Severe vomiting: Hyperemesis Gravidarum

Nausea with or without vomiting is common in early pregnancy. Severe vomiting resulting in dehydration and weight loss is termed hyperemesis gravidarum and occurs infrequently. Symptoms usually resolve by mid pregnancy regardless of severity and therapy. Management of affected women depends upon the impact of her symptoms on her health.

Vomiting is a symptom which may be related to pregnancy or may be a manifestation of some medical-surgical-gynecological complications which can occur at any time during pregnancy. The vomiting is most of the time related to the pregnant state and is classified as simple vomiting of pregnancy (milder type) and hyperemesis gravidarum (severe type)

Hyperemesis gravidarum is a severe type of vomiting of pregnancy which has got deleterious effect on the health of the mother and incapacitates her in day to day activities. There has been marked fall in the incidence during the last 30 years. Now the incidence is less than one in 1000 pregnancies. The reasons are better application of family planning knowledge which reduces the number of unplanned pregnancies, early visit to the antenatal clinic and the availability of potent antihistaminic and antiemetic drugs. 

Theories of hyperemesis gravidarum

Hormonal: Excess of chorionic gonadotrophin, proved by the frequency of vomiting at the peak level of HCG and also the increased association with hydatidiform mole or multiple pregnancy when the HCG titer is very much raised.

Psychogenic: It probably aggravates the nausea once it begins.

Dietetic deficiency: Probably due to low carbohydrate reserve, as it happens after a night without food. Deficiency of vitamin B6, Vitamin B1 and proteins may be the effects rather than the cause.

Allergic: May be related to some products secreted from the ovum

Immunological basis.

Risk factors for hyperemesis gravidarum

A risk factor is something that increases a person’s chance of getting a disease or condition. Risk factors do not necessarily mean that a person will develop a condition. 

In the case of hyperemesis gravidarum, the following are risk factors:

Hyperemesis gravidarum during a previous pregnancy

Being overweight

Having a multiple pregnancy

Being a first-time mother

The presence of trophoblastic disease, which involves the abnormal growth of cells inside a woman's uterus

Main symptoms

Hyperemesis gravidarum usually occurs in the first pregnancy and in the early months of pregnancy. The onset is insidious. 

Vomiting occurs independent of food, spread throughout the day and everything taken in is rejected. The vomiting consists of bile stained fluid or only food.

Normal activities are curtailed.

Nutrition of the mother is good.

On examination, she looks well and no abnormality is detected

Blood investigations and urine analysis is normal

Physical findings

Progressive emaciation with loss of weight

Anxious look

Eyes-sunken, apathetic and becoming dull

Skin is lusterless and inelastic

Tongue-dry, becoming brown, thickly coated or red and raw

Teeth covered with sores

Breath acetone smell

Pulse is rapid (100-120 per minute)

Low blood pressure

Jaundice is a late feature

Final stage

Vomiting is increased in amount and in frequency. Retching and nausea persist in between vomiting. The vomitus may be coffee ground or even contain blood.

Urinary quantity is diminished

Constipation, at times diarrhea.

Epigastric pain

The patient is confined to bed

Mental apathy, restlessness, sleeplessness, convulsion or even coma.

Mental confusion with loss of memory to recent events

Features of peripheral neuritis

Eye complications- double vision, dimness of vision or even blindness

Beware…!

Steady deterioration of the patient

A rising pulse rate of 100/minute or more

Increasing oliguria (reduction in the quantity of urine)

Appearance of jaundice

Appearance of neurological complications

Wii cause the termination of pregnancy

Hyperemesis gravidarum treatment

The type of treatment that is required depends on how ill a woman becomes. 

Possible treatments might include:

Preventive measures—These might include a pressure-point wristband — similar to those used for motion sickness — vitamin B6, and/or ginger.

Small frequent meals—Nausea and vomiting might be treated with dry foods (such as crackers), small frequent meals, and emotional support.

Intravenous fluids—It is important for a pregnant woman to maintain her fluid intake. IV fluids might be needed if a woman continues to vomit throughout pregnancy. In severe cases, the woman might require hospitalization and given IV fluids. IV fluids might be discontinued when a woman is able to take in fluids by mouth.

Total parenteral nutrition—The most severe cases of hyperemesis gravidarum might require that complex, balanced solutions of nutrients be given through an IV throughout pregnancy. This is called total parenteral nutrition (TPN).

Medicines—Medicine to prevent nausea is used when vomiting is persistent and poses possible risks to the mother or baby. If a woman cannot take medicines by mouth, the drugs might be administered through an IV or a suppository. Medicines used to prevent nausea include Promethazine, Meclizine, and Droperidol.

Although there are no known ways to completely prevent hyperemesis gravidarum, the above measures might help keep morning sickness from becoming severe