Final Hyperemesis gravidarum.pptx. Excessive vomiting

extreme vomiting

1. HYPEREMESIS GRAVIDARUM Mrs. Nancy Chandra Priya P M.sc(N),MBA (HM) Assistant professor Shri Sathya Sai College of Nursing , Chennai

2. INTRODUCTION Morning sickness : is the nausea felt by about 50% of pregnant women on getting up in the morning. Emesis Gravidarum : Actual vomiting in the morning. These two conditions usually start between the 4th and 6th weeks of pregnancy and improves or disappears about the 12 th week. Hyperemesis Gravidarum: The vomiting is not confined to the morning but it is repeated throughout the day until it affects the general condition of the patient

3. DEFINITION It is a severe type of vomiting of pregnancy which has got deleterious effect on the health of the mother and incapacitates her in day to day activities .

4. RISK FACTORS

5. Continued

6. THEORIES HORMONAL : Excess chorionic gonadotrophin Excess progesterone 2. PSYCHOGENIC: 3. DIETETIC DEFICIENCY : Low carbohydrate reserve Deficiency of Vit B6,Vit B1 and proteins 4. ALLERGIC OR IMMUNOLOGIC BASIS 5.DECREASED GASTRIC MOTILITY

7. PATHOLOGY LIVER: Centrilobular fatty infiltration without necrosis KIDNEYS: Fatty change in the cells of first convoluted tubule HEART: Subendocardial haemorrhages BRAIN: Small haemorrhage in hypothalamic region

8. PATHOGENESIS

9. PSYCHOLOGICAL FACTORS

10. HORMONES Estrogen Progesterone Beta hCG These hormones relax smooth muscle and thus slow gastrointestinal transit time and may alter gastric emptying. Relax the lower oesophageal sphincter

11. PATHOLOGICAL CHANGES Metabolic changes Biochemical changes Circulatory changes

12. METABOLIC,BIOCHEMICAL AND CIRCULATORY CHANGES

13. METABOLIC CHANGES REDUCED INTAKE OF FOOD Depletion of glycogen stores Excretion through Accumulation of ketone bodies Mobilization of fat stores Increased tissue protein metabolism Increased non protein nitrogen Urine - Ketone + ve Breath - Ketone odour

14. Dehydration Keto acidosis Hypoglycemia Hypoglycemia Elevated blood Hypoproteinurea Nitrogen and uric acid Hypovitaminosis BIO CHEMICAL CHANGES VOMITTING LOSS OF WATER AND SALTS HEPATIC DYSFUNCTION NUTRITIONAL DISTURBANCES

15. CIRCULATORY: Haemoconcentration – rise in haemoglobin , RBC count,eosinophils and haematocrit values. WBC – increased slightly . Reduction of ECF.

16. CLINICAL COURSE EARLY :Vomiting throughout the day,No dehydration and starvation LATE: Dehydration and starvation present. Symptoms : Vomiting and retching Oliguria Epigastric pain, constipation Signs: Dry coated tongue Sunken eyes,acetone smell in breath,tachycardia,hypotension,rise in temperature. Jaundice is a late feature.

17. FEATURES OF DEHYDRATION AND KETO ACIDOSIS Dry coated tongue Sunken eyes Acetone smell Tachycardia Hypotension Hyperthermia Jaundice

18. INVESTIGATIONS URINALYSIS: Small quantity Dark colour High specific gravity with acid reaction Presence of acetone , occasionally protein and bile pigments

19. BIOCHEMICAL AND CIRCULATORY CHANGES: Routine and periodic estimation of serum electrolytes(sodium , potassium and chloride) OPHTHALMOSCOPIC EXAMINATION : Required only if patient is seriously ill Retinal haemorrhage and detachment of retina ECG: Abnormal potassium level

20. COMPLICATIONS Majority is due to dehydration and starvation with ketoacidosis. Neurologic complications- Wernicke’s Encephalopathy,pontine myelinolysis,peripheral neuritis,korsakoff’s psychosis, Stress ulcer in stomach, Oesophageal tear, Jaundice

21. MANAGEMENT PRINCIPLES: To control vomiting To correct fluids,electrolytes HOSPITALIZATION : FLUIDS: NPO for 24 hrs after cessation of vomiting Start IVF :Total-3 l(half 5% Dextrose + half RL) Extra 5% dextrose is added equal to the amount of vomit and urine in 24 hrs Enteral nutrition through NG tube is given.

22. DRUGS ANTIEMETIC DRUGS: Promethazine ( phenergan ) 25MG)/ Prochlorperazine ( Stemetil ) 5 mg / Triflupromazine ( siquil )10 mg twice or thrice daily IM. Trifluoperazine ( Espazine )1 mg twice daily IM . Metaclopromide stimulates gastric and intestinal motility without stimulating secretions Hydrocortisone 100mg IV – Hypotension or intractable vomiting . If severe – oral prednisolone NUTRITIONAL SUPPORT – Vit B1,Vit B6 , Vit C and Vit B 12

23. NURSING RESPONSIBILTIES Hyperemesis progress chart is maintained. Monitor vital signs,IO chart,urine for acetone,protein,bile,blood biochemistry and ECG( sr.potassium is abnormal) DIET -Gradually the foods are given orally.first dry CHO foods are given- biscuits,bread and toast.small but frequent feeds are given.