HYPEREMESIS GRAVIDARUM

DEFINITION:
Hyperemesis gravidarum(HG) means "excessive vomiting during pregnancy ".
HG has been technically defined as more than three episodes of vomiting per day such that
weight loss of 5% or three kilograms has occurred and ketones are present in the urine. HG is
the severe form of normal vomiting of pregnancy (NVP), which affects about 0.3–3.6% of
pregnant women. The aetiological theories for NVP and HG range from the fetoprotective and
genetic to the biochemical, immunological and biosocial.
RISK FACTORS: PRESENTATION:

 Signs of dehydration including decreased urine

History of
 Hyperemesis in a previous pregnancy
 nausea and vomiting while taking estrogen
preparations (as in birth control pills)
 menstrual migraines
 motion sickness
 gastrointestinal problems (ie, reflux, ulcers)
output, dark-colored urine, or dizziness with
standing
 Repeated and continuous vomiting, presence of
blood in the vomitus
 Abdominal or pelvic pain or cramping
 Unable to retain any food or drinks for more than 12
hours

. TREATMENT GOALS
 Determine the severity of disease and correct dehydration.
 Reduce symptoms by changing her diet and begin medication, in a step- wise approach.
 Prevent serious complications including electrolyte imbalance, vitamin deficiency (eg,
Wernicke encephalopathy) and weight loss.
 Minimize the fetal effects of hyperemesis and its treatment.
DIAGNOSIS:
 Typically starts between the 4th and 7th weeks of gestation, peaks in 9th week ninth
week and resolves by the 20th week in 90% ofwomen.
 Protracted vomiting with the triad of more than 5% prepregnancy weight loss
dehydration and electrolyte imbalance.
 An objective and validated index such as the Pregnancy-Unique Quantification of
Emesis (PUQE) score and Rhodes index can be used to classify the severity of NVP.

INITIAL ASSESMENT:
Look for -hyponatraemia, hypokalaemia, low serum urea, raised haematocrit and ketonuria
with a metabolic hypochloraemic alkalosis.
Urea and serum electrolyte levels should be checked daily
The biochemical thyrotoxicosis resolves as the HG improves
Liver function tests are abnormal in up to 40%, most likely transaminases being raised.
Ultrasound to confirm viability, for gestational age, as well as to rule out multiple pregnancy or
trophoblastic disease.
Unless there are other medical reasons for an urgent scan, this can be scheduled later.
DIFFERENTIAL DIAGNOSIS:
In presence of severe abdominal/epigastric pain
 Peptic ulcers, cholecystitis,
 Gastroenteritis, hepatitis, pancreatitis,  Serum amylase
genitourinary conditions such as urinary tract  Abdominal ultrasound, and possibly
 Infection or pyelonephritis,  Esophageal gastro duodenoscopy,
 Metabolic conditions,
 Neurological conditions and Rarely- testing for H. pylori antibodies
 Drug-induced nausea and vomiting.

MANAGEMENT:
Women with mild symtoms (no dehydration) should be managed in the community with
antiemetics, support, reassurance, oral hydration and dietary advice
Inpatient management : should be considered if there is at least one of the following:
 Inability to tolerate oral antiemetics
 Ketonuria and/or weight loss (> 5% of body weight), despite oral antiemetics
 Confirmed or suspected comorbidity (such as UTI and inability to tolerate oral
antibiotics).
Recommended antiemetic therapies and dosages
First line Second line Third line
 Cyclizine 50 mg PO, IM or  Metoclopramide 5–10 mg  Corticosteroids:
IV 8 hourly 8 hourly PO hydrocortisone 100 mg
 Prochlorperazine 5–10 mg twice daily IV
 Metoclopramide 5–10 mg
 Convert to prednisolone
6–8 hourly PO; 12.5 mg 8 8 hourly PO, IV or IM
40–50 mg daily PO,
hourly IM/IV; 25 mg PR/day (maximum 5 days’
 Gradually tapered to
 Promethazine 12.5–25 mg duration) lowest maintenance dose
4–8 hourly PO, IM, IV or PR  Domperidone 10 mg
8 hourly PO; 30–60 mg 8
 Chlorpromazine 10–25 mg
hourly PR
4–6 hourly PO, IV or IM; or
 Ondansetron 4–8 mg
50–100 mg 6–8 hourly PR
6–8 hourly PO; 8 mg over
15 minutes 12 hourly IV

Best rehydration regimen for ambulatory daycare and inpatient

management
Normal saline with additional potassium chloride in each bag, with administration guided
by daily monitoring of electrolytes, is the most appropriate intravenous hydration.
Dextrose infusions are not appropriate unless the serum sodium levels are normal and thiamine
has been administered.
Additional therapies
Histamine H2 receptor antagonists or proton pump inhibitors may be used for women
developing gastro- oesophageal reflux disease, oesophagitis or gastritis.
Thiamine supplementation (either oral or intravenous) should be given to all women
admitted with prolonged vomiting, especially before administration of dextrose or
parenteral nutrition.
Consider avoiding iron-containing preparations if these exacerbate the symptoms.
When all other medical therapies have failed, enteral or parenteral treatment should be
considered with a multidisciplinary approach.
TERMINATION OF PREGNANCY:
HG not an indication for MTP The Hyperemesis Education and Research (HER) Foundation in the
USA reports that 10% of pregnancies complicated by HG end in termination in women who
would not otherwise have chosen this.
Discharge and follow-up:
Women are advised to continue with their antiemetics where appropriate and that they know
how to access further care if their symptoms recur
Psychological and social support should be organised
Women with previous HG should be advised that there is a risk of recurrence
Early use of lifestyle/dietary modifications and antiemetics that were found to be useful in the
index pregnancy is advisable to reduce the risk