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Vomiting in Pregnancy
Vomiting is a symptom which may be
related to pregnancy or may be a
manifestation of some medicalsurgical-
gynecological complications, which can occur at
any time during pregnancy.
The former is by far the most common one and
is called vomiting of pregnancy.
The causes of vomiting in pregnancy can be
classified as follows
1. Early Pregnancy
Related to pregnancy (vomiting of
pregnancy)
•Simple vomiting (morning sickness, emesis
gravidarum)
•Hyperemesis gravidarum (pernicious
vomiting)
 Associated with pregnancy
Medical
•Intestinal infestation
•Urinary tract infection
•Hepatitis
•Ketoacidosis of diabetes
•Pyelonephritis, uremia
Surgical
•Appendicitis
•Peptic ulcer
•Intestinal obstruction
•Cholecystitis
•Pancreatitis
Gynecological
•Twisted ovarian tumor
• Red degeneration of fibroid
2.Late Pregnancy
Related to pregnancy
•Continuation or reappearance of simple
vomiting of pregnancy
•Acute fulminating preeclampsia
Associated with pregnancy
•Medical-surgical-gynecological causes in early
pregnancy
•Hiatus hernia
VOMITING IN PREGNANCY
The vomiting is related to the pregnant state and
depending upon the severity, it is classified as
Simple vomiting of pregnancy-milder type
Hyperemesis gravidarum-severe type
SIMPLE VOMITING (Syn: morning sickness, emesis
gravidarum)
The patient complains of nausea and occasional
sickness on rising in the morning. Slight vomiting
is so common in early pregnancy (about 50%)
that it is considered as a symptom of pregnancy.
It may, however, occur at other times of the day.
The vomitus is small and clear or bile
stained. It does not produce any
impairment of health or restrict the
normal activities of the women. The
feature disappears with or without
treatment by 12–14th week of pregnancy.
High level of serum human chorionic
gonadotropin, estrogen and altered
immunological states are considered
responsible for initiation of the
manifestation, which is probably
aggravated by the neurogenic factor.
Management
Assurance is important. Taking of dry toast
or biscuit and avoidance of fatty and spicy
foods are enough to relieve the symptoms
in majority.
Supplementation with vitamin B1 100 mg
daily is helpful.
If the simple measures fail, antiemetic
drugs — trifluoperazine (Espazine) 1 mg
twice daily is quite effective.
Promethazine and ondansetron can be
used. Patient is advised to take plenty of
fluids (2.5 L in 24 hours) and fruit juice.
HYPEREMESIS GRAVIDARUM
DEFINITION
t is a severe type of vomiting of pregnancy which
has got deleterious effect on the health of
mother and/or incapacitates her in day-to-day
activities.
The adverse effects of severe vomiting are
Dehydration
metabolic acidosis (from starvation)
alkalosis (from loss of hydrochloric acid)
electrolyte imbalance (hypokalemia)
weight loss
ETIOLOGY: The etiology is obscure but the
following are the known facts
It is mostly limited to the first trimester
It is more common in first pregnancy
Younger age
Low body mass
History of motion sickness or migraine
It has got a familial history
It is more prevalent in hydatidiform
mole and multiple pregnancy
THEORIES
Hormonal
Psychogenic
Dietetic deficiency
Allergic or immunological basis
Decreased gastric motility is found to cause
nausea.
Whatever may be the cause of initiation of
vomiting, it is probably aggravated by the
neurogenic element.
CLINICAL COURSE
From the management and prognostic point of
view, the cases are grouped into
Early „
Late
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.
Signs
Features of and ketoacidosis:
Dry coated tongue,
sdehydration unken eyes,
acetone smell in breath,
tachycardia, hypotension, rise
in temperature may be noted,
jaundice is a late feature.
