Hyperemesis gravidarum and its management

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1. Hyperemesis Gravidarum Sunil Kumar Daha

2. Causes of Vomiting in Pregnancy Early Pregnancy: Related to Pregnancy: -Simple Vomiting -Hyperemesis gravidarum (Pernicious vomiting) Associated with Pregnancy Medical: UTI, Hepatitis, Intestinal infestations, Uraemia, Ketoacidosis of DM Surgical: Appendicitis, Peptic Ulcer, Intestinal obstruction, Cholecystitis Gynecological : Twisted ovarian tumor , Fibroid

3. Causes of Vomiting in Pregnancy Late pregnancy: Related to Pregnancy - Continuation or reappearance of simple vomiting -Acute fulminating pre- eclampsia Associated with Pregnancy - Medical, surgical, gynaecological causes as in early pregnancy -Hiatus hernia

4. Vomiting of Pregnancy Simple vomiting of pregnancy or mild type or morning sickness Hyperemesis gravidarum or severe type

5. Morning Sickness Nausea and occasional sickness in the morning Slight vomiting is common in early pregnancy Considered as a symptom of pregnancy Vomitus small, clear or bile stained Does not impair health or restrict activities

6. Morning Sickness Disappears with/out treatment in the 12-14 th week of pregnancy Human chorionic gonadotrophin and estrogen Aggravated by psychogenic factors

7. Management of Morning Sickness Assurance Dry toast or biscuit Avoid fatty and spicy foods Plenty of fluids (2.5 L in 24 hrs) Fruit juice The smell of certain foods aggravates symptoms and should be avoided

8. Management of Morning Sickness If simple measures fail, then try anti-emetics V itamin B 6 or Vitamin B 6 plus Doxylamine is safe and effective and should be considered first-line pharmacotherapy (American College of Obstetricians and Gynecologists, 2004) Antihistaminics, D2 Antagonists, etc. can also be considered

9. Hyperemesis Gravidarum It is a severe type of vomiting of pregnancy which has got deleterious effect on health of the patient and/or incapacitates her day-to-day activities D efined variably as “ Vomiting sufficiently severe to produce weight loss Dehydration acidosis from starvation alkalosis from loss of hydrochloric acid in vomitus hypokalemia” It is the vomiting which is severe enough to lead to hospitalization of the lady

10. Risk factors Limited to 1 st trimester More common in 1 st pregnancy Tendency to recur again in subsequent pregnancies Familial history: Mother and sisters also suffer from the same manifestation More prevalent in hydatiform mole and multiple pregnancy Common in unplanned pregnancies

11. Theories Behind Hyperemesis Gravidarum A. HORMONAL High hCG High Estrogen High progesterone Other hormones involved: -thyroxine - prolactin - leptin - adrenocortical hormones B. PSYCHOGENIC C. DIETARY DEFICIENCY: Low carbohydrate reserve, Vit B6, Vit B1 D. Allergic or Immunologic E. Decreased gastric motility F. Liver Theory: Liver can’t adapt to the high level of hormones in pregnancy G. H.pylori infection

12. Pathology Liver: Fatty infiltration without necrosis Kidney: Occasionally shows fatty degeneration Brain: Small hemorrhagic spots in hypothalamus (may be due to Vit B1 deficiency) Blood: Mild leucocytosis and haemo -concentration due to dehydration

13. Pathology Metabolic Due to less intake of food Leads to depletion of glycogen  increases metabolism of fat  accumulation of ketone bodies  excreted through breath/urine Leads to excessive breakdown of proteins in the body  excessive accumulation of Nitrogen

14. Pathology Biochemical Changes Occurs due to vomiting  dehydration Decreased Na+, K+, Cl - Raised blood urea, creatinine, uric acid, ketone bodies Hypoglycemia Hypoproteinemia Hypovitaminosis Rare: Hyperbilirubinemia Fetal vulnerability to toxins peaks at around 3 months, which is time of peak susceptibility to morning sickness.

