Nausea and vomiting in pregnancy (NVP), including hyperemesis gravidarum (HG), are common conditions affecting up to 80% of pregnant women. NVP diagnosis is based on symptoms in the first trimester without other causes, while HG diagnosis requires weight loss of over 5%, dehydration, and electrolyte imbalance. Treatment involves antiemetics, rehydration, nutritional support, and monitoring for complications like dehydration. Recurrence is common, so management involves lifestyle changes, early antiemetic use, and multidisciplinary support in severe cases.

1. BY
MUHAMMAD HAMISU YUSUF
MODERATOR : DR. YAHYA

2. OUTLINE
 INTRODUCTION
 EPIDEMIOLOGY
 DIAGNOSIS AND ASSESSMENT
 PATHOGENESIS
 TREATMENT
 MONITORING AND PREVENTION OF COMPLICATIONS
 FURTHER TREATMENT
 FOLLOW UP
 CONCLUSION
 REFERENCES

3. INTORDUCTION
 Nausea and vomiting in pregnancy (also known as
morning sickness) are common complains.
 NVP in pregnancy can have a significant impact on
jobs, activities, family relationships, and moods.
 Nausea and vomiting are common in pregnancy,
affecting upto 70% to 85% of pregnant women.

4. EPIDEMIOLOGY
 Nausea and vomiting in pregnancy are more
common in
-Primigravidae.
-Multiple pregnancy.
-History of previous hyperemesis gravidarum.
 It is less common with increasing maternal age.
 It tends to be a disease of Western society and is
less common in developing countries, especially in
rural communities.
 The incidence of women with severe symptoms is
not well- documented; reports vary from 0.3 to 3.6
percent of pregnancies.

5.  NVP
-Up to 80% of pregnant women
- one of the most common indication for hospital
admission among pregnant women, with typical stays
of between 3 and 4 days.
 HG
- severe form of NVP
- 0.3 – 3.6% of pregnant women.
- recurrence rates 15-80%.

6. DIAGNOSIS AND ASSESSMENT
 NVP- Should only be diagnosed when onset is in the
first trimester and other causes of nausea and
vomiting have been excluded.
 HG – Diagnosed when there is protracted vomiting
with the triad of
1. ≥ 5% pregnancy weightloss
2. Dehydration
3. Electrolyte imbalance.

7.  Severity of NVP classified according to the pregnancy-
Unique Quantification of Emesis Score-24.
 An objective and validated index of nausea and
vomiting.

9. Initial clinical assessment
 1. History
-Previous history of NVP/HG
-Quantify severity using PUQE score
-nausea, vomiting, hypersalivation, spitting,
-loss of weight, inability to tolerate food and fluids,
effect on quality of life
 History to exclude other causes: –
– abdominal pain
– urinary symptoms
– infection
– drug history
– chronic Helicobacter pylori infection

10. 2. Examination
 Temperature, Pulse, Blood pressure, Respiratory rate
 Oxygen saturations
 Weight
 Signs of dehydration
 Signs of muscle wasting
 Abdominal examination
 Other examination as guided by history

11. 3. Investigation
 Urine dipstick:
– quantify ketonuria as 1+ ketones or more
 MSU
 Urea and electrolytes:
– hypokalaemia/hyperkalaemia
– hyponatraemia
– dehydration
– renal disease

12.  Full blood count:
– infection
– Anaemia
– haematocrit
 Blood glucose monitoring:
– exclude diabetic ketoacidosis if diabetic
 Ultrasound scan:
– confirm viable intrauterine pregnancy
– exclude multiple pregnancy and trophoblastic
disease

13.  In refractory cases or history of previous admissions,
check:
– TFTs: hypothyroid/hyperthyroid
– LFTs: exclude other liver disease such as hepatitis or
gallstones, monitor malnutrition
– calcium and phosphate
– amylase: exclude pancreatitis
– ABG: exclude metabolic disturbances to monitor
severity

15. TREATMENT
1. ANTIEMETICS
There are safety and efficacy data for first line
antiemetics such as
- Antihistamines (H1 receptor antagonists)
-Phenothiazines
And they should be prescribed when required for
NVP and HG.
 Combination of different drugs should be used
in women who do not respond to single
antiemetic.
 For women with persistent or severe HG
parenteral or rectal route may be necessary and
are more effective than the oral regimen.

