HYPEREMESIS GRAVIDARUM

Presented by Agatha Qyara Annabella

 DEFINISI
• Morning sickness  kondisi mual muntah yang terjadi pada
kehamilan hingga usia 16 minggu.
• Hiperemesis gravidarum  keadaan muntah-muntah yang berat (> 3
x / hari), dapat terjadi dehidrasi, gangguan asam basa dan elektrolit
dan ketosis
• Hiperemesis gravidarum adalah keadaan mual muntah yang berat
selama kehamilan, ditandai dengan mual yang menetap dan muntah
yang berhubungan dengan ketosis dan kehilangan berat badan (> 5%
dari berat badan sebelum kehamilan)
 EPIDEMIOLOGI
• 0.3-2% dari seluruh kehamilan di USA mengalami hiperemesis
gravidarum (5 : 1000 kehamilan)
• Terjadi pada 60-80% primigravida dan 40-60% multigravida. Mual dan
muntah mempengaruhi hingga > 50% kehamilan
 FAKTOR RISIKO
• Komplikasi medis dari hipertiroid, penyakit terkait psikiatrim riwayat menderita mola
hidatidosa, kelainan gastrointestinal, diabetes pregestasional, asma, riwayat kehamilan
kembar, kehamilan janin perempuan
• Risiko hipermesis gravidarum menurun seiring dengan pertambahan usia ibu
• Riwayat hiperemesis pada kehamilan sebelumnya.
• Status nutrisi: pada wanita obesitas lebih jarang di rawat inap karena hiperemesis.
• Psikologis: adanya stress dan emosi.
• Ras tidak berpengaruh terhadap kejadian hipermesis gravidarum, meskipun pada
populasi Indian dan Eskimo, Afrika, dan sebagian populasi di Asia (selain Jepang) angka
kejadiannya lebih kecil.
• Kondisi lain yang mirip dengan hiperemesis gravidarum adalah Couvade Syndrome,
dimana pada kondisi ini pihak ayah yang mengalami gejala-gejala morning sickness
seperti mual-muntah, penurunan nafsu makan, hingga dehidrasi dan kehilangan berat
badan.3
 ETIOLOGI
Etiologi pastinya masih belum jelas, tetapi ada beberapa teori yang diduga
menyebabkan hiperemesis gravidarum
• Adaptasi (kekurangan darah?)
• Peningkatan hormon-hormon kehamilan (hCG, estrogen, progesteron)
• Defisiensi vitamin B6 (precursor piridoksal sebuah pembentukan GABA,
membantu memetabolisme KH, lemak)
• Hipertiroidisme
• Infeksi Helicobacter pylori
• Faktor psikologis (unwanted pregnancy, mood swing, stress)
• Gangguan metabolisme karbohidrat
• Alergi?
PATOFISIOLOGI
 RPD
STRES
MAAG

TRIMESTER I
PERUBAHAN
FISIOLOGIS TUBUH
HAMIL

PRIMIGRAVIDA

PERUBAHAN PADA
PERUBAHAN
SISTEM
HORMONAL
GASTOINTESTINAL

FREKUENSI BAK &

MUAL-MUNTAH DEHIDRASI
BAB MENURUN
AFFERENTS PATHWAYS

The vomiting centre is predominantly activated by three different

mechanisms:
• By nervous impulses from the pharynx, esophagus, stomach, and upper
portions of the small intestines and other portions of the body, resulting in
a reflexive activation
• By stimulation from the higher brain centres
• By the chemoreceptor trigger zone (CTZ) sending impulses (ex : DA and SE)
• unpleasant sights and odours, as well as severe parietal pain

EFFERENTS PATHWAYS
The neural pathways involved in the motor act of vomiting are associated
mainly with the phrenic nerve to the diaphragm, the spinal nerves to the
abdominal and intercostal muscles, efferent visceral autonomic fibres to the
gut, and the viscera efferent fibres to parts of the voluntary muscles of the
pharynx and larynx. The vomiting reflex is mediated by both the autonomic
and somatic systems, and consists of two phases:

Prodomal phase (pre-ejection): Relaxation of gastric muscles followed by

small intestinal retrograde peristalsis;
Ejection phase: Comprises of retching and vomiting including expulsion of
gastric contents.
 CRF release from Neurotransmitter
Vasopressin release fro hypothalamus
paraventricular nuclei in release (SE, NE, Ach)
hypothalamus

ACTH release
from pituitary
gland NE increase during stress
SE decrease during stress
Cortisol and
progesterone *gut contains around 95
release from Glucocorticoid
release to
percent of body’s serotonin
adrenal gland
systemic and it helps to stimulate
circulation contractions that push food
through the intestines.
 Decrease SE may cause
constipation
reduce circulating
B cell numbers
 HORMONAL CHANGES DURING PREGNANCY

Progesterone Estrogen hCG

Nitrit oxide TSH receptor

vasodilatation Increase free

T4

Muscle
relaxation frequent
(including LES) nausea and
vomiting

Delayed travel time

reflux
& emptying time in
GI tract
 MANIFESTASI KLINIS
Keluhan (subjektif)
• Mual dan muntah
hebat
• Ibu terlihat pucat
• Kekurangan cairan
Gejala Klinis (objektif)
• Muntah yang hebat
• Mual dan sakit kepala terutama
pada pagi hari (morning sickness)
• Nafsu makan turun
• Berat badan turun
• Nyeri epigastrium
• Lemas
• Rasa haus yang hebat
• Gangguan kesadaran
 DIAGNOSIS
• Anamnesis : RPS, RPD, RPK
• Pemeriksaan fisik : tanda vital, tanda-tanda dehidrasi status generalis,
• Pemeriksaan penunjang : lab darah perifer lengkap & urinalisis
 TATALAKSANA
Non medikamentosa
• Kecukupan nutrisi ibu (termasuk suplementasi vitamin dan asam folat
di awal kehamilan)
• Anjurkan istirahat yang cukup dan hindari kelelahan
Medikamentosa
• Anti emetik
• Anti histamine
• Vitamin B6
• Kortikosteroid jika perlu
 KOMPLIKASI
• Maternal Complications
In severe cases of hyperemesis, complications include vitamin deficiency,
dehydration, and malnutrition, if not treated appropriately. Wernicke’s
encephalopathy, caused by vitamin-B1 deficiency, can lead to death and permanent
disability if it goes untreated. Additionally, there have been case reports of injuries
secondary to forceful and frequent vomiting, including esophageal rupture and
pneumothorax. Electrolyte abnormalities such as hypokalemia can also cause
significant morbidity and mortality. Additionally, patients with hyperemesis may
have higher rates of depression and anxiety during pregnancy.
• Fetal Complications
Studies report conflicting information regarding the incidence of low birthweight
and premature infants in the setting of nausea and vomiting in pregnancy.
However, studies have not shown an association between hyperemesis and
perinatal or neonatal morality. The frequency of congenital anomalies does not
appear to increase in patients with hyperemesis
 COUVADE SYNDROME
• COUVADE  from French verb “couver”, translated as to brood

• A phenomenon that affect the male partners of pregnant women who experience
a range of physical (nausea, weight gain, mood swing) and psychological
symptoms with no pathological basic* due to the bond between the baby and the
expectant father
• Onset is generally during the third gestational month

*not a recognized medical condition

Psychological Theory :
- A relationship between the syndrome and the man’s rivalry with his
unborn child
- A transitional crisis between men’s involvement in the pregnancy, role
preparation and the syndrome  resolve with childbirth
Hormonal changes :
- Increase of men’s hormonal levels of prolactin and estrogen
- Lower serotonin level