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HYPER-EMESIS GRAVIDARUM

Chapter-1

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INTRODUCTION

  • Nausea and vomiting during pregnancy, commonly termed "morning sickness"occur in 70% of all pregnancies. Although referred to as morning sickness, these symptoms can occur at any time of the day.
  • Most women experience symptoms only during the first trimester, but a few may continue to have symptoms throughout the pregnancy.

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  • Vomiting in pregnancy may be due to hormonal changes associated with pregnancy or it may be due to some medical-surgical or gynecological complications that may occur at any time during pregnancy.

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DEFINITION OF PERNICIOUS VOMITING

  • Pernicious vomiting is medically known as Hyperemesis Gravidarum.
  • It is a severe type of vomiting of pregnancy which has got deleterious effect on the health of mother and incapacitates her in day to day activities.

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ETIOLOGY

  • Endocrine: Excess HCG , Estrogen and progesterone
  • Infection: H.pylori bacteria
  • Upper GI dysmotility: due to smooth muscle relaxation induced by high level of progesterone and thyroxine.
  • Genetic factor
  • Psychological factor: Hyperemesis could be response to stress or psychosomatic disorder.

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PATHOLOGY

Metabolic Changes

Inadequate intake of fluid leads to glycogen depletion

Fat reserve is broken down, but there is incomplete oxidation of fat

Accumulation of ketone bodies in blood and

there is also increase in endogenous tissue protein metabolism.

Excessive excretion of non protein nitrogen in the urine.

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Biochemical Changes

Loss of water and salt in the vomitus.

Fall in plasma sodium, potassium, and chloride.

Acidosis and ketosis with rise in blood urea and uric acid, hypoglycemia, hypoproteinemia, hypovitaminosis, and rarely hyperbilirubinemia.

Hepatic dysfunction .

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Circulatory Changes

There is hemoconcentration.

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Raise in hemoglobin percentage, red blood cell (RBC) count and hematocrit values.

There is slight increase in the white cell count with increase in eosinophils.

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There is reduction in the extracellular fluid.

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CLINICAL MENIFESTATIONS

Symptoms:

  • Vomiting is increased in frequency with retching.
  • Oliguria
  • Epigastric pain and constipation may occur.

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CLINICAL MENIFESTATIONS

Signs:

  • Features of dehydration and ketoacidosis :

- dry coated tongue

- sunken eyes

-acetone smell in breath

-tachycardia

-loss of skin elasticity

-hypotension

-rise in temperature may be noted

  • Jaundice is a late feature.
  • Up to 5% of weight loss may be reported.

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  • Neurological complications:
  • Wernicke’s encephalopathy
  • Korsakoff’s syndrome
  • Peripheral neuritis
  • Stress ulcer in stomach.
  • Oesophageal rupture or tear.
  • Jaundice
  • Renal insufficiency
  • Retinal hemorrhage

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COMPLICATIONS

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MANAGEMENT

The principles of management are as follow:

• To control the vomiting.

• To correct fluids and electrolyte imbalance.

• To prevent or treat any complication.

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For mild to moderate cases:

  • Lifestyle and dietary modifications: avoiding offensive food and odors,eat small and frequent meals.
  • Avoid triggering factors: coffee,tea,oil, and smell of cooking, especially frying.
  • Supportive therapy: Reassurance and counseling.
  • Alternative Therapies: psychotherapy, acupressure, and medical hypnosis can be tried.
  • Medication: Doxinate, a combination of doxylamine and pyridoxine/vitamin B6, is very effective.

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For severe cases:

  • Hospitalisation
  • IV fluids
  • Medication:

-Antiemetic drugs

(doxylamine10mg,metoclopramide 10mg)

-Hydrocortisone

  • Nutritional Supplements
  • Termination of pregnancy : rarely indicated.

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Management of hyperemesis gravidarum

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NURSING MANAGEMENT

  • Hyperemesis progress chart is helpful to assess the progress of patient in hospital.
  • Social and psychological support should be given.
  • The signs of improvement must be noted like subsidence of vomiting, feeling of hunger, better look, disappearance of acetone from breath and urine, normal pulse and blood pressure, normal urine output.

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  • After vomiting has stopped, start feeding in small amount at frequent interval.
  • Provide a quiet and comfortable environment that is free from odor to enhance womans' comfort.
  • Nurse should observe the patient for any complications like metabolic acidosis, jaundice and hemorrhage.
  • Maintenance of oral hygiene is important before and after the episode of vomiting.

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