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DISORDERS OF

PREGNANCY
HYPEREMESIS
GRAVIDARUM

HYPEREMESIS GRAVIDARUM
Approximately 70% of all pregnancies complicated by
nausea and vomiting.
Beginning typically 4 to 6 weeks of gestation,
confined to the first trimester or the first 16 to 20
weeks of gestation, peaking from 8 to 12 weeks of
gestation.

HYPEREMESIS GRAVIDARUM
Distressing manifestations, typically begun with no
significant metabolic alterations or risk to the mother
or fetus.

Definition
Hyperemesis Gravidarum is excessive vomiting in pregnancy
occurring in the first trimester.
It is a severe type of vomiting of pregnancy which has got
deleterious effect on the health of mother and or incapacitates her
in day to day activities.
Hyperemesis Gravidarum is excessive nausea and vomiting
during pregnancy.

Incidence
The estimated incidence varies from 3.3 to 10 per
1000 births.
Approximately 1% of women require hospitalization.
Hyperemesis Gravidarum usually begins during the
first 10 weeks of pregnancy.

Incidence
It is associated with women who are nulliparous, have
increased

body

weight,

and

have

history

of

migraines, pregnant with twins or hydatidiform mole.

Women

with

Hyperemesis

decreased risk of miscarriage.

Gravidarum

have

Incidence
The reasons for marked fall in the incidence are;
Better application of family planning knowledge to
avoid number of unplanned pregnancies.
Early visit to the antenatal clinic.
Potent antihistaminic, antiemetic.

Etiology
The cause is unknown for 50% of pregnancies.
It is mostly limited to the first trimester.
It is mostly common in first pregnancy, with a
tendency to recur again in subsequent pregnancies.
Familial history

Etiology
Hydatidiform mole and multiple pregnancy.
Common in unplanned pregnancies but less among
illegitimate ones.
It may also occur if the pregnant women seeks
sympathy and attention from her husband and relatives.
It is most common in educated and nervous women.

1. Hormonal

Excess

of

chorionic

gonadotrophin

or

higher

biological activity of HCG is associated.


Progesterone excess leading to relaxation of the
cardiac sphincter and simultaneous retention of gastric
fluids due to impaired gastric motility.

2. Psychogenic
It probably aggravates the nausea once it begins.
But neurogenic elements sometimes play a role, as
evidenced by its subsidence after shifting the patient
from home surroundings.

3. Dietetic Deficiency
Probably due to low CHO reserve, as it happens after
a night without food.
Deficiency of Vit B6, Vit B1, and proteins may be the
effects rather than cause.

4. Allergic or immunologic
basis

5. Decreased Gastric Motility

Pathology
Liver
Kidneys

Centrilobular fatty infiltration


Acidosis

Heart

Subendocardial haemorrhage

Brain

Haemorrhage

Metabolic, Bio-chemical and


Circulatory Changes
Inadequate food intake
Glycogen depletion
Incomplete oxidation of food
Accumulation of ketone bodies
Increase in endogenous tissue protein
Excessive excretion of non-protein nitrogen

Clinical Manifestations
Pernicious vomiting.
Poor appetite, dry coated tongue, sunken eyes, acetone
smell in breath.
Weight loss, Dehydration,
Electrolyte imbalance, Acidosis due to starvation.
Alkalosis resulting from loss of hydrochloric acid in the
vomitus and Hyperkalemia.

Investigations
Investigations
1. Urinalysis
2. Biochemical and circulatory changes
3. Opthalmoscopic examination
4. Ultrasonography

Investigations - Urinalysis
Quantity - small, dark colour,
High specific gravity with acid reaction,
Presence of acetone,
Occasional presence of protein and rarely bile
pigments,
Diminished or even absence of chloride.

Investigations - Biochemical and Circulatory


Changes
Routine and periodic estimation of serum electrolytes
is helpful in the management of the case.

Investigations - Opthalmoscopic Examination


It is required if the patient is seriously ill.
Retinal haemorrhage and detachment of the retina
are the most unfavourable signs.

Investigations Ultrasonography
It is useful not only to confirm the pregnancy but also
to exclude obstetric, gynaecologic, surgical or medical
causes of vomiting.

