2. HYPEMESIS GRAVIDARUM...(HEG).pptx

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1. Hyperemesis Gravidarum Dejene Edosa (BSc, MSc in CMw) Jaaury 2021

2. HYPEREMESIS GRAVIDARUM (HEG) is persistent severe nausea and vomiting. May cause lose of more than 5% of their pre-pregnancy body weight , and ketoneuria, electrolyte abnormalities (hypokalemia), and In most cases, women with hyperemesis gravidarum will have blood and urine tests that show evidence of dehydration . Incidence: from 0.3 to 2% of pregnancies. 2

3. Definition…. Commonly occur b/n 5 and 18wks of Px . HEG may cause to vomit multiple times throughout the day, lose weight , and usually requires Rx in the hospital . Morning sickness versus hyperemesis " Morning sickness" is mild nausea and vomiting while "hyperemesis gravidarum" is the term used to describe a more severe condition. 3

4. Etiology and risk factors Hormonal : Excess hcG , hyper- thyroidism , hyper- progesteronism , hyper- estrogenism . Psychogenic :- Unwanted Px , uninformed mothers ( no ANC ). Dietary deficiencies : Low carbohydrate reserves, deficiency of B-complex vitamins. Non-pregnant women who experience nausea and vomiting related to estrogen–based medication & who had motion sickness. Multiple Px & hydatidiform mole px . 4

5. Pathogenesis The pathogenesis of nausea and vomiting in Px is unknown ( Predominant theories.) Psychological factors - a response to stress. A feeling of ambivalence about the P x. P sychological makeup of pts with hyperemesis gravidarum differs from those without the disorder. The woman’s psychological response to persistent N & V may exacerbate her symptoms as a result of conditioning . Hormonal changes - Elevated estrogen & progesterone. These hormones relax smooth muscle and thus slow gastrointestinal transient time and may alter gastric emptying. 5

6. Pathogenesis…. Helicobacter pylori  The infection may play a role in pathogenesis of disease in some women (in severe disease). Abnormal gastrointestinal motility  gastric motility may be abnormal (delayed or dysrhythmic ) HEG. The lower esophageal sphincter is relaxed in pregnancy, leading to an increase in gastro-esophageal reflux . Gastro-esophageal reflux results in heartburn and, in some individuals, nausea. 6

7. DIAGNOSIS AND CLINICAL COURSE The mean onset of symptoms is at 5-6wks of gestation, peaking at about 9 w ks , and usually abating/reduced by 16-20 wks. Common criteria for diagnosis of hyperemesis : Pregnancy-related persistent vomiting accompanied by weight loss > 3kg or > 5% of pre- Px body wt. Ketonuria unrelated to other causes. Hypersalivate ( ptyalism ) Increased vomiting Oliguria Epigastric pain 7

8. EVALUATION Laboratory tests and imaging     Laboratory evaluation is indicated in women with persistent nausea and vomiting to determine the severity of disease and to exclude other diagnoses that could account for the symptoms. The standard initial evaluation: measurement of weight, orthostatic BP, HR, serum electrolytes, and urine ketones. An obstetrical U/S: to look for gestational trophoblastic disease and multiple gestation 8

9. Clinical features General examination Progressive emaciation with weight loss Anxious look with sunken eyes Icterus /yellowish eye, skin and membrane. Dry, coated tongue Teeth covered with sordid/dirty Acetone smell in breath Tachycardia Hypotension 9

10. Investigations Blood Complete blood count (CBC). Urine Specific gravity – kidney’s ability to concentrate urine. Urine culture Urine acetone or ketones. Ophthalmic examination Retinal hemorrhage, rarely retinal detachment USG To rule out molar pregnancy, multiple Px . 10

11. MANAGEMENT OF HEG Non-pharmacologic interventions Avoidance of triggers - Stuffy rooms, odors ( eg , perfume, chemicals, food, smoke), Heat, Humidity, noise , visual or physical motion ( eg , flickering lights, driving). Quickly changing position and not getting enough rest , particularly after eating, may also aggravate symptoms. Lying down soon after eating and lying on the left side are additional potentially aggravating factors because these actions may delay gastric emptying. 11

12. Management… Cold solid foods are tolerated better than hot solid foods because they have less odor and require less preparation time ( ie , shorter exposure to the trigger if the woman is preparing her own meal). Brushing teeth after a meal, spitting out saliva, and frequently washing out the mouth can be helpful . Counseling may be helpful for women with anxiety. Ginger - Powdered ginger may help to relieve nausea and vomiting in some women. 12

13. Pharmacologic Management HEG Hospitalization and Fluid management Fast hydration first then based on the output (loss) & as maintenance. Fluid requirement – 1.5 Lit 5% dextrose, 1.5 lit. DNS and 5% dextrose equal to vomitus and in last 24hrs (usually 1 lit.) Drip rate =no . of lit. to be infused in 24 hours multiplied by 12. Drugs – used in order to tide over the situation fast & prevent complications: Metoclopramide-10 mg IM TID/BID, then PO when able to tolerate. Promethazine–12.5 - 25 mg IM/PR TID/BID, then 25mg PO BID Chlorpromazine – 12.5 - 25 mg IM TID/BID, then PO. 13

14. Management..… Vitamins - daily IM injection containing Vitamin B1, Vitamin B6 and Vitamin C. Vitamin B6 50-100 mg PO daily may be used when able to tolerate. Vitamin B complex may also be used with hydration crystalloid by adding an ampoule in 1000 ml of fluid. Corticosteroids - methylprednisolone 10mg TID for 2 days with rapid taper over 2wks in resistant cases. Accurate maintenance of input/output chart, vital sign chart, weight chart. 14

15. Diet Started before the IV fluid therapy is omitted in the form of dry carbohydrate rich foods like biscuit, toasts, etc. Role of termination of pregnancy – very rarely indicated and a very last option: Hemodynamic instability due to intractable vomiting in spite of adequate and appropriate treatment Hepatic failure and renal failure Neurological complications 15

16. . GALATOOMAA! ANY QUESTION ? 16