History

Fact Explanation
Severe nausea and vomiting Hyperemesis gravidarum is defined as uncontrolled vomiting leading to severe dehydration, muscle wasting, electrolyte imbalance, ketonuria, weight loss of more than 5% of body weight & requiring hospitalization.[1] It has an incidence of 0.3% to 2% of all pregnancies. [2] Nausea and vomiting is common during pregnancy which is currently believed to be multi-factorial in origin. The trophoblastic hormone - human chorionic gonadotrophin(hCG) plays an important role in the pathogenesis.
Anorexia This can lead to reduced food intake even leading to starvation.[3]
Weight loss The prolonged loss of fluids and inability to take & maintain a regular food intake leads to weight loss. A weight loss of more than 5% of the pre pregnancy weight is a predictor of maternal and fetal complications.[4]
Dizziness and syncope The severe dehydration associated with prolonged vomiting can result in a hypovolemic state which can lead to cerebral hypo-perfusion.[3]
Low urine output The severe dehydration associated with vomiting can result in a hypovolemic state.[3]
Symptoms of complications Patients with hyperemesis gravidarum can develop complications due to electrolyte imbalances, severe dehydration and also mechanical complications due to prolonged vomiting. Possible complications are : Wernicke’s encephalopathy causing restlessness, insomnia, seizures, unconsciousness; Korsakoff’s psychosis causing confusion, amnesia; Mallory Weiss syndrome causing hematemesis and ophthalmic complications causing blindness, blurring of vision, diplopia. [5]
References
  1. WEGRZYNIAK LJ,REPKE JT,URAL SH. Treatment of Hyperemesis Gravidarum. Reviews in Obstetrics Gynecology, 2012, 5(2), 78–84.
  2. KLEBANOFF MA, KOSLOWE PA, KASLOW R, RHOADS GG. Epidemiology of vomiting in early pregnancy. Obstetrics and Gynecology, 1985 Nov, 66(5), 612-6.
  3. PHILIP B. Hyperemesis Gravidarum: Literature Review. wisconsin medical journal, 2003, 103(3), 46-51.
  4. GROSS S, LIBRACH C, CECUTTI A. Maternal weight loss associated with hyperemesis gravidarum: a predictor of fetal outcome. American Journel of Obstetrics and Gynecology. 1989 Apr, 160(4), 906-9.
  5. ARULKUMARAN Sabaratnam, et al. Essentials of obstetrics. 2nd ed. New Delhi : Jaypee Brothers Medical Publishers, 2011.

Examination

Fact Explanation
Features of severe dehydration Anxious or confused appearance, sunken eyes, loss of skin elasticity, dry tongue, oliguria. weight loss >5% of total pre pregnancy body weight.[1]
Ketotic 'sickly sweet' odor of breath Starvation associated with the severe vomiting leads to depletion of glycogen stores in the patient. This leads to mobilization of lipid stores for generation of energy which produces ketone bodies.[2]
Tachycardia and hypotension Due to severe dehydration causing hypovolemia.[2]
Fundus larger than dates Assessment of the symphysio-fundal height (SFH), a height larger than weeks of gestation is seen in twin and molar pregnancy. These two conditions are associated with hyperemesis gravidarum due to the increased production of hCG from the increased placental mass. [3]
References
  1. ISMAIL SITI KHADIJAH, KENNY LOUISE. Review on hyperemesis gravidarum. Best Practice & Research Clinical Gastroenterology [online] 2007 October, 21(5):755-769 [viewed 12 September 2014] Available from: doi:10.1016/j.bpg.2007.05.008
  2. ARULKUMARAN Sabaratnam, et al. Essentials of obstetrics. 2nd ed. New Delhi : Jaypee Brothers Medical Publishers, 2011.
  3. The Management of Nausea & Vomiting of Pregnancy. The Society of Obstetricians and Gynaecologists of Canada, October 2002 [ Viewed 30 March 2014]. Available from : http://sogc.org/wp-content/uploads/2013/01/120E-CPG-October2002.pdf

