MANAGEMENT OF HYPEREMESIS GRAVIDARUM
WELCOME
DEFINITION
Hyperemesis gravidarum is defined as unexplained intractable nausea, retching, or vomiting beginning in the first trimester, incapacitates her in day-to-day activities or sufficient to warrant hospital admission resulting in dehydration, ketonuria, and typically a weight loss of more than 5% of prepregnancy weight.
DIAGNOSIS:
• The pregnancy is to be confirmed first. • Exclusion of other causes of vomiting• Proper history taking• Clinical examination• Relevant investigation
HISTORY and PATIENT PROFILEFirst trimester First pregnancyFamilial historyYounger motherUnplanned pregnancies Hydatidiform mole and multiple pregnancy Motion sickness, migraines, oral contraceptives Helicobacter pylori
CLINICAL FEATURE
Symptoms: • Vomiting is increased in frequency with retching. • Urine quantity is diminished even to the stage of oliguria. • Epigastric pain• Constipation • Complications may appear if not treated.• Result in frequently social isolation and negative impacts
on relationships with family and friends.• Excess salivation (ptyalism)
Signs:Features of dehydration and ketoacidosis:
INVESTIGATIONS
Hyperemesis gravidarum is a diagnosis of exclusion
investigations are performed for • Conformation of pregnancy• Exclusion of common and serious causes of
vomiting• Evaluating the extent of complication
• Urinalysis • Biochemical serum electrolytes Sodium- hyponatremiaPotassium- hypokalemiachloride • Ophthalmoscopic examination
• ECG • Biochemical hyperthyroidism• Abnormal LFTs • Hemoconcentration leading to rise in
Hemoglobin % RBC count Hematocrit values
Imaging Studies1.Ultrasound To confirm pregnancyTo establish the number of fetuses To exclude hydatidiform moleTo exclude other conditions such as • Pancreatitis• Cholecystitis• intracranial lesions
COMPLICATIONS: Maternal and Fetal RisksMaternal Risks(1) Neurologic complications — (a) Wernicke’s encephalopathy (b) Pontine myelinolysis(c) Peripheral neuritis(d) Korsakoff’s psychos(2) Stress ulcer in stomach (3) Mallory-Weiss syndrome
(4) Jaundice (5) Convulsions (6)Coma (7) Renal failure /acute tubular necrosis(8) Pneumomediastinum/ pneumothorax(9) Splenic avulsion(10) Psychological burden- depression, anxiety, lost
work(11) Anemia(12)Hyponatremia (plasma sodium < 120 mmol/L) can
cause confusion, seizures, and respiratory arrest. (13)Deep venous thrombosis /thromboembolism
Fetal Risks• No fetal complications • Women with HEG who gain <7 kg during the
entire pregnancy have a slightly higher risk of Low birth weight / small for gestational age/ IUGR Preterm birth / born before 37 weeks’ gestation • If the mother develops Wernicke’s
encephalopathy- chance of IUD
MANAGEMENT
Prince WiIliam and Duchess Kate when they left the King Edward VII hospital in central London in 2012, the last time Kate was treated for hyperemesis gravidarium
Hospitalization:
Whenever a patient is diagnosed as a case of hyperemesis gravidarum, she is admitted
Fluids: Rehydration Fluid replacement therapy should be with eitheNormal saline
Hartmann’s solution
Dextrose-containing fluids should not be used
Double-strength saline
Potassium supplements
Thiamine supplements
Enteral - nasogastric tubeParenteral feeding
MonitoringUrine output
Ketonuria- dipsticks
Body weight
Drugs:
(a) Antiemetic drugs CAT GROUP EXAMPLE DOSEB H 1
ANTIHISTAMINES MeclizineDoxylamine-pyridoxine
12.5 to 25 mg PO four times a day
SUBSTITUTED BENZAMIDES
Metoclopramide 10 mg PO four times a day
5-HT3 receptor blockers
Ondansetron 8 mg PO two times a day
ANTICHOLINERGIC Dicyclomine
C PHENOTHIAZINES Promethazine 25 mg PO or rectally every 4 to 6 hours
prochlorperazine
Efficacy of antiemetic drug
(b) Hydrocortisone • Severe and resistant symptoms • Unable to tolerate fluids Intravenous hydrocortisone 100 mg three times a
day
Prednisolone 40 mg once daily
(c) Nutritional support• Vit B1 • Vit B6 • Vit B12 • Vit C
Diet: At first, dry carbohydrate foods • Biscuits• bread • toastSmall but frequent feeds are recommended
Spicy food should be avoided
Other Treatment OptionsWhile they are inpatients Thromboembolic deterrent stockings
Thromboprophylaxis such as enoxaparine 40 mg daily
Nonpharmacologic measuresAcupuncture
Acupressure
Hypnotherapy
Herbal teasGinger/ ginger tea
Termination of pregnancy Rarely indicated• Intractable hyperemesis gravidarum inspite of
therapy• Wernicke’s encephalopathy • Jaundice• Persistant CVS change
Top Related