Hyperemesis Gravidarum - Disorder of Pregnancy

Hyperemesis gravidarum is characterized by severe nausea and intractable vomiting sufficient to interfere with maternal nutrition causing deleterious effect on her health. It has got deleterious effect on health of the patient and incapacitates her day-to-day activities. According to the national health portal 0.3%-3% pregnant women suffer from hyperemesis gravidarum – commonest indication for hospitalization in the first trimester of pregnancy.
This document covers following topics -
• Introduction
• Definition
• Prevalence
• Etiology
• Risk factors
• Theories behind hyperemesis gravidarum
• Symptoms:
• Signs
• Investigation
• Diagnosis
• Complications
• Prevention
• Management principles
• Nursing management

1. HYPEREMESIS GRAVIDARUM ( PERNICIOUS VOMITING)

2. DEFINITION 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. OR Hyperemesis G ravidarum is characterized by severe nausea and intractable vomiting sufficient to interfere with maternal nutrition causing deleterious effect on her health .

3. PREVALENCE According to the national health portal 0.3%-3% pregnant women suffer from hyperemesis gravidarum – commonest indication for hospitalization in the first trimester of pregnancy.

4. ETIOLOGY

5. RISK FACTORS Age below 17 years and over 35 years Primigravidae with Multiple pregnancy Underweight and obesity Psychological factors such as unwanted Pregnancy ,marital problems H/O Hyper emesis Gravidarum

6. Theories Hormonal High HCG ( Hydatiform mole, multiple pregnancy) High Oestrogen (increased incidence in OCP users) High progesterone (relaxation of cardiac sphincter) Other hormones involved (Thyroxin -Prolactin -Leptin -Adreno-cortisol hormones)

7. Psychogenic It probably aggravated nausea once it begins it trigger neurogenic elements. Dietary deficiency Probably due to low carbohydrate reserve as it happens after a night without food. Deficiency of vitamin B 1 , B 6 & protein may be the effect rather than cause. Allergic or immunological basis Decrease gastric motility is found to cause nausea

8. Clinical course Early: Vomiting throughout day Normal day to day activities are disturbed. No evidence of dehydration & starvation Late: Evidence of dehydration and starvation

9. INVESTIGATION Urinalysis Biochemical and circulatory Opthalmoscopic examination ECG

10. DIAGNOSIS Pregnancy is confirmed first Associated causes of vomiting are excluded like Gynaecological or Medical or Surgical causes USG –Pregnancy, Hydratiform mole, Multiple pregnancy

11. COMPLICATIONS Maternal - Neurologic complications — Wernicke’s encephalopathy, beriberi due to thiamine deficiency; Pontine myelinolysis ; Peripheral neuritis; Korsakoff’s psychosis. Stress ulcer in stomach; Esophageal tear ( MalloryWeiss syndrome); Jaundice, hepatic failure; Convulsions and coma; Hypoprothrombinemia due to vitamin K deficiency and Renal failure.

12. Effects on the foetus: The effects of vomiting on the foetus depend on the severity of vomiting. Mild to moderate vomiting does not have any effect on the foetus. But hyperemesis, leading to weight loss of the mother, can cause foetal growth restriction in one-third of the foetuses.

13. PREVENTION Import effective management to correct simple vomiting of pregnancy.

14. MANAGEMENT PRINCIPLES To control vomiting. To correct fluid & electrolyte imbalance. To correct metabolic disturbance. To prevent serious complications of severe vomiting.

15. 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

16. 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. Enteral nutrition through nasogastric tube may also be given

17. Drugs Antiemetic drugs: Promethazin -25mg IM BD or TDS Trifluopromazine -10mg IM Metachlopromide - 10mg IM Hydrocortisone:- 100mg IV in drip Prednisolone orally Nutritional support:- Vitamin B1, vitamin B6, vitamin B12 & vitamin C

18. NURSING MANAGEMENT Nursing Diagnosis Fluid and electrolyte imbalances related to excessive vomiting or lack of fluid intake. Imbalanced Nutrition Less Than Body Requirements related to nausea, vomiting or lack of nutritional intake. Anxiety related to hyperemesis influence on the health of the fetus . Knowledge deficit related to lack of information about the treatment of hyperemesis. Sleep pattern disturbance related to persistent vomiting. Activity Intolerance related to weakness.

19. Nursing Interventions 1 . Promote resolution of the complication. Make sure that the client is NPO until cessation of vomiting. Administer intravenous fluids as prescribed; they may be given on an ambulatory basis when dehydration is mild. Measure and record fluid intake and output. Encourage small frequent meals and snacks once vomiting has subsided. Administer antiemetics as prescribed. 2. Address emotional and psychosocial needs. Maintain a non judgmental atmosphere in which the  client and family can express concerns and resolve some of their fears.

20. Clinical features of improvement are evidenced by — subsidence of vomiting feeling of hunger better look normalization of blood biochemistry (electrolytes) disappearance of acetone from the breath and urine normal pulse and blood pressure normal urine output .

21. Dietary management: Before IV fluids is given oral Small and frequent dry meals without fat are given. First dry carbohydrates like Biscuit, bread and toast Ginger is helpful Gradually full diet is restored