2. Introduction
Vomiting is a symptom which may be related to pregnancy
or may be a manifestation of some medical surgical-
gynecological complications, which can occur at any time
during pregnancy. The former is by far the most common
one and is called vomiting of pregnancy.
3. The vomiting
is related to
the pregnant
state and
depending
upon the
severity, it is
classified as:
(i) Simple vomiting of
pregnancy or milder
type (ii) Hyperemesis
gravidarum or severe
type.
4. Types
SIMPLE VOMITING :
The patient complains of nausea and occasional sickness on rising in the
morning.
Slight vomiting is so common in early pregnancy (about 50%) that it is
considered as a symptom of pregnancy. It may, however, occur at other times
of the day.
The vomitus is small and clear or bile stained. It does not produce any
impairment of health or restrict the normal activities of the women.
The feature disappears with or without treatment by 1214th week of
pregnancy
5. Cont
High level of serum human chorionic gonadotropin,
estrogen and altered immunological states are
considered responsible for initiation of the
manifestation, which is probably aggravated by the
neurogenic factor.
6. HYPEREMESIS GRAVIDARUM
DEFINITION:
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. The adverse effects of severe
vomiting aredehydration, metabolic acidosis (from
starvation) or alkalosis (from loss of hydrochloric acid),
electrolyte imbalance (hypokalemia) and weight loss.
7. INCIDENCE:
There has been marked fall in the incidence during the last 30 years. It is now a
rarity in hospital practice (less than 1 in 1,000 pregnancies). The reasons are
(a) better application of family planning knowledge which reduces the number of
unplanned pregnancies
(b) early visit to the antenatal clinic and
(c) potent antihistaminic and antiemetic drugs.
8. ETIOLOGY
The etiology is obscure but the following are the
known facts:
It is mostly limited to the first trimester;
It is more common in first pregnancy, with a tendency to recur again
in subsequent pregnancies (15%);
Younger age;
Low body mass
9. Cont
History of motion sickness or migraine;
It has got a familial history mother and sisters also suffer from the
same manifestation;
It is more prevalent in hydatidiform mole and multiple pregnancy and
It is more common in unplanned pregnancies but much less amongst
illegitimate ones.
10. THEORIES:
(1) Hormonal: (a) Excess of chorionic gonadotropin or higher biological
activity of hCG is associated. This is proved by the frequency of vomiting at
the peak level of hCG and also the increased association with hydatidiform
mole or multiple pregnancy when the hCG titer is very much raised; (b)
High serum level of estrogen and (c) Progesterone excess leading to
relaxation of the cardiac sphincter and simultaneous retention of gastric
fluids due to impaired gastric motility. Other hormones involved are:
thyroxine, prolactin, leptin and adrenocortical hormones
11. (2) Psychogenic: It probably aggravates the nausea
once it begins. But neurogenic element sometimes
plays a role, as evidenced by its subsidence after
shifting the patient from the home surroundings.
Conversion disorder, somatization, excess perception of
sensations by the mother are the other theories.
12. (3) Dietetic deficiency: Probably due to low
carbohydrate reserve, as it happens after a night
without food. Deficiency of vitamin B6 , vitamin B1
and proteins may be the effects rather than the
cause.
13. (4) Allergic or immunological basis.
(5) Decreased gastric motility is found to
cause nausea.
14. PATHOLOGY
There are no specific morbid anatomical
findings. The changes in the various organs
as described by Sheehan are the generalized
manifestations of starvation and severe
malnutrition.
15. Liver: Liver enzymes are elevated. There is centrilobular fatty
infiltration without necrosis.
Kidneys: Usually normal with occasional findings of fatty
change in the cells of first convoluted tubule, which may be
related to acidosis.
Heart: A small heart is a constant finding. There may be
subendocardial hemorrhage.
Brain: Small hemorrhages in the hypothalamic region giving
the manifestation of Wernickes encephalopathy. The lesion
may be related to vitamin B1 deficiency
16. Clinical Course From the management and prognostic point of view, the cases are
grouped into:
Early
Late (moderate to severe)
The patient is usually a nullipara, in early pregnancy. The onset is insidious.
EARLY: Vomiting occurs throughout the day. Normal day-to-day activities are curtailed.
