Hyperemesis Gravidarum

Case Study
Presenter : Vaisnvi Muthoovaloo
Pembimbing : Dr. Achmad Djaenudin
SpOG

Identitas Pasien
Nama Lengkap : Ny. C

Jenis Kelamin : Wanita

Tempat / tanggal lahir : 24 Juli

Suku Bangsa : Sunda

1983/32 tahun
Status Perkawinan : Menikah

Agama : Islam

Pekerjaan : Guru

Pendidikan : S1

Alamat : Cengkareng, Jakarta

RM 49-07-48

Identitas Suami
Nama Lengkap : Tn. E

Jenis Kelamin : Laki laki

Tempat / tanggal lahir : 35 tahun

Suku Bangsa : Sunda

Status Perkawinan : Menikah

Agama : Islam

Pekerjaan : Pekerja Swasta

Alamat : Cengkareng, Jakarta

Keluhan Utama
Pasien mengeluh mual dan muntah
sejak 2 minggu.

Keluhan demam, BAB hitam, nyeri perut,

perdarahan per vaginanam disangkal. Keluhan
mual dan pusing pada kehamilan sebelumnya
disangkal. Riwayat penyakit seperti darah tinggi,
penyakit gula darah dan alergi kepada obatobatan serta makanan, asma dan sakit maag
disangkal. Konsumsi minuman beralkohol
disangkal.

Pasien mengaku hamil 8 minggu. HPHT tanggal 7

Januari 2016.

Riwayat kehamilan
An Tahu Jenis

Umur

ak n

Keham Persali

Kelamin

ke Persa

ilan

Jenis

Penolo Hidup Berat

Nifas

ng

Ibu

/ Mati

bayi

lin

1 201 Perempua 39mg norma bidan hidu

2

2900 Baik
gr

Rpd rpk
-

RIWAYAT HAID

Menarche
: 12 tahun
Siklus
: Teratur/ 28 hari
Lama
: 7 Hari
HPHT
: 07/01/2016
Taksiran Persalinan : 14/10/2016

RIWAYAT OBSTETRI
G2P1A0 hamil 8 minggu

Status Pernikahan
Status : Menikah
Pernikahan ke : 1
Lama : 5 tahun

KB
Pasien menggunakan kontrasepsi
spiral namun sudah lepas 1 tahun.

RIWAYAT ANTE NATAL

CARE
Pasien kontrol kehamilan pada bidan
puskesmas 1 kali

 Keadaan umum : Tampak Sakit

Sedang
Kesadaran : Compos Mentis
Tinggi badan
: 165 cm
Berat badan
: 50 kg
BMI
: 18.35kg/m

Status generalis
Tanda vital
Tekanan Darah : 90/70 mmHg
Nadi : 90 kali/menit
Nafas : 26 kali/menit
Suhu : 36,4 0C
Mata : Cekung. Konjungtiva anemis -/- , Sklera ikterik -/Mulut : Mukosa tampak kering.
Leher : Pembesaran KGB -, Pembesaran kelenjar tiroid Jantung : BJ I-II regular murni, Gallop - , Murmur Paru-paru : Suara nafas vesikuler, Ronkhi -/- , Wheezing -/Abdomen : Abdomen tampak merata, tampak linea alba
Ekstremitas
: Varices -/-, edema --/--, akral dingin + +/+ +

STATUS OBSTETRI
Pemeriksaan Luar
Inspeksi
: Abdomen mendatar,
tampak
linea alba
Palpasi
: TFU 3 jari di bawah
umbilicus,
nyeri tekan negatif

Pemeriksaan lab
Pemeriksaan

Hasil

Nilai rujukan

Hb

10,7 mg/dL

12,0-14,0

Leukosit

7.200 /uL

5000-10.000

Hematologi

Hematokrit

32,1 %

36-42

Tombosit

255.000 /uL

150000-450000

USG
Fetal heart monitoring : 156
kali/menit.
Fetal echo +
Gestational sac (+) 3.6 cm, usia
gestasi : 8 minggu 2 hari
Taksiran partus :16 Oktober 2016

Resume
Ny C, 32 tahun, G2P1A0 hamil 8 minggudengan
keluhan nausea dan hyperemesis sejak 2
minggu lebih dari 10 x/ hari. Pasien anorexia,
malaise, oliguria dan mengalami penurunan
berat badan 5%( 3 kg). Pasien juga
mengalami hipotensi ortostatik dan
tachypnea. 1 minggu yang lalu pasien
hemetemesis 2 kali kira kira setengah aqua
gelas. Sudah berobat ke RS Bunda Suci 2 kali.
3 hari yang lalu, pasien kembali nausea dan
hyperemesis.

