Hyper Emesis Gravidarum

HYPEREMESIS
GRAVIDARUM(HG)
Definition:
 It is a severe type of vomiting of pregnancy which has got
deleterious effect on the health of mother and/or incapacitates her
in day-to-day activities.
 The triad of adverse effect due to protracted Nausea vomiting in

pregnancy are:
 > 5% loss of pre pregnancy weight
 Dehydration and
 Electrolyte imbalance
 The other adverse effects are: metabolic acidosis due to starvation

or alkalosis due to loss of hydrochloric acid from vomiting.
Incidence:
• 1 in 1,000 pregnancies
There has been marked fall in the incidence during the last 30
years. The reasons are:-
a) Better application of family planning knowledge which
reduces the number of unplanned pregnancies,
b) Early visit to the antenatal clinic, and
c) Potent antihistaminic and antiemetic drugs.
Etiology:
1. It is mostly limited to the first trimester and resolves by 20
weeks (90%).
2. It is more common in first pregnancy, with a tendency to
recur again in subsequent pregnancies (15%).
3. Younger age
4. Low body mass
5. History of motion sickness or migraine
6. Familial history: mother and sisters also suffer from the same
manifestation.
7. When the women is on Combined Oral Contraceptives, It is
more prevalent in hydatidiform mole and multiple pregnancy
Theories:
1. Hormonal:
a. Excess of chorionic gonadotropin or higher biological
activity of hCG is associated.
b. High serum level of estrogen and
c. Progesterone excess leading to relaxation of cardiac sphincter
and simultaneous retention of gastric fluids due to impaired
gastric motility.
2. Psychogenic
3. Dietetic deficiency : Probably due to low carbohydrate
reserve, as it happens after a night without food. Deficiency
of Vitamin B6, Vitamin B1 and Proteins
4. Allergic or immunological basis
5. Decreased gastric motility
Pathology:
The changes in the various organs as described by Sheehan are
the generalized manifestations of starvation and severe
malnutrition.
Liver: Liver enzymes are elevated.
Kidneys: Usually normal with occasional findings of fatty
change in the cells of first convoluted tubule, which may be
related to acidosis.
Heart: There may be subendocardial hemorrhage.
Brain: Small hemorrhages in the hypothalamic region
Clinical Course:
• Early : Vomiting occurs throughout the day,
- Normal day to day activities are curtailed
- There is no evidence of dehydration or starvation
• Late (Moderate to severe): Evidences of dehydration and
starvation are present
Symptoms:
• Vomiting is increased in frequency
• Urine quantity is diminished
• Epigastric pain
• Constipation
Signs:
• Features of dehydration and ketoacidosis:
• Dry coated tongue
• Sunken eyes
• Acetone smell in breath
• Tachycardia
• Hypotension
• Rise in temperature may be noted
• Jaundice is a late feature
Investigations:
• Urinalysis: High specific gravity with acid reaction, presence
of acetone, presence of protein
• Biochemical and circulatory changes: LFTs are abnormal in
many patients with rise in the level of serum transaminases
and bilirubin. Jaundice may be present.
• Ophthalmoscopic examination: It is required if the patient is
seriously ill. Retinal hemorrhage and detachment of the retina
are the most unfavorable signs.
• ECG when there is abnormal serum potassium level.
Diagnosis:
Ultrasonography is useful not only to confirm the pregnancy but
also to exclude other obstetric (hydatidiform mole, multiple
pregnancy), gynecological, surgical or medical causes of vomiting.
Complications:
• Circulatory failure
• Jaundice due to liver involvement, hepatic failure
• Retinal hemorrhage
• Wernicke’s encephalopathy and Korsakoff’s syndrome
( disorientation and loss of memory)
• Renal failure
• Convulsions, coma
• Esophageal tear
Effects on the Fetus:
• Fetus usually remains unaffected once the problem is resolved.
• Fetal risks may be due to Low Birth Weight and Preterm Birth.
Management:
• Early causes with Nausea Vomiting in Pregnancy are managed
at home with oral antiemetics.
• The principles of management are:
 Maintenance of hydration
 To control vomiting
 To correct the fluids and electrolytes imbalance
 To correct metabolic disturbances (acidosis or alkalosis)
 To prevent the serious complications of severe vomiting
 To correct vitamin deficiencies
 Care of pregnancy
Hospitalization: Indications are:

a. Protracted NVP despite the use of oral antiemetics
b. Continued NVP with ketonuria and /or weight loss >5%
c. Presence of any comorbidity (medical/surgical)
Fluids: Oral feeding is withheld for at least 24 hours after the

