Dr Ahmed Adam Mohamud MD

1. HYPEREMESIS G
R
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Dr Ahmed Adam

2. INTRODUCTION
• At lest 80% of women experience nausea
&vomiting.
• The term morning sickness is often used to
describe this condition when symptoms usually
disappear after the first trimester.
• this mild form affects the quality of life of women
& her family where the severe form hyperemesis
gravidarum results in dehydration ,electrolyte
imbalance and the need for hospitalization

3. DEFINITION
Unlike morning sickness,
hyperemesisgravidarum:isacomplicationof pregnancy
characterized by persistent uncontrollable nausea
and vomiting that persists beyond the 20thweekof
pregnancy .

4. INTRODUCTION
HYPER:
EXCESSIVE
EMESIS: VOMIT
GRAVIDARUM : PREGNANCY
Nausea/vomit of moderate intensity are
especially common until about 16week.
HCG occurswhen vomiting becomes intractable
in early pregnancy &cause fluid & electrolyte
imbalances &nutritionaldeficiency.
women usually needs to be hospitalized.

5. DEFINITION
It is a severe type of vomiting of pregnancy
which has got harmful effect on health of the
patient and/or injure her day-to-day activities

6. E
T
I
O
L
O
G
Y
Limited to 1st trimester
More common in 1st pregnancy
Tendency to recur again in successive
pregnancies
Familial history: Mother and sisters also suffer
from the same manifestation
More prevalent in multiple pregnancy
Common in unplanned pregnancies
Maternal obesity
Smoking

7. RISKFACTORS
Age below 17 years and over 35 years
Primigravidae
Multiple pregnancy
Underweight and obesity
Psychological factors such as unwanted
Pregnancy ,marital problems
history Of Hyper emesis Gravidarum

8. TheoriesbehindHyperemesisGravidarum
1
.H
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High Hcg, multiple pregnancy
High Estrogen
High progesterone-relaxation of cardiac
sphincter
Other hormones involved:
-Thyroxin
-Prolactin
-Leptin
-Adreno-cortisol hormones

9. 2.PSYCHOGENIC
It probably aggravated nausea once it begins it
trigger neurogenic elements .

10. 3.DIETARYDEFICIENCY
Probably due to low carbohydrate reserve as it
happens after a night without food. Deficiency of
vitamin B1,B6 & protein may be the effect
rather than cause.
4. Allergic or immunological basis
5. Decrease gastric motility is found to cause
nausea

11. Clinicalcourse
Early:
• Vomiting throughout day
• Normal day to day activitiesare
disturbed.
• No evidence of dehydration &
starvation
Late:
• Evidence of dehydration and starvation

12. Cont..
S
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M
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S
:
• Excessvomiting &vomit day &night.
• Epigastric pain
• Constipation
• Spitting
• Fatigue
• Anorexia
• Complications will appear if not treated

13. Cont..
Signs:
• Signs of dehydration and
ketoacidosis
• Dry covered tongue
• Sunken eyes
• Acetone smell in breath
• Tachycardia
• Postural hypotension
• Raise in temperature
• Jaundice(later stage)
• Vaginal examination and
USG isdone to confirm
pregnancy

14. INVESTIGATION
a) URIN ANALYSIS
b) CBC
c) LIVERFUNCTIONTEST(LFT)
d) THYROIDFUNCTIONTEST
e) ULTRASOUNDSCAN
f) OPHTHELMOSCOPY

15. investigation
1.Urinalysis
• Quantity (too see for oliguria)
• Dark colour (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

16. C
o
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t
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2
.
B
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o
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h
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c
a
landcirculatorychangesSerum electrolytes
(Sodium,Pottasium and Chloride) has to
done

17. Cont..
3.Opthalmoscopicexamination
Its isrequired if patients isseriously ill. Retinal
haemorrage and detachment of the retina are the
most unfavorable signs

18. Cont..
4.ECG
When there is abnormal
serum potassium level

19. diagnosis
• Pregnancy isconfirmed first
• Associated causesof vomiting are excluded like
Gynecological or Medical or Surgical causes,
• USG –Pregnancy, Hydratiform mole,
Multiple pregnancy

20. complications
N
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1. Psychosis
2. Peripheral neuritis
3. Ophthalmic: Retinal haemorrhage
4. Convulsions
5. Coma

21. COMPLICATIONS
1. Weight loss
2. Dehydration
3. Metabolic acidosis from starvation
4. Alkalosis from loss of HCL
5. Hypokalemia (electrolyte imbalance)

22. COMPLICATIONS
Mallory Weisstears
Characterized by upper gastro-intestinal bleeding
secondary to longitudinal mucosal lacerations at the
gastroesophageal junction or gastriccardia

23. Othercomplications
• Stressulcer in the stomach
• Oesophageal tears
• Jaundice due to liver damage

24. prevention
The onlyprevention isto import effective
management to correct simple vomiting of
pregnancy.

25. management
Principles:
• Tocontrol vomiting.
• Tocorrect fluid &electrolyte imbalance.
• Tocorrect metabolic disturbance.
• Toprevent serious complications of severe
vomiting.

26. 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
• Testthe urine periodically for ketone
bodies

27. fluids
• Oral feeding iswith held for at least 24hours
after the cessation of vomiting.
• During this period, fluid given through IV drip
method.
• Theamount of fluid to be infused in 24hours is
calculated as: total amount of fluid approx. 3litres,
of which half is5
%isdextrose and half is Ringer’s
solution.
• Extra amount of 5
%dextrose equal to the amount
of vomitus and urine in 24hours, isto be added.
These measures help to correct dehydration,
electrolyte imbalance and keto- acidosis.
• Enternal nutrition through nasogastric tube may
also be given

28. drugs
Antiemetic:-
• Promethazin -25mgIM BD or
TDS
• Metachlopromide- 10mg IM
• Hydrocortisone:- 100mgIV in
drip
• Prednisolone orally
• Nutritional support:-
Vitamin B1,vitamin B6,
vitamin B12&vitaminC

29. Midwifecare
• Daily monitoring of the patient
• Look for signsof 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.
• Monitor lab results for dehydration
• Monitor FHR,Fetal activity and growth
• Encourage patient to sit in upright after
meal
• Encourage small &frequent meals.
• Liquids should be taken between meals to
avoid distending stomach and triggering
vomit

30. Dietarymanagement
• Before IV fluids isgiven
oral Small and frequent
dry meals without fat are
given.
• First dry carbohydrates
like Biscuit,bread
• Ginger is helpful
• Gradually full diet is
restored