Management
The principles in the management are;
To control vomiting.
To correct the fluids, electrolytes and other metabolic
disturbances promptly and effectively.
To prevent or to detect at the earliest, the ominous
complications that may arise.

Management Hospitalisation
Whenever the patient is stamped as a client of
Hyperemesis Gravidarum, she is admitted.
Surprisingly with the same diet and drugs used at
home, the patient improves rapidly.

Management - Fluids
Oral feeding withheld for at least 24 hours after the
cessation of vomiting.
IV fluids are mandatory.
Serum electrolytes should be estimated and corrected if
there is any abnormality.
Enternal nutrition through NG tube may also be given.

Management - Drugs
a. Antiemetic drugs: Promethazine (Phenergan) 25 mg twice or
thrice daily and Prochlorperazine (Stemetil) 5 mg.
b.Metaclopramide: Stimulates gastric and intestinal motility without
stimulating the secretions.
c. Hydrocortisone 100 mg IV - In case of hypotension and
intractable vomiting.
d. Nutritional support: With Vit B1, Vit B6, Vit C, and Vit B12.

Nursing Management
Sympathetic but firm handling of the client is
essential.
Extend social and psychological support.
Progress chart is helpful to assess the progress of
the patient in hospital.
History taking

Nursing Management
History taking
Frequency of vomiting episodes,
Dietary history,
Elimination frequency of diarrhoea and constipation,
Foul smell or faeces in vomitus,
Blood in vomitus,
Exposure to contaminated food,
Exposure to viral infection,
Abdominal pain,
Previous abdominal surgery.

Nursing Management
Complete physical examination
Monitoring vital signs.
Check the lab findings - BUN, Electrolyte

Diet
Before stopping the IV fluids oral foods to be given.
At the first dry CHO foods like biscuits, bread, and
toast are given.
Small and frequent foods are recommended.

Termination of Pregnancy
It is rarely indicated.
Interactable hyperemesis gravidarum in spite of
therapy is rare in these days.
Associated renal or neurological complications may
be considered for termination of pregnancy.

Complications
Neurologic complications
Wernickes encephalopathy
Pontine myelinolysis
Peripheral neuritis
Korsakoffs psychosis

Stress ulcers in stomach.


Oesophageal tear or rupture
Jaundice

Prevention
Impart effective management to correct simple
vomiting of pregnancy.

Nursing Care Plan


Nursing diagnosis

Nursing priorities

Imbalanced nutrition: Less than Monitor the patient for effects


body

requirements

related

to of nausea and vomiting that are

nausea, emesis, and subsequent unresponsive

to

nonmedical

inconsistent or insufficient food treatment, and initiate treatment


intake

before severe complications can


occur.

Nursing Care Plan


Nursing diagnosis

Nursing priorities

Deficient fluid volume related to Observe


for
signs
of
protracted emesis
dehydration
and
provide
replacement fluids and electrolytes
as needed.

Nursing Care Plan


Nursing diagnosis

Nursing priorities

Fear related to hospitalization and Provide


pregnancy outcome

the

patient

with

information to fight fears and offer


support.

Nursing Care Plan


Nursing diagnosis

Nursing priorities

Acute pain related to repeated Prevent


episodes of vomiting

vomiting

when

possible, or decrease the frequency


and severity of episodes.

Nursing Care Plan


Nursing diagnosis
Other potential nursing diagnoses:
Constipation related to inadequate food intake
Impaired home maintenance related to debilitating emesis
Disturbed sensory perception (gustatory) related to persistent emesis

Teaching Checklist
Characteristics of usual pregnancy nausea and vomiting
Signs and symptoms to report to the practitioner, such as excessive
vomiting and dehydration
Non-medicinal measures to relieve nausea and vomiting
Measures to maintain food and fluid intake despite nausea and
vomiting
Measures to medically rest the GI tract while providing supplemental
fluids, electrolytes, and nutrients

Teaching Checklist

Name, effects, dosage, administration, adverse effects,


and drug interactions of medications prescribed to treat
nausea, vomiting, and vitamin deficiencies

Relaxation techniques, massage, alternative medicine

practices, and distraction to alleviate the discomforts of


nausea and vomiting or the actual symptoms
Risks of prolonged nausea and vomiting to the fetus or
patient