17. 2. Rehydration
 Normal saline
- with additional potassium chloride in each bag
- with administration guided by daily monitoring of
electrolytes
- the most appropriate intravenous hydration.
 Dextrose infusions
- not appropriate unless the serum sodium levels are
normal and thiamine has been administered.

18. 3. Complementary therapies
 Ginger
may be used by women wishing to avoid antiemetic
therapies in mild to moderate NVP.
 Acustimulations – acupressure and acupuncture
- safe in pregnancy.
- Acupressure may improve NVP.
 Hypnosis
should not be recommended to manage NVP and HG.
{evidence was not sufficient to establish whether hypnosis
(trance induction) is effective}

19. COMPLICATION
 MATERNAL
 Dehydration
 Electrolyte or acid base imbalance
 Mallory Weiss tear
 Wernickes encephalopathy
 Death
 Fetal consequences are rare but intrauterine growth
restriction (IUGR).

20. 3. MONITORING AND PREVENTION OF
COMPLICATIONS
1. Urea and serum electrolyte levels
 should be checked daily in women requiring intravenous
fluids.
2. Histamine H2 receptor antagonists or proton pump
inhibitors
 may be used for women developing
-gastro-oesophageal reflux disease
-oesophagitis or
-gastritis.

21. 3. Thiamine supplementation
 Either oral or intravenous
 should be given to all women admitted with
prolonged vomiting, especially
 before administration of dextrose or parenteral
nutrition.

22. 4. Women admitted with HG
Thromboprophylaxis:
 low-molecular-weight heparin
 unless there are specific contraindications such as
active bleeding.
 can be discontinued upon discharge.
5. Women with previous or current NVP or HG should
consider avoiding iron-containing preparations if
these exacerbate the symptoms.

23. 4. FURTHER MANAGEMENT
1. Multidisciplinary team
 In women with severe NVP or HG,
 midwives, nurses, dieticians, pharmacists,
endocrinologists, nutritionists and gastroenterologists,
mental health team, including a psychiatrist.
2. Enteral and parenteral nutrition When all other medical
therapies have failed
3. Termination of pregnancy. All therapeutic measures
should have been tried before offering termination of a
wanted pregnancy.

24. 5. FOLLOW-UP
1. ANTENATAL
 An individualised management plan in place when they are
discharged from hospital.
 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.
2. Postnatal
 A woman’s quality of life can be adversely affected
 Practitioners should assess a woman’s mental health status
during the pregnancy and postnatally
 refer for psychological support if necessary.

25. 3. Future pregnancies
 Women with previous HG should be advised that
there is a risk of recurrence in future pregnancies.
 Early use of
- lifestyle/dietary modifications and Antiemetics that
were found to be useful in the index pregnancy to
reduce the risk of NVP and HG in the current
pregnancy.

26. CONCLUSION
 Vomiting in pregnancy is very common and is
multifactorial, therefore through history and
investigations are necessary to identify the etiologic
factor. About 50% of vomiting in pregnancy resolved
by the 14th week gestation and about 90% resolved by
22nd week of gestation however if left untreated can
lead to devastating consequences.

27. THANKS YOU
FOR LISTENING

28. REFERENCE
 Agbola textbook of obstetric and gynaecology
 Obstetric by ten teachers 19th Edition.
 American journal of obstetric and gynaecology, 2002.
 http://www.patient.co.uk/doctor/nausea-and- vomiting-
in-pregnancy-including-hyperemesis- gravidarum
 http://ezproxy.squ.edu.om:2265/contents/clinical-
features-and-evaluation-of-nausea-and-vomiting-of-
pregnancy?source=search_result&search=hyperemesis
&selectedTitle=2%7E42
 http://www.ncbi.nlm.nih.gov/pubmed/3341360