Investigations
Urinalysis
•Quantity—small
•Dark color
•High specifc gravity with acid reaction
•Presence of acetone, occasional presence of
protein and rarely bile pigments and
•Diminished or even absence of chloride
Biochemical
•Serum electrolytes-sodium, potassium and
chloride
•Serum TSH, T3 and Free T4
•ECG when there is abnormal serum potassium
level.
DIAGNOSIS
The pregnancy is to be confirmed first.
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.
COMPLICATIONS
Maternal
The majority of the clinical manifestations are
due to the effects of dehydration and starvation
with resultant ketoacidosis. Leaving aside those
symptomatology, the following complications may
occur which are fortunately rare nowadays
1. Neurologic complications
Wernicke’s encephalopathy, beriberi due to
thiamine deficiency
Pontine myelinolysis
Peripheral neuritis
Korsakoff’s psychosis
2.Stress ulcer in stomach
3.Esophageal tear (MalloryWeiss syndrome)
4.Jaundice, hepatic failure
5.Convulsions and coma
6.Hypoprothrombinemia due to vitamin K
deficiency
7.Renal failure
Effects on the fetus
Fetus usually remains unaffected once the
problem is resolved. Fetal risks may be due to
low birth weight.
PREVENTION: The only prevention is to impart
effective management to correct simple vomiting
of pregnancy
MANAGEMENT
The principles in the management are: ‹
Maintenance of hydration ‹
To control vomiting ‹
To correct the fuids and electrolytes
imbalance ‹
To correct metabolic disturbances
(acidosis or alkalosis) ‹
To prevent the serious complications of
severe vomiting ‹
Care of pregnancy.
Hospitalization
Whenever a patient is diagnosed as a case of
hyperemesis gravidarum, she is admitted.
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
Drugs
Antiemetic drugs promethazine (Phenergan) 25
mg or prochlorperazine (Stemetil) 5 mg or
triflupromazine (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.
Nutritional supplementation— with
vitamin B1 (100 mg daily), vitamin B6 ,
vitamin C and vitamin B12 are given

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Vomiting-in-Pregnancy.pptx

  • 1. Vomiting in Pregnancy Vomiting is a symptom which may be related to pregnancy or may be a manifestation of some medicalsurgical- gynecological complications, which can occur at any time during pregnancy. The former is by far the most common one and is called vomiting of pregnancy.
  • 2. The causes of vomiting in pregnancy can be classified as follows 1. Early Pregnancy Related to pregnancy (vomiting of pregnancy) •Simple vomiting (morning sickness, emesis gravidarum) •Hyperemesis gravidarum (pernicious vomiting)
  • 3.  Associated with pregnancy Medical •Intestinal infestation •Urinary tract infection •Hepatitis •Ketoacidosis of diabetes •Pyelonephritis, uremia Surgical •Appendicitis •Peptic ulcer •Intestinal obstruction •Cholecystitis •Pancreatitis Gynecological •Twisted ovarian tumor • Red degeneration of fibroid
  • 4. 2.Late Pregnancy Related to pregnancy •Continuation or reappearance of simple vomiting of pregnancy •Acute fulminating preeclampsia Associated with pregnancy •Medical-surgical-gynecological causes in early pregnancy •Hiatus hernia
  • 5. VOMITING IN PREGNANCY The vomiting is related to the pregnant state and depending upon the severity, it is classified as Simple vomiting of pregnancy-milder type Hyperemesis gravidarum-severe type SIMPLE VOMITING (Syn: morning sickness, emesis gravidarum) The patient complains of nausea and occasional sickness on rising in the morning. Slight vomiting is so common in early pregnancy (about 50%) that it is considered as a symptom of pregnancy. It may, however, occur at other times of the day.
  • 6. The vomitus is small and clear or bile stained. It does not produce any impairment of health or restrict the normal activities of the women. The feature disappears with or without treatment by 12–14th week of pregnancy. High level of serum human chorionic gonadotropin, estrogen and altered immunological states are considered responsible for initiation of the manifestation, which is probably aggravated by the neurogenic factor.
