1. 1
HYPEREMESIS GRAVIDARUM
DR ALKA MUKHERJEE
DR APURVA MUKHERJEE
NAGPUR M.S.

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty
Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN
RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Organizing secretary AMWICON – 2019
 Life member, IMA, NOGS, NARCHI, AMWN &
Menopause Society, India, Indian medico-legal &
ethics association(IMLEA), ISOPARB, HUMAN RIGHTS
 Founder Member of South Rapid Action Group,
Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS
Nagpur, NKPSIMS, ESIS and Treasury, Nagpur for “
WOMEN SEXUAL HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 VIDARBHA RATNA PURASKAR - 2019
Past Position
 Vice President of NOGS(2016-2017)
 Organizing joint secretary ENDO-GYN
 Vice President IMA Nagpur (2017-2018)
 Organizing joint secretary ENDO-GYN 2019

3. DEFINITION
 Hyperemesis gravidarum (HG) is a pregnancy
complication that is characterized by
severe nausea, vomiting, weight loss, and
possibly dehydration with fainting attacks
 Considered more severe than morning sickness.
 Severe type of vomiting of pregnancy which has got
deleterious effect on the health of the mother &/or
incapacitates her in day to day activities
 HG has been technically defined as more than three
episodes of vomiting per day such that weight loss of 5%
or three kilograms has occurred and ketones are present
in the urine after excluding urinary tract infection and
an overactive thyroid
Dr Alka Mukherjee Nagpur 3

4. ETIOLOGY
• Hormonal-
1. Higher HCG level- twins, GTT
2. Higher oestrogen level
3. Progesterone excess -relaxation
of cardiac sphincter & impaired
gastric motility
• Dietary deficiency-low
carbohydrate intake, vit B6,B1
deficiency
• Psychogenic
• Genetic
• Allergic or immunological basis
• Liver dysfunction
• Vestibular system dysfunction
Metabolic Changes -
• Glycogen Depletion-
Incomplete Oxidation Of
Fat- Ketone Bodies
Biochemical
• Plasma K, Na, Cl. Acidosis,
Ketosis,
• Blood Urea, Uric Acid
Circulatory
• Haemoconcentration- Rise
In Hb,rbc Count,
Haematocrit
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5. Dr Alka Mukherjee Nagpur 5
HG is estimated to affect 0.3–2.0% of pregnant women.
Previously known as a common cause of death in pregnancy, with
proper treatment this is now very rare
Those affected have a lower risk of miscarriage but a higher risk
of premature birth
Some pregnant women choose to have an abortion due to HG
symptoms.
Excessive salivation, also known as sialorrhea gravidarum , is another
symptom experienced by some women.
Hyperemesis gravidarum tends to occur in the first trimester
of pregnancy
While most women will experience near-complete relief of morning
sickness symptoms near the beginning of their second trimester, some
sufferers of HG will experience severe symptoms until they give birth
to their baby, and sometimes even after giving birth

6. CLINICAL FEATURES
a) Early-no evidence of dehydration or
starvation Late-evidence of dehydration
or starvation
b) When vomiting is severe:
 Loss of 5% or more of pre-pregnancy body weight
 Dehydration, causing ketosis and constipation
 Nutritional disorders, such as vitamin B1 (thiamine)
deficiency, vitamin B6 deficiency or vitamin
B12 (cobalamin) deficiency
 Metabolic imbalances such as
metabolic ketoacidosis or thyrotoxicosis
 Physical and emotional stress
 Difficulty with activities of daily living
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FEATURES OF DEHYDRATION
AND KETOACIDOSIS –
DRY COATED TONGUE,
SUNKEN EYES,
ACETONE SMELL IN THE
BREATH
TACHYCARDIA,
HYPOTENSION
RISE IN TEMPERATURE,
JAUNDICE

