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1. Hyperemesis Gravidarum
Sunil Kumar Daha

2. Causes of Vomiting in Pregnancy
• Early Pregnancy:
Related to Pregnancy:
-Simple Vomiting
-Hyperemesis
gravidarum
(Pernicious vomiting)
Associated with Pregnancy
Medical: UTI, Hepatitis, Intestinal
infestations, Uraemia, Ketoacidosis
of DM
Surgical: Appendicitis, Peptic Ulcer,
Intestinal obstruction, Cholecystitis
Gynecological: Twisted ovarian
tumor, Fibroid

3. Causes of Vomiting in Pregnancy
• Late pregnancy:
Related to Pregnancy
-Continuation or
reappearance of simple
vomiting
-Acute fulminating pre-
eclampsia
Associated with
Pregnancy
-Medical, surgical,
gynaecological causes as
in early pregnancy
-Hiatus hernia

4. Vomiting of Pregnancy
• Simple vomiting of pregnancy or mild type or
morning sickness
• Hyperemesis gravidarum or severe type

5. Morning Sickness
• Nausea and occasional sickness in the
morning
• Slight vomiting is common in early pregnancy
• Considered as a symptom of pregnancy
• Vomitus small, clear or bile stained
• Does not impair health or restrict activities

6. Morning Sickness
• Disappears with/out treatment in the 12-14th
week of pregnancy
• Human chorionic gonadotrophin and estrogen
• Aggravated by psychogenic factors

7. Management of Morning Sickness
• Assurance
• Dry toast or biscuit
• Avoid fatty and spicy foods
• Plenty of fluids (2.5 L in 24 hrs)
• Fruit juice
• The smell of certain foods aggravates
symptoms and should be avoided

8. Management of Morning Sickness
• If simple measures fail, then try anti-emetics
• Vitamin B6 or Vitamin B6 plus Doxylamine is
safe and effective and should be considered
first-line pharmacotherapy (American College
of Obstetricians and Gynecologists, 2004)
• Antihistaminics, D2 Antagonists, etc. can also
be considered

9. Hyperemesis Gravidarum
• It is a severe type of vomiting of pregnancy which has
got deleterious effect on health of the patient and/or
incapacitates her day-to-day activities
• Defined variably as “Vomiting sufficiently severe to
produce
 weight loss
 Dehydration
 acidosis from starvation
 alkalosis from loss of hydrochloric acid in vomitus
 hypokalemia”
• It is the vomiting which is severe enough to lead to
hospitalization of the lady

10. Risk factors
• Limited to 1st trimester
• More common in 1st pregnancy
• Tendency to recur again in subsequent
pregnancies
• Familial history: Mother and sisters also suffer
from the same manifestation
• More prevalent in hydatiform mole and multiple
pregnancy
• Common in unplanned pregnancies

11. Theories Behind Hyperemesis
Gravidarum
A. HORMONAL
•High hCG
•High Estrogen
•High progesterone
•Other hormones involved:
-thyroxine
-prolactin
-leptin
-adrenocortical hormones
B. PSYCHOGENIC
C. DIETARY DEFICIENCY: Low
carbohydrate reserve, Vit B6,
Vit B1
D. Allergic or Immunologic
E. Decreased gastric motility
F. Liver Theory: Liver can’t
adapt to the high level of
hormones in pregnancy
G. H.pylori infection

12. Pathology
• Liver: Fatty infiltration without necrosis
• Kidney: Occasionally shows fatty degeneration
• Brain: Small hemorrhagic spots in
hypothalamus (may be due to Vit B1
deficiency)
• Blood: Mild leucocytosis and haemo-
concentration due to dehydration

13. Pathology
• Metabolic
Due to less intake of food
Leads to depletion of glycogen  increases
metabolism of fat  accumulation of ketone
bodies  excreted through breath/urine
Leads to excessive breakdown of proteins in
the body  excessive accumulation of
Nitrogen

14. Pathology
• Biochemical Changes
Occurs due to vomiting dehydration
Decreased Na+, K+, Cl-
Raised blood urea, creatinine, uric acid, ketone
bodies
Hypoglycemia
Hypoproteinemia
Hypovitaminosis
Rare: Hyperbilirubinemia
Fetal vulnerability to
toxins peaks at around 3
months, which is time of
peak susceptibility to
morning sickness.