  • 7. Management Assurance is important. Taking of dry toast or biscuit and avoidance of fatty and spicy foods are enough to relieve the symptoms in majority. Supplementation with vitamin B1 100 mg daily is helpful. If the simple measures fail, antiemetic drugs — trifluoperazine (Espazine) 1 mg twice daily is quite effective. Promethazine and ondansetron can be used. Patient is advised to take plenty of fluids (2.5 L in 24 hours) and fruit juice.
  • 8. HYPEREMESIS GRAVIDARUM DEFINITION t is a severe type of vomiting of pregnancy which has got deleterious effect on the health of mother and/or incapacitates her in day-to-day activities. The adverse effects of severe vomiting are Dehydration metabolic acidosis (from starvation) alkalosis (from loss of hydrochloric acid) electrolyte imbalance (hypokalemia) weight loss
  • 9. ETIOLOGY: The etiology is obscure but the following are the known facts It is mostly limited to the first trimester It is more common in first pregnancy Younger age Low body mass History of motion sickness or migraine It has got a familial history It is more prevalent in hydatidiform mole and multiple pregnancy
  • 10. THEORIES Hormonal Psychogenic Dietetic deficiency Allergic or immunological basis Decreased gastric motility is found to cause nausea. Whatever may be the cause of initiation of vomiting, it is probably aggravated by the neurogenic element.
  • 11. CLINICAL COURSE From the management and prognostic point of view, the cases are grouped into Early „ Late 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
  • 12. Symptoms Vomiting is increased in frequency with retching. Urine quantity is diminished even to the stage of oliguria. Epigastric pain, constipation may occur. Signs Features of and ketoacidosis: Dry coated tongue, sdehydration unken eyes, acetone smell in breath, tachycardia, hypotension, rise in temperature may be noted, jaundice is a late feature.
  • 13. Investigations Urinalysis •Quantity—small •Dark color •High specifc gravity with acid reaction •Presence of acetone, occasional presence of protein and rarely bile pigments and •Diminished or even absence of chloride Biochemical •Serum electrolytes-sodium, potassium and chloride •Serum TSH, T3 and Free T4 •ECG when there is abnormal serum potassium level.
  • 14. DIAGNOSIS The pregnancy is to be confirmed first. 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.
  • 15. COMPLICATIONS Maternal The majority of the clinical manifestations are due to the effects of dehydration and starvation with resultant ketoacidosis. Leaving aside those symptomatology, the following complications may occur which are fortunately rare nowadays 1. Neurologic complications Wernicke’s encephalopathy, beriberi due to thiamine deficiency Pontine myelinolysis Peripheral neuritis Korsakoff’s psychosis
  • 16. 2.Stress ulcer in stomach 3.Esophageal tear (MalloryWeiss syndrome) 4.Jaundice, hepatic failure 5.Convulsions and coma 6.Hypoprothrombinemia due to vitamin K deficiency 7.Renal failure Effects on the fetus Fetus usually remains unaffected once the problem is resolved. Fetal risks may be due to low birth weight. PREVENTION: The only prevention is to impart effective management to correct simple vomiting of pregnancy
  • 17. MANAGEMENT The principles in the management are: ‹ Maintenance of hydration ‹ To control vomiting ‹ To correct the fuids and electrolytes imbalance ‹ To correct metabolic disturbances (acidosis or alkalosis) ‹ To prevent the serious complications of severe vomiting ‹ Care of pregnancy.
  • 18. Hospitalization Whenever a patient is diagnosed as a case of hyperemesis gravidarum, she is admitted. 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
  • 19. Drugs Antiemetic drugs promethazine (Phenergan) 25 mg or prochlorperazine (Stemetil) 5 mg or triflupromazine (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)
  • 20. 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. Nutritional supplementation— with vitamin B1 (100 mg daily), vitamin B6 , vitamin C and vitamin B12 are given