Hyperemesis gravidarumAlsaleh Yassin MahmoudSecurity Force Hospital

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And we have commended unto man kindness toward parents. his mother bear him with reluctance, and bring him forth with reluctance.

ObjectivesIntroduction.Epidemiology.Clinical picture.Investigation.Treatment.outcomes.

IntroductionNausea and vomiting in pregnancy is

extremely common. The nausea and vomiting associated with

pregnancy usually begins by 9-10 weeks of gestation, peaks at 11-13 weeks, and resolves in most cases by 12-14 weeks.

Normal nausea and vomiting may be an protective mechanism—it may protect the pregnant woman and her embryo from harmful substances in food.

DefinitionsMotion sickness:Nausea felt by pregnant woman on

getting up in the morning.Emesis gravidarum:actual vomiting in the morning.Hyperemesis gravidarum:Vomiting not confined to morning but

repeated throughout the day until it affect the general condition of the patient.

EpidemiologyIncidence:Of all pregnancies, 0.3-2% are affected

with HEG .more common in westernized

industrialized societies and urban areas than rural areas.

Race: No clear racial predominance is noted for HEG

Risk factorsPrevious pregnancies with HEGGreater body weightMultiple gestationsTrophoblastic diseaseNulliparity

The risk of HEG appears to decrease with advanced maternal age.

Cigarette smoking is associated with a decreased risk for HEG.

AetiologyUnknown.

Hormonal.Psychological. Vestibular and olfaction Hepatic dysfunction .Lipid alterations .Other (H.pylori infection)

Aetiology cont.Hormonal:Women with hyperemesis gravidarum often

have high hCG levels that cause transient hyperthyroidism.

High human chorionic gonado trophin (hCG) stimulate the chemo receptor trigger zone in the brain stem including vomiting center.

Evidence by High hCG in :Early pregnancy.Vesicular mole.Multiple pregnancy.

Aetiology cont. H . pylori infection:1-The incidence of H.pylori sero positive in

patients with hyperemesis gravidarum (HG) is high in comparison with non-HG pregnant women .

no one was able to demonstrate correlation between seropositivity for H. pylori and the time of onset or duration of HG symptoms.

Although H. pylori infection may be an importantm factor in exacerbating HG, it may not represent the sole cause of the disease.

No definitive

correlatio

n

Multiple fa

ctor

DiagnosisHistory.Examination.

Clinical picture (symptoms)Vomiting through day and night ptyalism dizziness Sleep disturbanceHyperolfactionDysgeusiaDepressionAnxietyIrritabilityMood changesDecreased concentration

Clinical picture (sign)Signs:Dehydration.Weight loss.Sunken eyeDry mouth.Mild fever.Hypotension.

CRITERIAHEG

Persistent vomiting

weight loss greater than 5%

Dehydration

Electrolyte abnormalities

Differential Diagnosis Gastrointestinal disorders Gastroenteritis Biliary tract disease Hepatitis Intestinal obstruction Peptic ulcer disease Pancreatitis Appendicitis Genitourinary tract

disorders Pyelonephritis Uremia Degenerating uterine

leiomyoma Torsion Kidney stones Drug toxicity or intolerance

Metabolic disorders Diabetic ketoacidosis Porphyria Addison’s disease Hyperthyroidism Neurologic disorders Pseudotumor cerebri Vestibular lesions Migraine headaches Central nervous system

tumors Pregnancy-related conditions Nausea and vomiting of

pregnancy hyperemesis gravidarum Acute fatty liver of

pregnancy Preeclampsia

InvestigationsUrinalysis: for ketones and specific

gravity .Serum electrolytes :-low Na or K.-hyperchloremic metabolic alkalosis or

acidosis.LFT: Elevated transaminase levels .TSH,free thyroxine :HEG is associated

with hyperthyroidism

Investigations contUrine culture: UTI can be associated

with nausea and vomiting.Hematocrit: This may be elevated.Hepatitis screening: hepatitis A, B, or C

may be confused with HEG.

Investigations contImaging Studies:

Obstetric ultrasonography : evaluate for multiple gestations or trophoblastic disease.

upper abdominal ultrasonography to evaluate the pancreas and/or biliary tree

In rare cases, abdominal CT scan may be indicated if appendicitis is under consideration.

Management1-Admission:2-Intravenous Fluids:Normal saline or lactated Ringer’s

solution is the mainstay of intravenous fluid therapy.

It should be given by infusion over 2-3 hours.

thiamine (vitaminB1).3-Enteral or Parenteral Nutrition.

Management contDIETARY AND LIFESTYLE CHANGES Separating solids and liquids. Eating small, frequent meals consisting of

bland foods. Avoiding fatty foods such as potato chips. Avoiding drinking cold or sweet beverages. Eliminate pills with iron High protein snacks are helpful.

Management cont5 - PHARMACOLOGICAL THERAPIES: Vitamins Pyridoxine (Nestrex) Essential for normal DNA synthesis and

play a role in various metabolic processes

- (Diclectin) combination of doxylamine with of pyridoxine (vitamin B6)

- A - Safe in pregnancy - at a dose of 10-12.5 mg PO qd/bid.

Management contAntiemetics : a.DOPAMINE ANTAGONISTS:Useful in the treatment of symptomatic nausea - phenothiazines (i.e., chlorpromazine,

perphenazine, prochlorperazine, promethazine, trifluoperazine)

- blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system

- C - Safety for use during pregnancy has not been established.

Management contMetoclopramide:is an upper

gastrointestinal motility stimulant.Blocks dopamine receptors and (when

given in higher doses) also blocks serotonin receptors in chemoreceptor trigger zone of the CNS

Metoclopramide is safe to be used for management of NVP, although evidence for efficacy is more limited

B - Usually safe but benefits must outweigh the risks

Management contSEROTONIN 5-HT3 ANTAGONISTS. Ondansetron (Zofran) :blocking serotonin, both peripherally on

vagal nerve terminals and centrally in the chemoreceptor trigger zone

In general, 5-HT3 antagonists may be safe to use during the first trimester, but the data are scant.

Management contAntihistamines :Meclizine (Antivert) , Diphenhydramine

(Benadryl) Appears to be as efficacious as pyridoxine Causes sedation; caution must be used in

performing tasks which require alertness

Management contCorticosteroids:Methylprednisolone (Medrol, Solu-

Medrol) Recent studies revealed a small but

significantly increased risk of oral clefting associated with first trimester exposure to corticosteroids.

Management contA doxylamine/ pyridoxine combination

should be the standard of care since it has the greatest evidence to support its efficacy and safety.

Other drugs may also be used, primarily dimenhydrinate, in conjunction with the doxylamine/pyridoxine combination.

If possible, corticosteroid use should be avoided in the first 10 weeks .

Management contOther modalities:(antidepressent):- Selective serotonin re-uptake inhibitors- Tricyclic antidepressants (TCAs) Helicobacter pylori eradication.ACUPUNCTURE.Stimulation of the P6 point, located three-

fingers’ breadth proximal to the wrist, has been used for treat nausea and vomiting

Ginger (Zingiber officinale)

outcomesEsophageal rupture or perforationPneumothorax and pneumomediastinumWernicke encephalopathy or blindnessHepatic diseaseSeizures, coma, or death

HEG is self-limited and, in most cases, improves by the end of the first trimester. However, symptoms may persist through 20-22 weeks of gestation and, in some cases, until delivery.

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