Hyperemesis gravidarum - Clinicals, Diagnosis, and Management

Obstetrics

Clinicals - History

Fact Explanation
Severe nausea and vomiting Hyperemesis gravidarum is defined as uncontrolled vomiting leading to severe dehydration, muscle wasting, electrolyte imbalance, ketonuria, weight loss of more than 5% of body weight & requiring hospitalization. It has an incidence of 0.3% to 2% of all pregnancies. Nausea and vomiting is common during pregnancy which is currently believed to be multi-factorial in origin. The trophoblastic hormone - human chorionic gonadotrophin(hCG) plays an important role in the pathogenesis. Severe nausea and vomiting
Hyperemesis gravidarum is defined as uncontrolled vomiting leading to severe dehydration, muscle wasting, electrolyte imbalance, ketonuria, weight loss of more than 5% of body weight & requiring hospitalization. It has an incidence of 0.3% to 2% of all pregnancies. Nausea and vomiting is common during pregnancy which is currently believed to be multi-factorial in origin. The trophoblastic hormone - human chorionic gonadotrophin(hCG) plays an important role in the pathogenesis.
Anorexia This can lead to reduced food intake even leading to starvation. Anorexia
This can lead to reduced food intake even leading to starvation.
Weight loss The prolonged loss of fluids and inability to take & maintain a regular food intake leads to weight loss. A weight loss of more than 5% of the pre pregnancy weight is a predictor of maternal and fetal complications. Weight loss
The prolonged loss of fluids and inability to take & maintain a regular food intake leads to weight loss. A weight loss of more than 5% of the pre pregnancy weight is a predictor of maternal and fetal complications.
Dizziness and syncope The severe dehydration associated with prolonged vomiting can result in a hypovolemic state which can lead to cerebral hypo-perfusion. Dizziness and syncope
The severe dehydration associated with prolonged vomiting can result in a hypovolemic state which can lead to cerebral hypo-perfusion.
Low urine output The severe dehydration associated with vomiting can result in a hypovolemic state. Low urine output
The severe dehydration associated with vomiting can result in a hypovolemic state.
Symptoms of complications Patients with hyperemesis gravidarum can develop complications due to electrolyte imbalances, severe dehydration and also mechanical complications due to prolonged vomiting. Possible complications are : Wernicke’s encephalopathy causing restlessness, insomnia, seizures, unconsciousness; Korsakoff’s psychosis causing confusion, amnesia; Mallory Weiss syndrome causing hematemesis and ophthalmic complications causing blindness, blurring of vision, diplopia. Symptoms of complications
Patients with hyperemesis gravidarum can develop complications due to electrolyte imbalances, severe dehydration and also mechanical complications due to prolonged vomiting. Possible complications are : Wernicke’s encephalopathy causing restlessness, insomnia, seizures, unconsciousness; Korsakoff’s psychosis causing confusion, amnesia; Mallory Weiss syndrome causing hematemesis and ophthalmic complications causing blindness, blurring of vision, diplopia.

Clinicals - Examination

Fact Explanation
Features of severe dehydration Anxious or confused appearance, sunken eyes, loss of skin elasticity, dry tongue, oliguria.
weight loss >5% of total pre pregnancy body weight.
Features of severe dehydration
Anxious or confused appearance, sunken eyes, loss of skin elasticity, dry tongue, oliguria.
weight loss >5% of total pre pregnancy body weight.
Ketotic 'sickly sweet' odor of breath Starvation associated with the severe vomiting leads to depletion of glycogen stores in the patient. This leads to mobilization of lipid stores for generation of energy which produces ketone bodies. Ketotic 'sickly sweet' odor of breath
Starvation associated with the severe vomiting leads to depletion of glycogen stores in the patient. This leads to mobilization of lipid stores for generation of energy which produces ketone bodies.
Tachycardia and hypotension Due to severe dehydration causing hypovolemia. Tachycardia and hypotension
Due to severe dehydration causing hypovolemia.
Fundus larger than dates Assessment of the symphysio-fundal height (SFH), a height larger than weeks of gestation is seen in twin and molar pregnancy. These two conditions are associated with hyperemesis gravidarum due to the increased production of hCG from the increased placental mass. Fundus larger than dates
Assessment of the symphysio-fundal height (SFH), a height larger than weeks of gestation is seen in twin and molar pregnancy. These two conditions are associated with hyperemesis gravidarum due to the increased production of hCG from the increased placental mass.