There is no evidence of dehydration or starvation.
LATE: (Evidences of dehydration and starvation are present).
17. Symptoms:
Vomiting is increased in frequency with retching. Urine
quantity is diminished even to the stage of oliguria.
Epigastric pain, constipation may occur. Complications may
appear (see below) if not treated.
18. Signs:
Features of dehydration and ketoacidosis: Dry coated
tongue, sunken eyes, acetone smell in breath, tachycardia,
hypotension, rise in temperature may be noted, jaundice is a
late feature. Such late cases are rarely seen these days.
Vaginal examination and/or ultrasonography is done to
confirm the diagnosis of pregnancy.
19. Investigations:
Urinalysis:
Quantitysmall,
Dark color,
High specific gravity with acid reaction,
Presence of acetone, occasional presence
of protein and rarely bile pigments and
Diminished or even absence of chloride.
20. Biochemical and circulatory
changes:
The changes are mentioned previously.
Routine and periodic estimation of the serum
electrolytes (sodium, potassium and chloride)
is helpful in the management of the case.
21. Serum TSH, T3 and Free T4
Women may suffer from transient phase of thyroid
dysfunction (clinical or subclinical).
Ophthalmoscopic examination is required if the patient
is seriously ill. Retinal hemorrhage and detachment of
the retina are the most unfavorable signs.
ECG when there is abnormal serum potassium level
22. DIAGNOSIS
The pregnancy is to be confirmed first. Thereafter,
all the associated causes of vomiting (enumerated
before) are to be excluded. Ultrasonography is
useful not only to confirm the pregnancy but also to
exclude other, obstetric (hydatidiform mole, multiple
pregnancy), gynecological, surgical or medical
causes of vomiting
23. Management:
The principles in the management are:
Maintenance of hydration
To control vomiting
To correct the fluids and electrolytes imbalance
To correct metabolic disturbances (acidosis or alkalosis)
To prevent the serious complications of severe vomiting
Care of pregnancy.
24. Hospitalization:
Whenever a patient is diagnosed as a case of
hyperemesis gravidarum, she is admitted.
Surprisingly, with the same diet and drugs used at
home, the patient improves rapidly. The relatives
may be too sympathetic or too indifferent.
25. Fluids:
Oral feeding is withheld for at least 24 hours after the cessation of vomiting.
During this period, fluid is given through intravenous drip method. The amount
of fluid to be infused in 24 hours is calculated as follows: The total amount of
fluid approximates 3 liters, of which half is 5% dextrose and half is Ringers
solution. Extra amount of crystalloids equal to the amount of vomitus and
urine in 24 hours, is to be added. With this regime dehydration,
ketoacidosis, water and electrolyte imbalance are likely to be rectified. Serum
electrolyte should be estimated and corrected if there is any abnormality.
27. Drugs:
(a) Antiemetic drugs
Vitamin B6 and doxylamine are also safe and effective.
Metoclopramide stimulates gastric and intestinal motility without
stimulating the secretions. It is found useful.
(b) Hydrocortisone 100 mg IV in the drip is given in a case with
hypotension or in intractable vomiting. Oral method prednisolone
is also used in severe cases.
(c) Nutrition
28. Nursing care
Nursing care: Sympathetic but firm handling of the
patient is essential. Social and psychological support
should be extended.
29. Nursing care
Hyperemesis progress chart is helpful to assess the progress
of patient while in hospital. Daily record of pulse,
temperature, blood pressure at least twice daily, intake-
output, urine for acetone, protein, bile, blood biochemistry
and ECG (when serum potassium is abnormal) are important
30. Clinical features of improvement are
evidenced by
Clinical features of improvement are evidenced by
(a) subsidence of vomiting
(b) feeling of hunger
(c) better look
(d) normalization of blood biochemistry (electrolytes)
(e) disappearance of acetone from the breath and urine
(f) normal pulse and blood pressure and
31. Diet: Before the intravenous fluid is omitted, the foods
are given orally.
At first, dry carbohydrate foods like biscuits, bread and
toast are given.
Small but frequent feeds are recommended.
Gradually full diet is restored.
Termination of pregnancy is rarely indicated.
Intractable hyperemesis gravidarum in spite of therapy
