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1. HYPEREMESIS GRAVIDARUM (HEG)

2. Definition Unlike morning sickness, hyperemesis gravidarum : is a complication of pregnancy characterized by persistent uncontrollable nausea and vomiting that persists to 20th week of pregnancy . is unexplained intractable nausea or vomiting beginning in the first trimester. HG is severe form of nausea and vomiting during pregnancy resulting in dehydration and weight loss 2 By Fasika A

3. Incidence Mild to moderate nausea and vomiting are especially common in 50% to 90% pregnant women until approximately 16 weeks’ gestation. The severe end of the continuum, hyperemesis gravidarum , may complicate up to 2 % of pregnancies. HEG is as the most common reason for hospitalization during 1st trimester pregnancy 3 By Fasika A

4. Pathogenesis The pathogenesis of nausea and vomiting in pregnancy is unknown. But the predominant theories are described below. Hormonal changes Elevated estrogen and progesterone;- These hormones relax smooth muscle and thus slow gastrointestinal transit time and may alter gastric emptying Human chorionic gonadotropin ( hCG );- Peak during the first trimester, The serum hCG concentration is higher in women with hyperemesis than in other pregnant women 4 By Fasika A

5. Psychological factors A feeling of ambivalence about the pregnancy has also been proposed as an etiologic or contributing factor The woman’s psychological response to persistent nausea and vomiting may exacerbate her symptoms as a result of conditioning 5 By Fasika A

6. Risk factors Primi gravidia Multiple gestation molar pregnancy Hyperthyroid disorders Tumor in the pituitary 6 By Fasika A

7. Approach History (Symptoms ) The mean onset of symptoms is at 5 to 6 weeks of gestation, peaking at about 9 weeks, and usually abating by 16 to 20 weeks of gestation. Early manifestations No evidence of dehydration and/or starvation Vomitus contains only food or bile stained Nutrition is not affected Blood biochemistry and urine analysis is normal Late manifestations Increased vomiting Oliguria epigastria pain Constipation 7 By Fasika A

8. Physical examination General examination weight loss, look with sunken eyes, Dry , coated tongue Vital sign , Tachycardia, Hypotension Respiratory system Signs of acidosis, ketosis Cardiovascular system Findings due to anemia Abdominal examination Uterus may be less than/greater than weeks of gestation, Epigastric tenderness 8 By Fasika A

9. Investigations Serum electrolytes. Urine ketones. CBC RBS RFT An obstetrical ultrasound examination is performed to look for GTD and MG 9 By Fasika A

10. Differentials Acute appendicitis Cholecystitis Diabetic ketoacidosis Gastritis Hepatitis Small bowel obstruction Urinary tract infection Peptic ulcer disease 10 By Fasika A

11. Management Principles Correction of Fluid and electrolyte deficits Identification and treatment of any co-morbidities Identification and management of complications Inpatient management Indications for admission Weight loss > 5% from pre-pregnancy Ketonuria above +2 Electrolyte imbalance Deranged renal and liver function tests Persistent vomiting / failed OPD management 11 By Fasika A

12. Fluid management Oral feeding withheld for 24 to 48hrs Give 2 to 3 liters of saline or ringer lactate within 2 – 3 hrs until the clinical signs of hypovolemia improves . Avoid dextrose containing fluid, Give maintenance fluid after deficit is corrected 12 By Fasika A

13. Vitamins Thiamine (vitamin B1): Pyridoxine (Vitamin B6): 40% of glucose Antiemetics Metoclopramide- 5–10 mg IV TID Promethazine 5-10 mg IM every 6-8hrs 13 By Fasika A

14. Diet PO diets that minimize nausea and vomiting can be starts after a short period of gut rest. Advise the patient to avoid empty stomach Advise intake of small and frequent diet Counsel on restriction of coffee, and spicy, odorous, high fat, acidic and very sweet foods Counsel on preferably taking protein dominant, low fat, tasteless and dry snacks/meals Encourage on fluid intake 14 By Fasika A