15. Clinical Features
•Signs of dehydration:
dry coated tongue,
sunken eyes, oligouria,
loss of skin elasticity ,
increased pulse rate
•Weight loss >5% of Total
Body Weight
•Electrolyte imbalances
like hypokalemia,
hypocalcemia
•Starvation related
ketoacidosis that can
lead to acetone smell in
the breath
•Rise in temperature may
occur

16. Complications
NEUROLOGICAL
1. Wernicke’s
encephalopathy due
to thiamine deficiency
2. Pontine myelinolysis
3. Peripheral neuritis
4. Korsakoff’s psychosis
5. Ophthalmic: Retinal
haemorrhage
6. Convulsions
7. Coma
OTHER
1. Stress ulcer in the
stomach
2. Esophageal tears
(Mallory-Weiss
Syndrome)
3. Jaundice due to liver
damage
4. Renal failure
5. Vit K deficiency:
bleeding manifestations

17. Investigations
1. Complete Blood Count
 Haemoconcentration leads to rise Hb, RBC
count, and Hematocrit
 Slight increase in WBC count
2. Electrolytes: Na+, K+, Cl- decreased due to loss in
vomitus
3. Random Blood Glucose: Hypoglycemia

18. Investigations
4. Urinalysis:
Quantity (too see for oligouria)
Dark color (due to concentration)
High specific gravity with acid reaction
Presence of acetone, occasional presence of
protein and bile pigments
Diminished or even absence of chloride

19. Investigations
5. Liver Function Tests: Albumin, Prothrombin
time, ALT, AST, ALP, Bilirubin levels
6. Renal Function Test: Urea and Creatinine
levels
7. Ophthalmoscopic examination
Retinal hemorrhage
Detachment of retina

20. Investigations
8. ECG
Abnormal serum potassium level can cause
arrythmias
9. USG
Confirms pregnancy
Excludes molar or twin pregnancy
Excludes other gynaecological, surgical and medical
causes for the hyperemesis

21. Management
PRINCIPLES
•To correct vomiting
•To correct the fluids and electrolytes imbalance
•To correct metabolic disturbances (acidosis and
alkalosis)
•To prevent the serious complications of severe
vomiting

22. Management
1. Hospitalization
2. Fluids
3. Drugs
4. Nursing Care
5. Diet

23. 1. Hospitalization
When general measures like dietary advice,
rest and anti-emetics fail to control the
vomiting
When there is clinical evidence of dehydration
like sunken eyeballs, tachycardia, dry furred
tongue, loss of skin turgor and oligouria
When there is presence of ketone bodies in
the urine (Rothera’s Test Positive)

24. 1. Hospitalization
Admit the patient
Open IV line and correct fluids
 Send for relevant investigations
Maintain an intake-output chart
Monitor urine output (catheterize the patient)
Monitor the vitals
Test the urine periodically for ketone bodies

25. 2. Fluids
 Oral feeding is withheld for at least 24 hours after the
cessation of vomiting
 During this period, fluid given through IV drip method
 The amount of fluid to be infused in 24 hours is calculated
as: total amount of fluid approx. 3litres, of which half is 5%
is 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.
 These measures help to correct dehydration, electrolyte
imbalance and keto-acidosis.

26. 3. Drugs
• Antiemetics such as:
 Vitamin B6 + Doxylamine
 Promethazine
 Prochlorperazine
 Chlorpromazine
 Triflupromazine
 Meclozine HCl
 Metoclopramide  D2 Antagonist
• Given parenterally
H1
Antihistaminics

27. 3. Drugs
• Vitamin supplements like Vitamin B1, Vitamin
B6, Vitamin C and Vitamin B12 may be given
• Hydrocortisone in cases of hypotension or
intractable (hard to heal) vomiting.
• Oral Prednisolone is also useful is severe
cases.

28. 4. Nursing Care
• Sympathetic but firm handling of patient
• Daily monitoring of the patient
• Look for signs of improvement in the patient:
subsidence of vomiting, feeling hungry, better
look, disappearance of acetone from breath
and urine, normal pulse and blood pressure,
normal urine output

29. 5. Diet
• Diet:
Before IV fluids are omitted, food is given
orally
Small and frequent dry meals without fat
Biscuit, bread and toast
Ginger is helpful
Gradually full diet is restored

30. References
1. Williams Obstetrics, 24th Edition
2. DC Dutta’s Textbook of Obstetrics, 7th Edition