Differential Diagnoses

Fact Explanation
Alternative non- obstetric causes Hyperemesis gravidarum occurs between 9 and 20 weeks of gestation. Other diseases should be considered when vomiting occurs after 20 weeks gestation.[1]Clinical features which may suggest an alternative diagnosis include severe abdominal pain or tenderness, prominent urinary symptoms, fever, headache or abnormal neurological findings etc.[2]
Gastrointestinal diseases Gastritis, peptic ulcer disease, acute pancreatitis, Intestinal obstruction, hepatitis, cholelithiasis, appendicitis.[3]
Genito-urinary conditions Urinary tract infection, pyelonephritis, ovarian torsion.[3]
Other pregnancy-related conditions Acute fatty liver of pregnancy; in addition onset of nausea and vomiting in the second half of pregnancy can be a presenting feature of pre-eclampsia.[3]
Metabolic disorders and endocrine conditions Hypercalcaemia, hyperthyroidism, diabetic ketoacidosis, Addison's disease may also cause vomiting.[3]
Neurological disorders Vestibular disease, migraine.[3]
Drug-induced vomiting Drugs which can cause vomiting include iron, opioid analgesics and antibiotics such as erythromycin.[3]
References
  1. ARULKUMARAN Sabaratnam, et al. Essentials of obstetrics. 2nd ed. New Delhi : Jaypee Brothers Medical Publishers, 2011.
  2. Nausea/vomiting in pregnancy. National institute for health and care excellence. June 2013 [ Viewed on 31 March 2014]. Available from : http://cks.nice.org.uk/nauseavomiting-in-pregnancy#!background
  3. ELIAKIM R, ABULAFIA O, SHERER DM. Hyperemesis gravidarum: a current review. Am J Perinatol [online] 2000, 17(4):207-18 [viewed 12 September 2014] Available from: doi:10.1055/s-2000-9424

Investigations - for Diagnosis

Fact Explanation
The diagnosis of hyperemesis gravidarum is usually based on the clinical presentation of severe vomiting during early pregnancy. It is a diagnosis of exclusion.[1] Investigations are used to assess the severity of the condition and to exclude a secondary etiology.
Ultrasound scan Used to exclude multiple pregnancy and gestational trophoblastic disease.[2]
Urinalysis Helps in determining the presence/absence of ketone bodies in urine and assessment of the degree of ketosis. Additional information that can be gauged include exclusion of a urinary tract infection, elevation of specific gravity of urine.[3]
References
  1. ARULKUMARAN Sabaratnam, et al. Essentials of obstetrics. 2nd ed. New Delhi : Jaypee Brothers Medical Publishers, 2011.
  2. The Management of Nausea & Vomiting of Pregnancy. The Society of Obstetricians and Gynaecologists of Canada, October 2002 [ Viewed 30 March 2014]. Available from : http://sogc.org/wp-content/uploads/2013/01/120E-CPG-October2002.pdf
  3. ELIAKIM R, ABULAFIA O, SHERER DM. Hyperemesis gravidarum: a current review. Am J Perinatol [online] 2000, 17(4):207-18 [viewed 12 September 2014] Available from: doi:10.1055/s-2000-9424

Investigations - Fitness for Management

Fact Explanation
Full blood count The degree of hemoconcentration can be assessed.[1]
Serum electrolytes Excessive loss of fluids and gastric contents can lead to electrolyte changes like hypokalemia, hypocalcaemia etc. Monitoring of serum electrolytes regularly is important in the management of hyperemesis gravidarum.[1]
Liver function test Transient disturbances can be seen during the acute stages.[1]
Thyroid function tests The placental hormone hCG is closely linked with the pathogenesis of hyperemesis gravidarum. This hormone is also known to have thyroid stimulating activity. Hyperthyroidism is known to occur in patients suffering from hyperemesis gravidarum due to the presence of a variant of hCG with increased thyroid stimulating activity. [2] This clinical condition is called ‘Transient hyperthyroidism of hyperemesis gravidarum’. Hyperthyroidism is also known to precipitate hyperemesis gravidarum.[3],[4]
References
  1. ELIAKIM R, ABULAFIA O, SHERER DM. Hyperemesis gravidarum: a current review. Am J Perinatol [online] 2000, 17(4):207-18 [viewed 12 September 2014] Available from: doi:10.1055/s-2000-9424
  2. ARULKUMARAN Sabaratnam, et al. Essentials of obstetrics. 2nd ed. New Delhi : Jaypee Brothers Medical Publishers, 2011.
  3. WEGRZYNIAK LJ,REPKE JT,URAL SH. Treatment of Hyperemesis Gravidarum. Reviews in Obstetrics Gynecology, 2012, 5(2), 78–84.
  4. WILSON R, MCKILLOP JH, MACLEAN M, WALKER JJ, FRASER WD, GRAY C, DRYBURGH F, THOMSON JA. Thyroid function tests are rarely abnormal in patients with severe hyperemesis gravidarum. Clinical Endocrinology (Oxf). 1992 Oct, 37(4), 331-4.