Investigations - Diagnosis

Fact Explanation
The diagnosis of hyperemesis gravidarum is usually based on the clinical presentation of severe vomiting during early pregnancy. It is a diagnosis of exclusion. Investigations are used to assess the severity of the condition and to exclude a secondary etiology. The diagnosis of hyperemesis gravidarum is usually based on the clinical presentation of severe vomiting during early pregnancy.
It is a diagnosis of exclusion. Investigations are used to assess the severity of the condition and to exclude a secondary etiology.
Ultrasound scan Used to exclude multiple pregnancy and gestational trophoblastic disease. Ultrasound scan
Used to exclude multiple pregnancy and gestational trophoblastic disease.
Urinalysis Helps in determining the presence/absence of ketone bodies in urine and assessment of the degree of ketosis.
Additional information that can be gauged include exclusion of a urinary tract infection, elevation of specific gravity of urine.
Urinalysis
Helps in determining the presence/absence of ketone bodies in urine and assessment of the degree of ketosis.
Additional information that can be gauged include exclusion of a urinary tract infection, elevation of specific gravity of urine.

Investigations - Management

Fact Explanation
Full blood count The degree of hemoconcentration can be assessed. Full blood count
The degree of hemoconcentration can be assessed.
Serum electrolytes Excessive loss of fluids and gastric contents can lead to electrolyte changes like hypokalemia, hypocalcaemia etc. Monitoring of serum electrolytes regularly is important in the management of hyperemesis gravidarum. Serum electrolytes
Excessive loss of fluids and gastric contents can lead to electrolyte changes like hypokalemia, hypocalcaemia etc. Monitoring of serum electrolytes regularly is important in the management of hyperemesis gravidarum.
Liver function test Transient disturbances can be seen during the acute stages. Liver function test
Transient disturbances can be seen during the acute stages.
Thyroid function tests The placental hormone hCG is closely linked with the pathogenesis of hyperemesis gravidarum. This hormone is also known to have thyroid stimulating activity. Hyperthyroidism is known to occur in patients suffering from hyperemesis gravidarum due to the presence of a variant of hCG with increased thyroid stimulating activity. This clinical condition is called ‘Transient hyperthyroidism of hyperemesis gravidarum’.
Hyperthyroidism is also known to precipitate hyperemesis gravidarum.,
Thyroid function tests
The placental hormone hCG is closely linked with the pathogenesis of hyperemesis gravidarum. This hormone is also known to have thyroid stimulating activity. Hyperthyroidism is known to occur in patients suffering from hyperemesis gravidarum due to the presence of a variant of hCG with increased thyroid stimulating activity. This clinical condition is called ‘Transient hyperthyroidism of hyperemesis gravidarum’.
Hyperthyroidism is also known to precipitate hyperemesis gravidarum.,

Management - Supportive

Fact Explanation
Patient education and counseling The patient should be educated on the condition, its natural course and etiology. The patient can be reassured that hyperemesis gravidarum per se is not associated with adverse fetal outcomes., Patient education and counseling
The patient should be educated on the condition, its natural course and etiology. The patient can be reassured that hyperemesis gravidarum per se is not associated with adverse fetal outcomes.,
Thromboprophylaxis The severe dehydration associated with hyperemesis gravidarum can precipitate deep vein thrombosis. Adequate hydration, mobilization & use of lower limb stockings can prevent the occurrence of this. Thromboprophylaxis
The severe dehydration associated with hyperemesis gravidarum can precipitate deep vein thrombosis. Adequate hydration, mobilization & use of lower limb stockings can prevent the occurrence of this.

