Definition

Severe and unremitting nausea and

vomiting that persist after the first trimester.
Usually occurs with the first pregnancy and
commonly effects pregnant women with
conditions that produce high levels of human
chorionic gonadotropin (hCG), such as
gestational trophoblastic disease or multiple
gestations.
 Pathophysiology

Exact cause is unknown, but it’s linked to trophoblastic

activity, gonadotropin production, and psychological factors.
Various possible causes:

Hormonal changes
Pancreatitis
Biliary tract disease
Decreased secretion of free hydrochloric acid in the
stomach
Urinary tract infection
Gastroenteritis Drug induced vomiting
Decreased gastric motility (slowed emptying of the
stomach and intestines)
Gastrointestinal dysfunction
Drug toxicity
Vitamin deficiency (especially of B6)
Multiple pregnancy
Hydatidiform mole
Diabetic ketoacidosis
Vestibular and olfaction
Hepatitis
Bowel obstruction
Hyperthyroid disorders
Psychological factors (in some cases)
Greater body weight
Infection
 Symptoms of hyperemesis gravidarum

The following are the most common symptoms of

hyperemesis gravidarum. However, each woman may
experience symptoms differently.

Symptoms may include:

constant nausea, especially after the first trimester
vomiting after eating or drinking
vomiting not related to eating
weight loss
dehydration
ptyalism (excessive salivation), fatigue, weakness,
and dizziness.
When HG is severe and/or inadequately treated, it may result in:
Loss of 5% or more of pre-pregnancy body weight
Dehydration
Nutritional deficiencies
Metabolic imbalances
Difficulty with daily activities
Altered sense of taste
Sensitivity of the brain to motion
Food leaving the stomach more slowly
Rapidly changing hormone levels during pregnancy
Stomach contents moving back up from the stomach
Physical and emotional stress of pregnancy on the body
Physical and emotional stress on ones coworkers
The popping of blood vessels in eyes.
Hallucinations .
The appearance of a blue aura around people.
Complications
For the pregnant woman
If inadequately treated, HG can cause renal failure, central
pontine myelinolysis, coagulopathy, atrophy, Mallory-Weiss
syndrome, hypoglycemia, jaundice, malnutrition, Wernicke's
encephalopathy results from a deficiency of thiamine (vitamin
B1) and is manifested by confusion, ophthalmoplegia (paralysis
of the eye muscles), or convulsions , esophageal rupture,
pneumomediastinum (presence of air or gas in the mediastinum),
vasospasms of cerebral arteries, rhabdomyolysis (disintegration
of striated muscle fibers with excretion of myoglobin in the
urine), deconditioning, splenic avulsion, peripheral neuropathy
due to vitamin B6 and B12 deficiency, and coagulopathy due to
vitamin K deficiency. Depression is a common secondary
complication of HG. There is also a side effect of constipation.
For the fetus
No long-term follow-up studies have been conducted on
children of hyperemetic women. Children born to hyperemetic
women appear to have no greater risk of complications or birth
defects than the general population. However, recent research in
fetal programming indicates that prolonged stress, dehydration
and malnutrition during pregnancy can put the fetus at risk for
chronic disease, such as diabetes or heart disease, later in life, or
neurobehaviorial issues from birth. This underscores the
importance of aggressive treatment of the condition.
Diagnosis and investigations
 The diagnosis of hyperemesis is only made
after exclusion of other pathology
• Obtain detailed history including any
maternal disease or conditions related to nausea
and vomiting
• Clinical assessment for signs of dehydration
• Exclude maternal disease, molar or multiple
pregnancy
Investigations are required to determine the degree of
physiological disturbance and to exclude significant
pathology if indicated by history and examination.

Ward urinalysis, microurine and culture

Blood for urea, electrolytes and serum creatinine
Blood sugar if diabetic
Liver function tests (specific hepatitis serology if
indicated)
Thyroid stimulating hormone, free T4 level to
exclude thyrotoxicosis
Serum amylase if pancreatitis considered
Obstetric ultrasound to confirm ongoing pregnancy
and exclude multiple pregnancy or hydatidiform mole
Abdominal erect and supine x-rays if suspected
bowel obstruction
Exclusion of other pathology before diagnosis of hyperemesis
gravidarum
Possible cause
Urinary tract infection
Gastroenteritis
Drug induced vomiting
Multiple pregnancy
Hydatidiform mole
Diabetic ketoacidosis
Hepatitis
Addison's disease
Thyrotoxicosis
Pancreatitis
Bowel obstruction
Raised intracranial pressure
Investigations if indicated by history and
examination
Urinalysis, microurine, urine culture
Stool culture
Obstetric ultrasound
Obstetric ultrasound
Urinalysis, electrolytes, blood sugar level
Liver function tests
Specific hepatitis serology
Electrolytes, creatinine
Thyroid stimulating hormone, free T4
level
Serum amylase
Erect / supine abdominal X-ray with
appropriate shielding
MRI or CT head
Treatment
Intravenous rehydration
 Intravenous fluid replacement: usually 2 litres of sodium
chloride 0.9 % with each litre given over 2 to 3 hours. This may
be reduced but should not be exceeded according to assessment
of fluid balance. Potassium containing fluids should be used
depending on the most recent electrolyte measurement.
 This is the most important component of management
 Use electrolyte solutions containing sodium- and
potassium to correct the hyponatremia + / - hypokalemia
 It is recommended glucose is avoided as it may
precipitate Wernicke's encephalopathy (Bergin 1992). If glucose
is used, thiamine (100 mg once daily either orally or
intravenous) should be given to prevent this.
 Antiemetics
Metoclopramide (Maxolon) - 10 mg tablets, one tablet taken
three times a day. Side effects may include extrapyramidal signs
and oculogyric crises
Doxylamine (Restavit) - 25 mg tablets, one at night.
Doxylamine with Vitamin B6 (Diclectin) is the only medication
approved in Canada for nausea and vomiting in pregnancy
(Category A)
Promethazine theoclate (Avomine) - 25 mg morning and night.
Side effects include sedation
Prochlorperazine (Stemetil) - Suppositories, 25 mg once or
twice daily for severe, persistent and uncontrolled hyperemesis
gravidarum, not relieved by the above treatment
Promethazine and prochlorperazine - Category C for use in
pregnancy, as when used in large doses late in pregnancy, they
have been associated with extrapyramidal side effects in the
infants after birth
Vitamins
 Studies report pyridoxine (vitamin B6) significantly
reduces nausea, but there was no significant reduction in
vomiting (Sahakian 1991;Vutyavanich 1995)
 Pyridoxine - 25 mg tablets, one tablet taken three
times a day
Observations
Temperature, pulse, respiratory rate and blood pressure on
admission and every two hours during intravenous fluid
treatment.