HYPEREMESIS GRAVIDARUM

HYPEREMESIS GRAVIDARUM is a complication during pregnancy that involves severe nausea and vomiting. It's a more severe form of morning sickness.

Hyperemesis gravidarum causes severe nausea, vomiting and weight loss during pregnancy. It sometimes requires IV fluids treatments.

The incidence of women with severe symptoms varies from 0.3 to 3% pregnancies.

In a prospective study published recently which included 800 patients, while 57% reported nausea, 27% reported both nausea and vomiting by 8weeks of gestation.

Even though it is believed to be common among older women, new studies have shown that it might be traced to young mothers, nulliparous, past medical history, family history, non-Caucasian and surprisingly, non-smokers.

Risk factor

The risk factor includes

·       multiple gestations,

·       hydatidiform mole,

·       heart burn and acid reflux,

·       the non-use of multivitamins before 6 weeks of gestation or during the period conception period,

·       motion sickness,

·       migraine,

·       family history of hyperemesis gravidarum

·

The hormonal change is estrogen, progesterone, Beta HCG. These hormones relax smooth muscles and thus slow GI transit time and may alter gastric emptying, also the relaxation of the esophageal sphincter.

INVESTIGATION

Its investigation includes the following,

·       Electrolyte imbalance : hypokalemia, hypohloremic alkalosis, hyponatremia

·       Hematocrit can be raised due to hemo-concentration

·       FBC may show lymphocytosis

·       LFT raised, ALT and AST(IN 50%)

·       Bilirubin doesn’t rise in >4

·       Serum amylase and lipase in 10 to 15%

·       Thyroid function: mild hyperthyroidism due to raised BHCG (transient biochemical hyperthyroidism)

·       Check blood glucose to r/o DKA

·

Management

Its management depends on the severity: mild, moderate and severe. These are,

·       supportive measures,

·       rehydration,

·       correction of electrolyte imbalances,

·       vitamin supplement,

·       antiemetics,

·       psychological support,

·       nonpharmacological support.

·       Nausea and vomiting of pregnancy should be treated according to the severity (ACOG 2018)

·       Diet changes: small meals every 2 hours, Avoid triggers and Add ginger to diet

·

·       Vomiting without dehydration: Antihistamine (H1 antagonists): diphenhydramine, meclizine, dimenhydrinate

·   Dopamine Antagonist: metoclopramide, promethazine, prochloperazine

·   Serotonin Antagonist: Ondansetron, granisetron and dolasetron

·   Acid reducing agents: antacids, H2 blockers, proton pump inhibitors

 

·       Vomiting without dehydration:

IVF and electrolyte correction

Vitamins and minerals

Antiemetics

Diet therapy

 

·       IV Rehydration And Electrolyte Correction:

2L iv ringers lactate infused over 3 to 5 hours,

Consider isotonic saline if serum Na+ levels >120 meq/L,

Dextrose saline can be used for maintenance, and

Monitor levels of K+ and other electrolytes.

 

·       Vitamins and minerals:

Thiamine 100mg IV  for 3 days,

Folic acid 0.6mg dly,

Vitamin B6 25mg in 1L fluid, and

magnesium 2g(16mEq) mg sulphate infused as a 10% solution over 10 to 20mins.

 

·       First Line Medications:

Cyclizine 50mg PO, IM OR IV 8hourly

Prochlorperazine 5-10mg 6- 8mg 6-8hrly PO,

12.5mg 8hrly IM/IV,

Promethazine 12.5 – 25mg 4-8hrly PO,IM, and

IV Chlorpromazine 10-25mg 4-6hrly PO,IV or IM.

 

·       Second Line Medications:

Metoclopromide 5-10mg 8hrly, PO,IV or IM.

Ondansetron 4-8mg 6-8hrly PO,

8mg over 15mins 12hrly IV, and

Domperidone 10mg 8hrly PO.

·       Third Line Medications:

Corticosteroids: hydrocortisone 100mg twice daily,

Once clinical improvement occurs, convert to Prednisolone 40 -50mg dly PO, and

Taper dose gradually until the lowest maintenance that control symptoms is achieved.

 

·       Non-pharmacological treatment:

Role of acustimulation such as acupressure, acupuncture

Role of ginger in mild and moderate cases of nausea and vomiting in pregnancy.