Hyperemesis gravidarum.pptx

HYPEREMESIS GRAVIDARUM

1. Hyperemesis gravidarum SUDHA GAUTAM ASSOCIATE PROFESSOR M.SC. N (OBG)

2. Definition Hyperemesis gravidarum or Pernicious Vomiting is extreme, persistent nausea and vomiting during pregnancy which can lead to dehydration, weight loss, electrolyte imbalances and may have adverse fetal consequences. It is a severe type of vomiting of pregnancy which has got deleterious effect on the health of the patient and / or incapacitates her day to day activities. - D. C. Dutta HYPER – INCREASED/ EXCESSIVE EMESIS – VOMIT GRAVIDARUM - PREGNANCY .

3. MORNING SICKNESS Morning sickness is mild nausea and vomiting that occurs in early pregnancy and affects most women to some extent. Begins early in pregnancy , mostly between 4 th and 7 th week and subsides by 12 to 14 weeks. Irrespective of the name it can occur during any time of the day and night .

4. ETIOLOGY Abnormal upsurge in the pregnancy hormones – HCG Rise in Estrogen and Progesterone leading to nausea and digestive issues. Family history Can reoccur in subsequent pregnancy if once she has suffered with the problem. Hydatidiform mole / Molar pregnancy Multiple pregnancy More common in unplanned pregnancy

5. Etiology (continued) Early primigravida (age <17 years) Elderly primigravida (age >35 years) Psychological factors like marital problems or unmarried mother or teenage pregnancy

6. Suggested theories for hg HORMONAL THEORY: High levels of HCG – Molar pregnancy, multiple pregnancy Increased levels of Estrogen High progesterone which leads to relaxation of cardiac sphincter Other hormones: Thyroxine, Prolactin, Leptin, Adeno- cortisol hormones .

7. Theories ( Continued) PSYCHOGENIC THEORY : Nausea gets aggravated once neurogenic elements are triggered. C. DIETARY DEFICIENCY: When a woman stays a night without food, the low carbohydrate reserve in her body and its increasing demand over time by her body and the fetus can lead to HG. Deficiency of Vitamin B1, B6 and Protein may be the effect rather than the cause.

8. THEORIES ( CONTINUED) Allergic or Immunological Basis Decrease gastric motility can lead to increased nausea .

9. CLINICAL COURSE EARLY – Vomiting through out the day Daily activities are disturbed No evidence of dehydration and starvation LATE – Evidenced by dehydration and starvation Weight loss

10. symptoms Excess vomiting and retching day and night Epigastric pain Constipation Ptyalism Fatigue Anorexia Dehydration & Ketoacidosis

11. SYMPTOMS ( CONTINUED) Dry coated tongue Sunken eyes Acetone smell in breath Tachycardia Postural hypertension

12. Lab INVESTIGATION URINANALYSIS – For analysis of ketones and specific gravity ( a sign of starvation, ketones may be harmful for fetal development and high specific gravity occurs with volume depletion). SERUM ELECTROLYTES AND KETONES – To evaluate low potassium or sodium or chloride (to identify hyperchloremic metabolic alkalosis or acidosis and evaluate renal function and volume status). LIVER ENZYMES AND BILIRUBIN – Elevated liver enzymes as a sign of underlying liver condition such as hepatitis, liver injury. AMYLASE/ LIPASE ESTIMATION, TSH AND FREE THYROXINE may suggest overt hyperthyroidism which is often associated with HG. OTHERS : Opthalmic examination for retinal detachment and ECG

13. Diagnosis Pregnancy should be confirmed first. Differential Diagnosis should be done to find the associated causes of vomiting like Gynecological or Medical Or Surgical Causes. USG – Pregnancy, Multiple Pregnancy, Hydatidiform mole

14. Complications NEUROLOGICAL - Wernicke’s encephalopathy d/t thiamine def. Peripheral Neuritis Psychosis Retinal Hemorrhage Convulsion Coma OTHER’S - Stress ulcer in stomach Oesophageal Tear Jaundice d/t Liver Damage

15. PREVENTION Although there are no known ways to completely prevent hyperemesis gravidarum, the following measures might help keep morning sickness from becoming severe: Eating small, frequent meals. Eating bland foods. Waiting until nausea has improved before taking iron supplements

16. management PRINCIPLES: To control vomiting To correct fluid and electrolyte imbalance To correct Metabolic disturbance To prevent serious complication of severe vomiting

17. hospitalization Admit the patient Administer IV Fluids and electrolytes to correct the imbalances. Send for relevant investigations Maintain intake- output chart Monitor urine output ( catheterize the patient) Monitor the vitals. Periodical urine test should be done to check for presence and concentration of ketone bodies.

18. 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 .

19. drugs • Antiemetics such as: Vitamin B6 + Doxylamine Promethazine Prochlorperazine Chlorpromazine Triflupromazine Meclozine HCl Metoclopramide D2 Antagonist Given parenterally H1 Antihistaminics

20. Drugs (continued) 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 .

21. 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.

22. 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

23. REFERENCES Williams Obstetrics, 24th Edition DC Dutta’s Textbook of Obstetrics, 7th Edition

24. Thank you