Hyperemesis Gravidarum

SIMPLE VOMITING ( MORNING SICKNESS, EMESIS GRAVIDARUM)

 

Slight nausea and vomiting is so common in early pregnancy(50%) that is considered as a symptom of pregnancy. The vomitus is small, 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 12-14^th week of pregnancy.

 

Management: Assurance is important. Taking dry toast or biscuit and avoidance of fatty and spicy foods are enough to relieve the symptoms in majority. If the simple measures fail, antiemetic drugs – trifluoperazine 1mg twice daily and phenobarbitone 30-60mg at bedtime are quite effective. Patient is advised to take plenty of fluids (2.5L in 24hours) and fruit juice.

 

 

HYPEREMESIS GRAVIDARUM

 

Definition: It is a severe type of vomiting in pregnancy which has got deleterious effect on the health of the mother and incapacitates her in day to day activities.

 

Incidence: Less than 1 in 1000 pregnancies.

 

Etiology: Exact etiology is unknown but the following are the known facts.

1. it is mostly limited to the first trimester
2. it is more common in first pregnancy with a tendency to recur again
3. It has got familial history ( mother and sisters)
4. it is more prevalent in hydatidiform mole and multiple preganancy
5. it is more common in unplanned pregnancy

 

Theories

1. Hormonal
• Excess of human chorionic gonadotrophin or higher biological activity of hCG.
• Progesterone excess leading to relaxation of the cardiac sphincter and simultaneous retention of gastric fluids due to impaired gastric motility.
2. Psychogenic: It aggravates nausea once it begins.
3. Dietic deficiency: Probably due to low carbohydrate reserve as it happens after a night without food.
4. Allergic or immunological basis
5. Decreased gastric motility is also found to cause nausea.

 

Metabolic, Biochemical and Circulatory Changes

 

Metabolic: Inadequate intake of food results in glycogen depletion. For the energy supply the fat reserve is broken down. Due to low carbohydrate there is incomplete oxidation of fat and accumulation of ketone bodies in the blood. The acetone is ultimately excreted through the kidneys and in the breath. Water and electrolyte metabolism are seriously affected leading to biochemical and circulatory changes.

 

Biochemical: Loss of water and salts in the vomitus results in fall in plasma sodium, potassium and chlorides. Hepatic dysfunction results in acidosis and ketosis with rise in blood urea and uric acid.

 

Circulatory: There is haemoconcentration leading to rise in hemoglobin percentage and haematocrit values. There is concomitant reduction of extracellular fluid.

 

 

Clinical Features

 

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.

 

Symptoms: Vomiting is increased in frequency with retching. Urine quality is diminished even to the stage of oliguria. Epigastric pain, constipation may occur. Complications may appear if not treated.

 

Signs: Features of dehydration and ketoacidisis like dry coated tongue, sunken eyes, acetone smell of breath, tachycardia, hypotension, rise in temperature, jaundice.

 

Investigations

 

• Urinanalysis: Quantity-small, dark coloured, high specific gravity, presence of acetone, diminished or absence of chloride.
• Biochemical and Circulatory changes: Routine and periodic estimation of Serum electrolytes ( Sodium, Potassium, Chloride)
• Ophthalmoscopic examination: Retinal hemorrhage and detachment
• ECG when there is abnormal serum potassium level.

 

Management

 

The principles of management are:

1. To control vomiting
2. To correct the fluid, electrolyte and other metabolic disturbances
3. To prevent or detect at the earliest, the complications that may arise.

 

§  Hospitalization: When hospitalized, surprisingly with the same diet and drugs used at home, the patient improves rapidly.

 

§  Fluids: Oral feeding is withheld for atleast 24hours 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 3litres, of which half is 5% Dextrose and half is Ringer’s Solution. Extra amount of 5% dextrose equal to the amount of vomitus and urine in 24hours is to be added.  

 

With this regime dehydration, ketoacidosis, water and electrolyte imbalance are likely to be rectified. Enteral nutrition through nasogastric tube can also be given.

 

§  Drugs:

 

- Antiemetic drugs like:

1.      Promethazine (Phenargan) 25mg or

2.      Prochlorperazine (Stemetil) 5mg or

3.      Triflupromazine (Siquil) 10mg may be administered twice or thrice daily.

4.      Metachlopramide stimulates gastric and intestinal motility without stimulating the secretions and is also useful.

-        Hydrocortisone 100mg IV drip is given in a case with hypotension or in intractable        vomiting.

-          Nutritional support with Vitamin B1, Vit B6, Vit C and Vit B12 are given.