Hyperemesis gravidarum (vomiting of pregnancy)
Vomiting is a symptom which may be related to pregnancy or may be a manifestation of some medical-surgical-gynaecological 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.
What are the causes of hyperemesis gravidarum?
What are the theories that explain hyperemesis gravidarum?
- It is mostly limited to the first trimester.
- It is more common in the first pregnancy, with a tendency to recur again in subsequent pregnancies.
- It has got a family history-mother and sisters also suffer from the same manifestation.
- It is more prevalent in hydatidiform mole and multiple pregnancies.
- It is more common in unplanned pregnancies but much less amongst illegitimate ones.
What are the symptoms in the patient with 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.
Hyperemesis gravidarum usually occurs in the first pregnancy and in the early months of pregnancy. The onset is insidious.
Early stage (only the activities are limited without evidence of dehydration or starvation)
Late stage( Evidences of dehydration and starvation are present)
- 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 in a mother who is suffering form hyperemesis gravidarum
- 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
Investigations to be done are:
- 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 sordes.
- Breath acetone smell
- Pulse is rapid (100-120 per minute)
- Low blood pressure
- Jaundice is a late feature
Complications of hyperemesis gravidarum
- Urine analysis
- Routing blood investigations and Serum sodium and potassium.
- Eye check up to rule out retinal hemorrhage or detachment.
These are due to effects of dehydration and starvation with resulting ketoacidosis
Prevention of hyperemesis gravidarum
- Wernicke's encephalopathy
- Peripheral Neuritis
- Korsakoff's psychosis
- Stress ulcers in stomach
The only prevention is to impart effective management to correct simple vomiting of pregnancy. Once the condition worsens, it is better to manage the patient in the hospital.
- Hospitalization: When a patient is stamped as a case of hyperemesis gravidarum, it is desirable to hospitalize the patient even in the early stage. Surprisingly, with the same diet and drugs used at home, the patient improves rapidly. The relatives may be too sympathetic or too indifferent. The mother should be cared by competent and tactful nurses.
- Fluids: Oral fluids are withheld for at least 24 hours after the vomiting stops. Fluid should be given intravenously during this period.
- Adequate sedation should be given.
- Antihistaminic and anti-emetic drugs like promethazine or prochlorperazine are used to control vomiting.
- Vitamins are used to prevent neuropathy.
- Hydrocortisone is used in cases of severe hypotension.
- Sympathetic caring of the patient is essential. Care of teeth, gums and oral hygiene is taken care. With these measures, the condition usually improves and patient is able to take oral feeds.
Nowadays, following medical management, termination of pregnancy has become rare event in a case of hyperemesis gravidarum.
The following are the indications for termination of pregnancy:
- 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