cessation of vomiting.
• During this period, fluid is given through intravenous drip
method.
• The amount of fluid to be infused in 24 hours is calculated as follows:
The total amount of fluid approximates 3 liters of which half is 5%
dextrose and half is Ringer’s solution.
• Extra amount of crystalloids equal to the amount of vomitus and urine in
24 hours is to be added.
• Potassium chloride may be given additionally.
• Enteral nutrition through nasogastric tube may be also be given.
Drugs:
a. Antiemetic drugs : Promethazine (Phenergan) 25mg or
Prochlorperazine (Stemetil) 5 mg may be administered twice or thrice
daily intramuscularly.
- Doxylamine 25 mg is an effective antihistamine for nausea and vomiting
of pregnancy.
-Vitamin B6 (Pyridoxine- 25mg) also safe and effective
-Metoclopramide stimulates gastric and intestinal motility without
stimulating the secretions. It is found useful and used as a second line drug.
b. Hydrocortisone 100 mg IV in the drip is given in a case with
hypotension or in intractable vomiting.
c. Nutritional supplementation: with Vitamin B1 (100mg
daily), vitamin B6, vitamin C and vitamin B12 are given.
Rarely, patients may need parenteral nutritional therapy.
d. Ondansetron is safe and effective and used as a second line
therapy.
Nursing care: Sympathetic but firm handling of the patient is

essential.
 Social and psychological support should be extended.
 Parenteral thiamine should be given to prevent Wernicke’s
encephalopathy.
 Maternal complications and preventive measures are to be
taken:
• Neurological complications are to be treated with Inj.
Thiamine 100mg IV daily.
• Stress ulcer with the use of proton pump inhibitors (IV).
• Hemoconcentration may need thromboprophylaxis with
LMWH.
 Woman with NVP and HG need to be multidisciplinary team
management involving physician, psychiatrist, nutritionist and
the midwife.
 Hyperemesis progress chart is helpful to assess the progress
of patient while in hospital.
 Daily record of pulse, temperature, blood pressure at least
twice daily, intake-output, urine for acetone , protein, bile and
ECG ( when serum potassium is abnormal).
Common measures managing nausea and vomiting in
preganncy are:
1. To take small amount and at frequent intervals.
2. To drink fluids in between meals and not after the meals.
3. Not to lie down immediately after meals.
4. To avoid food that causes gastric irritation.
5. To avoid food (high fat) and odors that trigger nausea and
vomiting.
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 and
 Normal fetal growth on follow up.
Diet: Before the intravenous fluid is omitted, the foods are given
orally.
• At first, dry carbohydrate foods like biscuits, bread and toast
are given.
• Small but frequent feeds are recommended.
Nursing Diagnosis:
 Risk for fetal injury
 Risk of infection
 Ineffective airway clearance
 Risk of aspiration
 Altered family process
 Anxiety
 Risk for altered parenting
Supportive Research Study
A study was conducted by London Victoriya, Grube Stephanie et al.
In the United States, hyperemesis gravidarum is the most common
cause of hospitalization during the first half of pregnancy and is
second only to preterm labor for hospitalizations in pregnancy
overall. In approximately 0.3-3% of pregnancies, hyperemesis
gravidarum is prevalent and this percentage varies on account of
different diagnostic criteria and ethnic variation in study populations.
Despite extensive research in this field, the mechanism of the disease
is largely unknown. Although cases of mortality are rare,
hyperemesis gravidarum has been associated with both maternal and
fetal morbidity. The current mainstay of treatment relies heavily on
supportive measures until improvement of symptoms as part of the
natural course of hyperemesis gravidarum, which occurs with
progression of gestational age. However, studies have reported that
severe, refractory disease manifestations have led to serious adverse
outcomes and to termination of pregnancies.
Bibliography:
 Konar H.. DC Dutta’s Textbook Of Obstetrics. JAYPEE. 9th
Edition.2019. Page no: 147-150.
 Jacob A. A Comprehensive Textbook Of Midwifery &
Gynecological Nursing. JAYPEE. 3rd Edition.2012. Page
no:267-268.
 Marshall J., Raynor M.. Myles Textbook For Midwives.
ELSEVIER. 16th Edition. 2014. Page no:228-229.
Online Reference:
 www.wikipedia.com
 https://pubmed.ncbi.nlm.nih.gov/28641304/

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HYPEREMESIS

 The triad of adverse effect due to protracted Nausea vomiting in

 The other adverse effects are: metabolic acidosis due to starvation

Hospitalization: Indications are:

Fluids: Oral feeding is withheld for at least 24 hours after the

Nursing care: Sympathetic but firm handling of the patient is

Clinical features of improvement are evidenced by:

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