15. Advice not to take drugs that may cause nausea and vomiting, e.g. iron supplement should be temporarily discontinued. Advise on taking ginger or ginger containing preparations. 15 By Fasika A

16. Outpatient management IV fluids: Give 2Ls of IV fluid, infuse first liter over 1-2 hours and then 1000 ml over 4 Followed by further assessment, including urine ketone testing. Discharge the patient from outpatient care with PO medications and dietary advice Medications Vitamin B6 (pyridoxine): - 10–25mg PO BID Metoclopramide : - 5-10 mg PO TID 16 By Fasika A

17. 3/31/2024 17

18. Endometriosis Is the presence of actively growing and functioning endometrial tissue out side the uterus Adenomyosis : is considered as endometrosis found in the myometrium . In case of endometrosis, the endometrial tissues are responsive for oestrogen hormone where ever the site is. 18

19. Incidence- Predominantly found in reproductive age group(7%) Etiology – theories proposed for the occurrence of endometriosis. Ectopic translocation of endometrial – it is based on the assumption that endometrosis is caused by the seeding or implantation of endometrial cell by trance tubal regurgitation during menstruation 19

20. 2. Aberrant lymphatic and vascular spread of endometrial tissue 3. Coelomic metaplasia- transformation of coelomic epithelium in to endometrial tissue has been proposed as a mechanism for the origin of endometrosis. . 20

21. Risk factors for Endometriosis Nulliparity Early menarche late menopause Short menstrual cycles Prolonged menses Müllerian anomalies Genetic factor- risk of it is 7 times greater if their is family hx 21

22. Clinical features pain- Dysmenorrhoea before and throughout menses Chronic pelvic pain Dyspareunia 2. Sub fertility When endometrosis is moderate or sever involving the ovaries and causing adhesion then block tubo ovarian motility and ovum pick up 22

23. Clinical finding Infertility Dyspareunia classical triads Dysmenorrheal Chronic pelvic pain Bloody urine or stool in pre menstrual interval 3/31/2024 23

24. Physical examination Often no abnormal findings are seen in physical examination. Most common finding is tenderness when palpating the posterior fornix Tender nodule in posterior vaginal fornix Tender abdominal mass secondary endodermoma Pain full swelling of the recto vaginal septum 3/31/2024 24

25. 25 P/E Utrosacral or culdesac nodularity In sever case fixed, retroverted uterus, and reduced mobility of fallopian tubes and ovaries Final diagnosis is confirmed by laparoscopy Laparoscopy is the gold standard investigation.

26. Implantation site Cervix(50%) Uterine culde sac Posterior broad ligament Utero-sacral ligament fallopian tube, ovary, sigmoid colon, appendix… 3/31/2024 26

27. Differential Diagnosis of Endometriosis Pelvic inflammatory disease – Tuboovarian abscess Hemorrhagic ovarian cyst Ovarian torsion Degenerating leiomyoma Ectopic pregnancy Interstitial cystitis Inflammatory bowel disease

28. 3/31/2024 28

29. Management Depend on pts future fertility desire Severity of the disease(stage of the disease) Patients age, It includes: 1 . Expectant Management 2 . Medical treatment 3 . Hormonal treatment 4 . Surgical treatment 5 . Combination Medical and surgical treatment

30. Expectant management Mild discomfort minimal or mild endometriosis Management includes; Analgesic therapy by NSAID 3/31/2024 30

31. Hormonal therapy OCP progestin danazole GnRH agonist 3/31/2024 31

32. Definitive surgery Hystrectomy,salphingo-oopherectomy Indicated for patient who Do not desire future childbearing and has severe disease or symptoms, This entails total abdominal hysterectomy, bilateral salpingo-oophorectomy, and excision of remaining adhesions or implants. 3/31/2024 32

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