Understanding Hyperemesis Gravidarum: Causes, Diagnosis, and Management in Pregnancy

1. Vomiting in pregnancy Dr sadiqa

2. Learning objectives • Define hyperemesis gravidarum • Etiology • Diagnosis • Other causes of vomiting • Select appropriate investigation • Complications of HG • Outline the management of HG

3. Hyperemesis Gravidarum • Definition : sever type of vomiting of pregnancy which has got deleterious effect on the the health of the mother and /or incapacitates her in day to day activities.

4. Incidence: 0.8-1.5% now less reduction in unplanned preg better application of FPM potent antihistaminics

5. Aetiology • Endocrine - Hcg, Estrogen, progesterone, PRL • Infection - helicobacter pylori • Upper GI dysmotility • Psychological • Dietetic deficiency –B6 B1 • Familial predisposition

6. Pathology • Vomiting – dehydration – carbohydrate starvation – depletion of glycogen stores – mobilization of fat stores- production of ketone bodies – excreted thro’ urine & breath. • Increased tissue protein metabolism- increased BUN • Prolonged vomiting - hypoglycemia, hypokalemia hyponatremia , hypoproteinemia.

7. Biochemical : Alkalosis, Hyponatremia, Hypokalemia Hypochloremia. • Brain : Small Hge in the hypothalamus • Liver :transient hepatic dysfunction-cetrilobular fatty infiltration with out necrosis. • Kidney : ARF can develop due to dehydration. • Vascular : Hemo-concentration, mild leucocytosis, eosinophelia

8. Clinical features • Vomits frequently prolonged and severe, strong aversion for food and Ptyalism. • Diminished quantity of urine • Epigastric pain • Constipation

9. Signs of dehydration • Dry coated tongue • Sunken eye, rise in temp • Loss of skin turgor • Ketotic odour of breath • Loss of skin elasticity • Tachycardia / Hypotension • 5% wt. loss may be there • Severe case jaundice may develop.

10. Causes of vomiting • Related to pregnancy: morning sickness (emesis gravidarum) hyperemesis gravidarum continuation / reapprearance of vomiting acute fulminant preeclampsia

11. Causes of vomiting • Associated with pregnancy: Medical: UTI, hepatitis, diabetic ketoacidosis, pylelonephritis, intestinal infestation, uremia. Surgical: appendicitis, peptic ulcer, cholecystitis, pancreatitis, intestinal obstruction. Gynecological : twisted ovarian tumor, red degeneration of fibroid.

12. Investigation • Urine analysis: quantity – small, dark color high sp gravity presence of acetone absence of chloride

13. Raised hematocrit • BUN – S creatinine • S. electrolyte • LFT • TFT : transient phase of thyroid dysfunction • USG –Viability no. of fetus, Role out molar Adnexal pathology • Retinal Hge, Retinal detachment • ECG

14. Complications • Electrolyte imbalance • Liver dysfunction • Depression • Hyperalimentation • Diaphramatic rupture • Esophageal rupture (Boerhaave syn.) • Acute kidney injury

15. Mallory Weiss tears • wernicke’s encephalopathy • Pontine mylinosis • Peripheral neuritis • Hypoprothrombenemia - Vit K def. • Korsakoff’s psychoses

16. Management • Maintenance of hydration • Control vomiting-promethazine,triflupromazine vitB6,doxylamine, metaclopromide • Correct fluid & electrolyte imbalance • Prevent complications • Care of pregnancy