XV . DIAGNOSIS
Ibu: G2 P1 A0 hamil 8 minggu dengan
hyperemesis gravidarum

PENATALAKSANAAN
Rencana Diagnostik:
Pemasangan kateter, urinalisis, elektrolit serum, kalsium, fungsi
tiroid dan fungsi hati
Rencana pengelolaan :
Puasa 24 jam
Terapi cairan : Hartmann/NaCl 2000ml dalam 3-5 jam lanjut
dengan maintenance 25-30ml/kgBB/24 jam diatur sesuai dengan
jumlah output urine (minimal 100ml/jam)
Ondansetron IM/ slow IV 4-8mg seterusnya PO 4-8mg 2kali/hari.
Ranitidine IV 50mg 3kali/sehari. Seterusnya PO 150mg
2kali/sehari.
Multivitamin IV
Folic Acid 5mg sekali/hari

EDUKASI PASIEN
Edukasi pasien tentang penyakitnya.
Makan makanan kesukaan ketika
rasa lapar muncul, terlepas dari
jadwal makan yang biasanya
Makannya sering tapi dalam jumlah
porsi kecil
Hindari makan yang berbau dan
yang berlemak dan pedas.

PROGNOSIS
Ibu:
Ad vitam: Dubia ad bonam
Ad fungsionam : Dubia ad bonam
Ad sanationam : Dubia ad bonam
Janin:
Ad vitam: Dubia ad bonam
Ad fungsionam : Dubia ad bonam
Ad sanationam : Dubia ad bonam

HYPEREMESIS
GRAVIDARUM
Definition
Persistent and excessive vomiting starting before
the end of the 22nd week of gestation being
associated with metabolic disturbances such as
carbohydrate depletion, dehydration, or electrolyte
imbalance.
HG is a diagnosis of exclusion, characterized by
prolonged and severe nausea and vomiting,
dehydration, large ketonuria, and more than 5%
body weight loss.

 Pada pemeriksaan fisik didapatkan

keadaan umum tampak sakit sedang,
kesadaran compos mentis. Tekanan
darah 9070 mmHg, nadi 98x/menit,
pernafasan 28x/menit, suhu 36,4oC.
Ditemukan mata cekung, mukosa
mulut tampak kering dan akral
dingin.

Pathophysiology multifactorial
HCG increased levels in patients with HG
as HCG stimulates secretions in upper GIT
Estrogen- positive assoc between NVP and
maternal serum estrogen level. Increased
estrogen causes a decrease in GI motility
and gastric emptying altering GI pH and
encourages subclinical H pylori infection
Thyroid hormone- physiological
gestational transient thyrotoxicosis.
Raised FT3 & low TSH found in 66% HG

Risk factors
Elevated HCG level
Molar/trisomy pregnancy

Psychological factors
Female fetus
Low maternal age
Use of vitamins in early pregnancy
Nausea associated with
contraception

HYPEREMESIS
GRAVIDARUM
Symptoms
Nausea
Vomiting
Ptyalism
Enhanced olfactory senses
Food and/or fluid intolerance
Lethargy

HYPEREMESIS
GRAVIDARUM
Signs
Dehydration
Weight loss
Ketonuria
Anaemia
Tachycardia

HYPEREMESIS GRAVIDARUM
Initial Investigations
Urea and Electrolytes
LFT
CBC
Urinalysis
USG-multiple/molar pregnancies

Additional investigations
Calcium
Blood sugar
TSH

COMPLICATIONS
COMPLICATIONS
Maternal
Hypokalemia
Hyponatremia and central pontine myelinosis
Wernickies encephalopathy
Malnutrition
Mallory- Weiss esophageal tears

Fetal
Growth restriction
Wernickes encephalopathy is associated with
40% fetal death

 Hyponatremia (Na<120 mmol/l) - anorexia,

headache, nausea, vomiting and lethargy

Severe hyponatremia may lead to central pontine

myelinolysis (osmotic demyeliniation)

Pyramidal tract signs

Spastic quadriparesis
Pseudobulbar palsy
Altered sensorium
Ataxia and convulsion

 Vitamin B1 deficiency

precipitated by IV fluid
containing high concentration of dextrose
Ophthalmoplegia (typically sixth nerve palsy, diploia),
Ataxia
Altered sensorium

