Nausea and vomiting in pregnancy is extremely
The nausea and vomiting associated with
pregnancy usually begins by 9-10 weeks of
gestation, peaks at 11-13 weeks, and resolves in
most cases by 12-14 weeks.
Normal nausea and vomiting may be an
protective mechanism—it may protect the
pregnant woman and her embryo from harmful
substances in food.
Nausea felt by pregnant woman on getting up in
actual vomiting in the morning.
Vomiting not confined to morning but repeated
throughout the day until it affect the general
condition of the patient.
Of all pregnancies, 0.3-2% are affected with HEG .
more common in westernized industrialized
societies and urban areas than rural areas.
Race: No clear racial predominance is noted for
Previous pregnancies with HEG
Greater body weight
The risk of HEG appears to decrease with
advanced maternal age.
Cigarette smoking is associated with a
decreased risk for HEG.
Women with hyperemesis gravidarum often have
high hCG levels that cause transient
High human chorionic gonado trophin (hCG)
stimulate the chemo receptor trigger zone in the
brain stem including vomiting center.
Evidence by High hCG in :
H . pylori infection:
1-The incidence of H.pylori sero positive in
patients with hyperemesis gravidarum (HG) is
high in comparison with non-HG pregnant
o d lat
no one was able to demonstrate correlation
cH. pylori and the
between seropositivity for
time of onset or tduration of HG symptoms.
Although H.M u
pylori infection may be an
importantm factor in exacerbating HG, it may
not represent the sole cause of the disease.
Urinalysis: for ketones and specific gravity .
Serum electrolytes :
-low Na or K.
-hyperchloremic metabolic alkalosis or acidosis.
LFT: Elevated transaminase levels .
TSH,free thyroxine :HEG is associated with
Urine culture: UTI can be associated with
nausea and vomiting.
Hematocrit: This may be elevated.
Hepatitis screening: hepatitis A, B, or C may be
confused with HEG.
Obstetric ultrasonography : evaluate for multiple
gestations or trophoblastic disease.
upper abdominal ultrasonography to evaluate the
pancreas and/or biliary tree
In rare cases, abdominal CT scan may be
indicated if appendicitis is under consideration.
Normal saline or lactated Ringer’s solution is the
mainstay of intravenous fluid therapy.
It should be given by infusion over 2-3 hours.
3-Enteral or Parenteral Nutrition.
DIETARY AND LIFESTYLE CHANGES
Separating solids and liquids.
Eating small, frequent meals consisting of bland
Avoiding fatty foods such as potato chips.
Avoiding drinking cold or sweet beverages.
Eliminate pills with iron
High protein snacks are helpful.
5 - PHARMACOLOGICAL THERAPIES:
Vitamins Pyridoxine (Nestrex)
Essential for normal DNA synthesis and play a
role in various metabolic processes
(Diclectin) combination of doxylamine with of
pyridoxine (vitamin B6)
A - Safe in pregnancy
at a dose of 10-12.5 mg PO qd/bid.
Useful in the treatment of symptomatic nausea
- phenothiazines (i.e., chlorpromazine,
perphenazine, prochlorperazine, promethazine,
- blocking postsynaptic mesolimbic dopamine
receptors through anticholinergic effects and
depressing reticular activating system
- C - Safety for use during pregnancy has not been
Metoclopramide:is an upper gastrointestinal
Blocks dopamine receptors and (when given in
higher doses) also blocks serotonin receptors in
chemoreceptor trigger zone of the CNS
Metoclopramide is safe to be used for
management of NVP, although evidence for
efficacy is more limited
B - Usually safe but benefits must outweigh the
SEROTONIN 5-HT3 ANTAGONISTS.
Ondansetron (Zofran) :
blocking serotonin, both peripherally on vagal
nerve terminals and centrally in the
chemoreceptor trigger zone
In general, 5-HT3 antagonists may be safe to use
during the first trimester, but the data are scant.
Meclizine (Antivert) , Diphenhydramine
Appears to be as efficacious as pyridoxine
Causes sedation; caution must be used in
performing tasks which require alertness
Methylprednisolone (Medrol, Solu-Medrol)
Recent studies revealed a small but significantly
increased risk of oral clefting associated with first
trimester exposure to corticosteroids.
A doxylamine/ pyridoxine combination should be
the standard of care since it has the greatest
evidence to support its efficacy and safety.
Other drugs may also be used, primarily
dimenhydrinate, in conjunction with the
If possible, corticosteroid use should be avoided
in the first 10 weeks .
- Selective serotonin re-uptake inhibitors
- Tricyclic antidepressants (TCAs)
Helicobacter pylori eradication.
Stimulation of the P6 point, located three-fingers’
breadth proximal to the wrist, has been used for
treat nausea and vomiting
Ginger (Zingiber officinale)
Esophageal rupture or perforation
Pneumothorax and pneumomediastinum
Wernicke encephalopathy or blindness
Seizures, coma, or death
HEG is self-limited and, in most cases, improves
by the end of the first trimester. However,
symptoms may persist through 20-22 weeks of
gestation and, in some cases, until delivery.
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