “Blueprints Obstetrics and Gynaecology”
Sixth Edition 2013 by Lippincott Williams & Wilkins, a Wolters Kluwer business.
• DC Dutta, Hiralal Konar. “DC DUTTA’s TEXTBOOK OF OBSTETRICS Including
Perinatology and Contraception Enlarged & Revised Reprint of 7th Edition 2013.