Thiamine replacement may improve the

symptoms of Wernickes encephalopathy

Condition

Disease

Condition

Disease

Infections

Acute pyelonephritis

Gastrointestinal

Pancreatitis

Acute gastroenteritis

disorders

Appendicitis

Viral fever

Peptic ulcer disease

Encephalitis

Biliary tract disease

Viral hepatitis
Malaria

Neurological

Benign

disorders

hypertension

Metabolic

Diabetic ketoacidosis

Tumour

disorders

Hyperthyroidism

Severe migraine

Hyperparathyroidism

Vestibular disease

Hypercalcemia
Uraemia
Addisons disease

Others

Drugs induced

intracranial;

 Correction of dehydration and electrolyte

imbalance
Prophylaxis against recognized complications
Provision of symptomatic relief
Admit if :
Symptom are severe despite 24 hrs of medication
Evidence of dehydration and ketosis
Admit earlier if coexisting conditions eg diabetes

 IV fluid- NS and Hartmanns

solution preferrable if ketotic or
fluid intolerant.
*Avoid dextrose

 Antiemetics are safe and

recommended liberally in HG
Patients on antiemetic -better
pregnancy outcome due to
better nutrition

Anti-emetics
Drug

Recommended

Route

dose
1st line

Promethazine

25 mg t.d.s

PO/IM

Cyclizine

And/or

PO/IM/IV

50 mg t.d.s
2nd line

Prochlorperazine

12.5mg t.d.s.

IM

Metoclopramide

10mg t.d.s.

PO

3-6 mg b.d.

Buccal

And/or

PO/IM/IV

10mg t.d.s.
3rd line

Ondansetron

4-8mg then

IM/ slow IV

4-8mg b.d.

PO

 Steroids should be used for

intractable hyperemesis which is not
responding to above management
IV Hydrocortisone 100 mg BD for 48
hrs
Oral prednisolone 30 40 mg/day -1
week then tapered gradually 5mg
reduction every week

Summary for Management of Hyperemesis

Gravidarum-NHS 2013
Prolonged nausea
& vomiting
Intolerable to fluid
and/or food
Clinical
dehydration
Ketouria
Weight loss

Admission

Nausea & vomiting

History of other medical
condition e.g diabetes,

Admission

Initial assessment
Temp, Pulse, Resp,
BP, Body weight
U&E
LFT
Urinalysis/ MSU
USS

Additional
investigations
FBC (full blood
count)
Blood glucose
TFT (thyroid function
test)
Calcium

Diagnosis

Intractable vomiting

Antiemetics (2nd
group)
Promethazine
(phenergan) 25 mg a
day IM/oral
Chlorpromazine 10-25
mg t.d.s. PO
25 mg t.d.s. IM
Domperidone 10 mg
q.d.s PO
30-60 mg b.d PR

With consultant
decision
Ondansetron 4-8 mg b.d.
PO, IM or IV
Hydrocortisone 100 mg
b.d. IV for 48 hr followed
by:
Prednisolone 30-40 mg
o.d. PO for one week then
reduce the dose by 5
mg/week

Other supportive
treatment
Diet & lifestyle (small
frequent dry meal,
learn to avoid certain
scents which make
the patient
intolerable)
Ginger
Acupressure/acupunct
ure

The options for severe

hyperemesis who failed to
response to above
measures
Enteral nutrition
Parenteral nutrition
(TPN)
Termination of
pregnancy

 A doxylamine/pyridoxine combination should

be the standard of care, since it has the
greatest evidence to support its efficacy and
safety. (I-A)
H1 receptor antagonists should be considered
in the management of acute or breakthrough
episodes of NVP. (I-A)
Pyridoxine monotherapy supplementation may
be considered as an adjuvant measure. (I-A)
Phenothiazines are safe and effective for
severe NVP. (I-A)
SOGC 2002, ACOG 2010

Hyperemesis guidelines
Metoclopramide is safe to be used for
management of NVP, although evidence for
efficacy is more limited. (II-2D)
Corticosteroids should be avoided during the
first trimester because of possible increased
risk of oral clefting and should be restricted to
refractory cases. (I-B)
When NVP is refractory to initial
pharmacotherapy, investigation of other
potential causes should be undertaken. (III-A)
SOGC 2002, ACOG 2010