15. Clinical Features Signs of dehydration: dry coated tongue, sunken eyes, oligouria, loss of skin elasticity , increased pulse rate Weight loss >5% of Total Body Weight Electrolyte imbalances like hypokalemia, hypocalcemia Starvation related ketoacidosis that can lead to acetone smell in the breath Rise in temperature may occur

16. Complications NEUROLOGICAL Wernicke’s encephalopathy due to thiamine deficiency Pontine myelinolysis Peripheral neuritis Korsakoff’s psychosis Ophthalmic: Retinal haemorrhage Convulsions Coma OTHER Stress ulcer in the stomach Esophageal tears (Mallory-Weiss Syndrome) Jaundice due to liver damage Renal failure Vit K deficiency: bleeding manifestations

17. Investigations Complete Blood Count Haemoconcentration leads to rise Hb , RBC count, and Hematocrit Slight increase in WBC count 2. Electrolytes: Na+, K+, Cl - decreased due to loss in vomitus 3. Random Blood Glucose: Hypoglycemia

18. Investigations 4. Urinalysis: Quantity (too see for oligouria) Dark color (due to concentration) High specific gravity with acid reaction Presence of acetone, occasional presence of protein and bile pigments Diminished or even absence of chloride

19. Investigations 5. Liver Function Tests: Albumin, Prothrombin time, ALT, AST, ALP, Bilirubin levels 6. Renal Function Test: Urea and Creatinine levels 7 . Ophthalmoscopic examination Retinal hemorrhage Detachment of retina

20. Investigations 8. ECG Abnormal serum potassium level can cause arrythmias 9. USG Confirms pregnancy Excludes molar or twin pregnancy Excludes other gynaecological , surgical and medical causes for the hyperemesis

21. Management PRINCIPLES To correct vomiting To correct the fluids and electrolytes imbalance To correct metabolic disturbances (acidosis and alkalosis) To prevent the serious complications of severe vomiting

22. Management 1. Hospitalization 2. Fluids 3. Drugs 4. Nursing Care 5. Diet

23. 1. Hospitalization When general measures like dietary advice, rest and anti-emetics fail to control the vomiting When there is clinical evidence of dehydration like sunken eyeballs, tachycardia, dry furred tongue, loss of skin turgor and oligouria When there is presence of ketone bodies in the urine ( Rothera’s Test Positive )

24. 1. Hospitalization Admit the patient Open IV line and correct fluids Send for relevant investigations Maintain an intake-output chart Monitor urine output (catheterize the patient) Monitor the vitals Test the urine periodically for ketone bodies

25. 2. Fluids Oral feeding is withheld for at least 24 hours after the cessation of vomiting During this period, fluid given through IV drip method The amount of fluid to be infused in 24 hours is calculated as: total amount of fluid approx. 3litres, of which half is 5% is dextrose and half is Ringer’s solution. Extra amount of 5% dextrose equal to the amount of vomitus and urine in 24 hours, is to be added. These measures help to correct dehydration, electrolyte imbalance and keto -acidosis.

26. 3. Drugs Antiemetics such as: Vitamin B6 + Doxylamine Promethazine Prochlorperazine Chlorpromazine Triflupromazine Meclozine HCl Metoclopramide  D2 Antagonist Given parenterally H1 Antihistaminics

27. 3. Drugs Vitamin supplements like Vitamin B1, Vitamin B6, Vitamin C and Vitamin B12 may be given Hydrocortisone in cases of hypotension or intractable (hard to heal) vomiting. Oral Prednisolone is also useful is severe cases.

28. 4. Nursing Care Sympathetic but firm handling of patient Daily monitoring of the patient Look for signs of improvement in the patient: subsidence of vomiting, feeling hungry, better look, disappearance of acetone from breath and urine, normal pulse and blood pressure, normal urine output

29. 5. Diet Diet: Before IV fluids are omitted, food is given orally Small and frequent dry meals without fat Biscuit, bread and toast Ginger is helpful Gradually full diet is restored

30. References Williams Obstetrics, 24 th Edition DC Dutta’s Textbook of Obstetrics, 7 th Edition