MANAGEMENT OF HYPEREMESIS GRAVIDARUM

WELCOME

DEFINITION

Hyperemesis gravidarum is defined as unexplained intractable nausea, retching, or vomiting beginning in the first trimester, incapacitates her in day-to-day activities or sufficient to warrant hospital admission resulting in dehydration, ketonuria, and typically a weight loss of more than 5% of prepregnancy weight.

DIAGNOSIS:

• The pregnancy is to be confirmed first. • Exclusion of other causes of vomiting• Proper history taking• Clinical examination• Relevant investigation

HISTORY and PATIENT PROFILEFirst trimester First pregnancyFamilial historyYounger motherUnplanned pregnancies Hydatidiform mole and multiple pregnancy Motion sickness, migraines, oral contraceptives Helicobacter pylori

CLINICAL FEATURE

Symptoms: • Vomiting is increased in frequency with retching. • Urine quantity is diminished even to the stage of oliguria. • Epigastric pain• Constipation • Complications may appear if not treated.• Result in frequently social isolation and negative impacts

on relationships with family and friends.• Excess salivation (ptyalism)

Signs:Features of dehydration and ketoacidosis:

INVESTIGATIONS

Hyperemesis gravidarum is a diagnosis of exclusion

investigations are performed for • Conformation of pregnancy• Exclusion of common and serious causes of

vomiting• Evaluating the extent of complication

• Urinalysis • Biochemical serum electrolytes Sodium- hyponatremiaPotassium- hypokalemiachloride • Ophthalmoscopic examination

• ECG • Biochemical hyperthyroidism• Abnormal LFTs • Hemoconcentration leading to rise in

Hemoglobin % RBC count Hematocrit values

Imaging Studies1.Ultrasound To confirm pregnancyTo establish the number of fetuses To exclude hydatidiform moleTo exclude other conditions such as • Pancreatitis• Cholecystitis• intracranial lesions

COMPLICATIONS: Maternal and Fetal RisksMaternal Risks(1) Neurologic complications — (a) Wernicke’s encephalopathy (b) Pontine myelinolysis(c) Peripheral neuritis(d) Korsakoff’s psychos(2) Stress ulcer in stomach (3) Mallory-Weiss syndrome

(4) Jaundice (5) Convulsions (6)Coma (7) Renal failure /acute tubular necrosis(8) Pneumomediastinum/ pneumothorax(9) Splenic avulsion(10) Psychological burden- depression, anxiety, lost

work(11) Anemia(12)Hyponatremia (plasma sodium < 120 mmol/L) can

cause confusion, seizures, and respiratory arrest. (13)Deep venous thrombosis /thromboembolism

Fetal Risks• No fetal complications • Women with HEG who gain <7 kg during the

entire pregnancy have a slightly higher risk of Low birth weight / small for gestational age/ IUGR Preterm birth / born before 37 weeks’ gestation • If the mother develops Wernicke’s

encephalopathy- chance of IUD

MANAGEMENT

Prince WiIliam and Duchess Kate when they left the King Edward VII hospital in central London in 2012, the last time Kate was treated for hyperemesis gravidarium

Hospitalization:

Whenever a patient is diagnosed as a case of hyperemesis gravidarum, she is admitted

Fluids: Rehydration Fluid replacement therapy should be with eitheNormal saline

Hartmann’s solution

Dextrose-containing fluids should not be used

Double-strength saline

Potassium supplements

Thiamine supplements

Enteral - nasogastric tubeParenteral feeding

MonitoringUrine output

Ketonuria- dipsticks

Body weight

Drugs:

(a) Antiemetic drugs CAT GROUP EXAMPLE DOSEB H 1

ANTIHISTAMINES MeclizineDoxylamine-pyridoxine

12.5 to 25 mg PO four times a day

SUBSTITUTED BENZAMIDES

Metoclopramide 10 mg PO four times a day

5-HT3 receptor blockers

Ondansetron 8 mg PO two times a day

ANTICHOLINERGIC Dicyclomine

C PHENOTHIAZINES Promethazine 25 mg PO or rectally every 4 to 6 hours

prochlorperazine

Efficacy of antiemetic drug

(b) Hydrocortisone • Severe and resistant symptoms • Unable to tolerate fluids Intravenous hydrocortisone 100 mg three times a

day

Prednisolone 40 mg once daily

(c) Nutritional support• Vit B1 • Vit B6 • Vit B12 • Vit C

Diet: At first, dry carbohydrate foods • Biscuits• bread • toastSmall but frequent feeds are recommended

Spicy food should be avoided

Other Treatment OptionsWhile they are inpatients Thromboembolic deterrent stockings

Thromboprophylaxis such as enoxaparine 40 mg daily

Nonpharmacologic measuresAcupuncture

Acupressure

Hypnotherapy

Herbal teasGinger/ ginger tea

Termination of pregnancy Rarely indicated• Intractable hyperemesis gravidarum inspite of

therapy• Wernicke’s encephalopathy • Jaundice• Persistant CVS change