Management - Specific

Fact Explanation
Hospitalization In-ward management is required in severe cases for monitoring of vital parameters, carrying out relevant investigations and management of complications. Hospitalization
In-ward management is required in severe cases for monitoring of vital parameters, carrying out relevant investigations and management of complications.
Intravenous hydration The mainstay of management of hyperemesis gravidarum is intravenous fluids to correct the fluid and electrolyte deficit. The main types of fluids used are the Hartmann’s solution and 0.9% physiological saline. Bolus doses followed by a maintenance should be used if the patient presents in a shock state. Dextrose containing solutions should only be used after administration of thiamine to avoid precipitation of Wernicke’s encephalopathy. Intravenous hydration
The mainstay of management of hyperemesis gravidarum is intravenous fluids to correct the fluid and electrolyte deficit. The main types of fluids used are the Hartmann’s solution and 0.9% physiological saline. Bolus doses followed by a maintenance should be used if the patient presents in a shock state. Dextrose containing solutions should only be used after administration of thiamine to avoid precipitation of Wernicke’s encephalopathy.
Correction of electrolyte imbalances Correction of electrolyte imbalances can be achieved with use of IV solutions such as Hartmann’s. Serum electrolyte measurements should be monitored regularly. However correction of severe hypokalemia may need IV potassium supplementation. Rapid administration of replacement electrolytes should be avoided in order to prevent complications such as central pontine myelinolysis. Correction of electrolyte imbalances
Correction of electrolyte imbalances can be achieved with use of IV solutions such as Hartmann’s. Serum electrolyte measurements should be monitored regularly. However correction of severe hypokalemia may need IV potassium supplementation. Rapid administration of replacement electrolytes should be avoided in order to prevent complications such as central pontine myelinolysis.
Nutritional support Oral feeding is withheld until the patient is stable and no longer vomiting profusely. Feeding is started with small liquid meals and gradually increased to solids. Parental vitamins including thiamine is administered. Thiamine is required to prevent Wernicke’s encephalopathy. Pyridoxine( Vitamin B6) is also used with a dosage of 12.5mg to 25mg thrice a day. Total parental nutrition is rarely required in extreme cases of hyperemesis gravidarum. Nutritional support
Oral feeding is withheld until the patient is stable and no longer vomiting profusely. Feeding is started with small liquid meals and gradually increased to solids. Parental vitamins including thiamine is administered. Thiamine is required to prevent Wernicke’s encephalopathy. Pyridoxine( Vitamin B6) is also used with a dosage of 12.5mg to 25mg thrice a day. Total parental nutrition is rarely required in extreme cases of hyperemesis gravidarum.
Anti-emetic drug therapy. Control of vomiting can be achieved with anti-emetics such as dimenhydrinate, prochloperazine, metaclopramide, cyclizine. When administering a drug the safety profile should be considered. Category A,B,C drugs are safe to use in pregnancy. The above mentioned drugs are considered first line drugs in the management of vomiting in pregnancy. The use of ondansetron is currently not recommended. Anti-emetic drug therapy.
Control of vomiting can be achieved with anti-emetics such as dimenhydrinate, prochloperazine, metaclopramide, cyclizine. When administering a drug the safety profile should be considered. Category A,B,C drugs are safe to use in pregnancy. The above mentioned drugs are considered first line drugs in the management of vomiting in pregnancy. The use of ondansetron is currently not recommended.
Use of steroids Steroids are used in extremely severe cases for control of vomiting. Steroids control vomiting by acting on the central vomiting centers.Further evaluation is required to recommend its routine use. Use of steroids
Steroids are used in extremely severe cases for control of vomiting. Steroids control vomiting by acting on the central vomiting centers.Further evaluation is required to recommend its routine use.
Non pharmacological treatment options Certain non-pharmacological treatments have being used as adjuncts in the management of hyperemesis gravadarum. Ginger: the root of Zingiber officinale is used for control of vomiting. Acupuncture: used for the control of nausea,vomiting and retching. Out of the varies types of acupuncture, active PC6 acupuncture has being shown to provide symptomatic relief in these patients. Medical hypnosis has also been effective in some cases. Non pharmacological treatment options
Certain non-pharmacological treatments have being used as adjuncts in the management of hyperemesis gravadarum. Ginger: the root of Zingiber officinale is used for control of vomiting. Acupuncture: used for the control of nausea,vomiting and retching. Out of the varies types of acupuncture, active PC6 acupuncture has being shown to provide symptomatic relief in these patients. Medical hypnosis has also been effective in some cases.

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