HYPEREMESIS GRAVIDARUM

DEFINITION It is a sever type of vomiting which has got deleterious effect on the health of the mother and/or incapacitates her in day-to-day activities

EFFECTS OF SEVERE VOMITING Dehydration Metabolic acidosis (from starvation) Alkalosis (from loss of hydrochloric acid) Electrolyte imbalance Weight loss

INCIDENCE Less than 1 in 1000 pregnancies Marked reduction in the incidence

ETIOLOGY Mostly limited to the first trimester More common in first pregnancy with a tendency to recur Has got familial history More prevalent in hydatidiform mole and multiple pregnancy More common in unplanned pregnancies Less among illegitimate ones

HORMONAL THEORIES PSYCHOGENIC DIETETIC DEFICIENCY Vitamin B6,B1 Increased HCG High serum level of estrogen Excess progesterone Thyroxin,prolactin and Adrenocortical hormone PSYCHOGENIC DIETETIC DEFICIENCY Vitamin B6,B1 ALLERGIC IMMUNOLOGICAL BASIS DECREASED GASTRIC MOTILITY

PATHOLOGY LIVER – Centrilobular fatty infiltration without necrosis KIDNEY – Fatty changes in the cells of convoluted tubule HEART – Subendocardial hemorrhage Brain – Wernicke’s encephalopathy

METABOLIC CHANGES Inadequate intake of food Glycogen depletion Fat reserve is broken down Inadequate oxidation of fat Accumulation of ketone bodies Acetone excreted through breath and kidney

METABOLIC CHANGES….Contd Increase in endogenous tissue protein metabolism Excessive excretion of non – protein nitrogen in the urine

CIRCULATORY CHANGES Fall in plasma sodium,pottasium and chlorides Acidosis and ketosis Rise in blood urea and uric acid Hypoglycemia Hypoproteinemia Hypovitaminosis Hyperbilirubinemia

BIOCHEMICAL CHANGES Haemoconcentration Rise in hemoglobin percentage Rise in RBC count Rice in haematocrit value

CLINICAL MANIFESTATION For the purpose of management the cases are grouped into: EARLY LATE

CLINICAL MANIFESTATION….Contd EARLY Vomiting occurs throughout the day Normal day to day activities are curtailed No evidence of dehydration and starvation

CLINICAL MANIFESTATION….Contd LATE SYMPTOMS Vomiting increase in frequency Retching Urine quantity diminished to the extend of oliguria Epigastric pain Constipation

CLINICAL MANIFESTATION….Contd LATE SIGNS Features of dehydration and ketosis Dry coated tongue Sunken eye Acetone smell in breath Tachycardia Hypotension Rise in temperature Jaundice is a late sign

INVESTIGATIONS URINALYSIS Quantity – Small Dark colour High specific gravity Presence of acetone and rarely protein Dimnished or absence of BIOCHEMICAL AND CIRCULATORY CHANGES OPHTHALMIC EXAMINATION Retinal haemorrhage and detachment of retina ECG

DIAGNOSIS Pregnancy is to be confirmed first USG

COMPLICATIONS Neurologic complications Wernicke’s encephalopathy Pontine myelinolysis Peripheral neuritis Korsakoff’s psychosis Stress ulcers in the stomach Esophageal tear Jaundice Convulsions and coma Renal failure

MANAGEMENT PRINCIPLES To control vomiting To correct fluid and electrolyte imbalance To correct metabolic disturbances To prevent serious complications

MANAGEMENT…..Contd HOSPITALISATION FLUIDS NPO status IV Fluids 3 liters of which Half is 5% dextrose and Half is RL DRUGS Antiemetic Promethazine 25mg Prochlorperazine 5mg Trifluopromazine10mg Hydrocortisone 100mg IV Nutritional support DIET

NURSING CARE HYPEREMESIS PROGRESS CHART Pulse Temperature Blood pressure Intake-output Urine for acetone,protein,bile Blood biochemistry ECG