Management - General Measures

Fact Explanation
Patient education and counseling The patient should be educated on the condition, its natural course and etiology. The patient can be reassured that hyperemesis gravidarum per se is not associated with adverse fetal outcomes.[1],[2]
Thromboprophylaxis The severe dehydration associated with hyperemesis gravidarum can precipitate deep vein thrombosis. Adequate hydration, mobilization & use of lower limb stockings can prevent the occurrence of this.[3]
References
  1. ELIAKIM R, ABULAFIA O, SHERER DM. Hyperemesis gravidarum: a current review. American Journel of Perinatology, 2000, 17(4), 207-18.
  2. ARULKUMARAN Sabaratnam, et al. Essentials of obstetrics. 2nd ed. New Delhi : Jaypee Brothers Medical Publishers, 2011.
  3. BOTTOMLEY C, BOURNE T. Management strategies for hyperemesis. Best Practice & Research Clinical Obstetrics & Gynaecology, 2009 Aug, 23(4), 549-64.

Management - Specific Treatments

Fact Explanation
Hospitalization In-ward management is required in severe cases for monitoring of vital parameters, carrying out relevant investigations and management of complications.[1]
Intravenous hydration The mainstay of management of hyperemesis gravidarum is intravenous fluids to correct the fluid and electrolyte deficit. The main types of fluids used are the Hartmann’s solution and 0.9% physiological saline. Bolus doses followed by a maintenance should be used if the patient presents in a shock state. Dextrose containing solutions should only be used after administration of thiamine to avoid precipitation of Wernicke’s encephalopathy.[2]
Correction of electrolyte imbalances Correction of electrolyte imbalances can be achieved with use of IV solutions such as Hartmann’s. Serum electrolyte measurements should be monitored regularly. However correction of severe hypokalemia may need IV potassium supplementation. Rapid administration of replacement electrolytes should be avoided in order to prevent complications such as central pontine myelinolysis.[2]
Nutritional support Oral feeding is withheld until the patient is stable and no longer vomiting profusely. Feeding is started with small liquid meals and gradually increased to solids. Parental vitamins including thiamine is administered. Thiamine is required to prevent Wernicke’s encephalopathy. Pyridoxine( Vitamin B6) is also used with a dosage of 12.5mg to 25mg thrice a day.[3] Total parental nutrition is rarely required in extreme cases of hyperemesis gravidarum.[4]
Anti-emetic drug therapy. Control of vomiting can be achieved with anti-emetics such as dimenhydrinate, prochloperazine, metaclopramide, cyclizine. When administering a drug the safety profile should be considered. Category A,B,C drugs are safe to use in pregnancy. The above mentioned drugs are considered first line drugs in the management of vomiting in pregnancy.[5] The use of ondansetron is currently not recommended.
Use of steroids Steroids are used in extremely severe cases for control of vomiting. Steroids control vomiting by acting on the central vomiting centers.Further evaluation is required to recommend its routine use.[6]
Non pharmacological treatment options Certain non-pharmacological treatments have being used as adjuncts in the management of hyperemesis gravadarum. Ginger: the root of Zingiber officinale is used for control of vomiting. Acupuncture: used for the control of nausea,vomiting and retching. Out of the varies types of acupuncture, active PC6 acupuncture has being shown to provide symptomatic relief in these patients.[7] Medical hypnosis has also been effective in some cases.[8]
References
  1. ELIAKIM R, ABULAFIA O, SHERER DM. Hyperemesis gravidarum: a current review. Am J Perinatol [online] 2000, 17(4):207-18 [viewed 12 September 2014] Available from: doi:10.1055/s-2000-9424
  2. WEGRZYNIAK LJ, REPKE JT, URAL SH. Treatment of Hyperemesis Gravidarum Rev Obstet Gynecol [online] 2012, 5(2):78-84 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410506
  3. ARULKUMARAN Sabaratnam, et al. Essentials of obstetrics. 2nd ed. New Delhi : Jaypee Brothers Medical Publishers, 2011.
  4. WEGRZYNIAK LJ,REPKE JT,URAL SH. Treatment of Hyperemesis Gravidarum. Reviews in Obstetrics Gynecology, 2012, 5(2), 78–84.
  5. American College of Obstetrics and Gynecology, authors. ACOG (American College of Obstetrics and Gynecology) Practice Bulletin: nausea and vomiting of pregnancy. Obstetrics & Gynecology. 2004 Apr, 103(4), 803-14.
  6. NELSON-PIERCY C, FAYERS P, DE SWIET M. Randomised, double-blind, placebo-controlled trial of corticosteroids for the treatment of hyperemesis gravidarum. BJOG [online] 2001 Jan, 108(1):9-15 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11213010
  7. CARLSSON CP, AXEMO P, BODIN A, CARSTENSEN H, EHRENROTH B, MADEGåRD-LIND I, NAVANDER C. Manual acupuncture reduces hyperemesis gravidarum: a placebo-controlled, randomized, single-blind, crossover study. J Pain Symptom Manage [online] 2000 Oct, 20(4):273-9 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11027909
  8. SIMON EP, SCHWARTZ J. Medical hypnosis for hyperemesis gravidarum. Birth, 1999 Dec, 26(4), 248-54.