7. PATHOPHYSIOLOGY
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Source Cause Pathophysiology
Placenta Beta hcg Distention of the gastrointestinal tract
Crossover with TSH, causing
gestational thyrotoxicosis
Placenta
Corpus
luteum
Estrogen
Progesterone
•Decreased gut mobility
•Elevated liver enzymes
•Decreased lower esophageal
sphincter pressure
•Increased levels of sex steroids in hepatic
portal system
Gastrointestin
al tract
Helicobacter
pylori
Increased steroid levels in circulation
Poorly understood, the most commonly
accepted theory suggests that levels of β-hcg
are associated with it.Leptin a hormone that
inhibits hunger, may also play a role

8. Dr Alka Mukherjee Nagpur 8
By IAN RAMSDEN, ROBIN CALLANDER - Obstetrics illustrated (ISBN 0443072671), Public Domain,
https://commons.wikimedia.org/w/index.php?curid=23323186

9. Dr Alka Mukherjee Nagpur 9
DIFFERENTIAL DIAGNOSIS
Type Differential diagnoses
Infections(usually accompanied by
fever or associated neurological
symptoms)
•Urinary tract infection
•Hepatitis
•Meningitis
•Gastroenteritis
Gastrointestinal disorders(usually
accompanied by abdominal pain)
•Appendicitis
•Cholecystitis
•Pancreatitis
•Fatty liver
•Peptic ulcer
•Small bowel obstruction
Metabolic
•Thyrotoxicosis (common in Asian
subcontinent)
•Addison's disease
•Diabetic ketoacidosis
•Hyperparathyroidism
Drugs
•Antibiotics
•Iron supplements
Gestational trophoblastic
diseases (rule out with urine β-hCG)
•Molar pregnancy
•Choriocarcinoma
diagnosis of exclusion

10. INVESTIGATIONS
• Haematological & biochemical changes
• Urinanlysis
- dark coloured, oliguria, acidic PH
- high specific gravity with acid reaction
- presence of ketones
- Diminished or absent chlorides
• Serum electrolytes
• KFT
• TFT
• LFT
• Ophthalmoscopic examination-retinal haemorrhages & detachment
• ECG-when there is hypokalemia
• USG – To rule out multiple pregnancy, molar pregnancy
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11. COMPLICATIONS
ANEMIA
HYPONATREMIA
WERNICKE'S
ENCEPHALOPATHY
KIDNEY FAILURE,
CENTRAL PONTINE
MYELINOLYSIS
COAGULOPATHY
ATROPHY
MALLORY-WEISS TEARS
HYPOGLYCEMIA,
JAUNDICE
,MALNUTRITION
PNEUMOMEDIASTINUM
RHABDOMYOLYSIS
DECONDITIONING
DEEP VEIN THROMBOSIS
PULMONARY EMBOLISM
SPLENIC AVULSION,
OR VASOSPASMS OF CEREBRAL
ARTERIES
DEPRESSION AND POST-
TRAUMATIC STRESS
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FETAL –
lower birth weight,
small for gestational age
and born before 37 weeks
gestation.

12. MANAGEMENT
• PRINCIPLES IN MANAGEMENT
• To control vomiting
• To correct fluids & electrolyte imbalance
• To correct metabolic disturbances
• To prevent the serious complications of severe vomiting
• Care of pregnancy
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13. • FLUIDS
• Witheld oral fluids for 24hrs after cessation of vomiting
• IV fluids in 24hrs- total 3 litres, half of which is 5%D &
half RL.
• Extra amount of 5%D equal to the amount of vomitus &
urine in 24hrs.
• Correct serum electrolytes
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14. MEDICATIONS
• Antiemetics - Promethazine (phenergan)
Prochlorperazine (stemetil), Trifluperazine.
• Metoclopramide Stimulates Gastric And Intestinal
Motility Without Stimulating The Secretions
• Hydrocortisone 100mg I.V For Hypotension Or
Intractable Vomiting.
• Nutritional Support- vit B1,b6,c,b12
• Nursing Care, Hyperemesis Progress Chart.
• Daily Record-vitals, I/O Chart, Urine For Acetone, Blood
Biochemistry, ECG
• Termination Of Pregnancy Rarely Indicated.
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15. MEDICATIONS
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