1. Nausea and Vomiting of Pregnancy
Dr. Bara’a Lukman Humo AL_Ibrahim
FABOG/FIBOG/DGO

2. is the symptom of nausea &/ or vomiting during early pregnancy where there is no other causes
It is often called morning sickness’ but it can occur at any time of the day or night.
Affect up to 80% of pregnant women
1-3% have sever nausea and vomiting of pregnancy which is hyperemesis gravidarum

3. It typically starts between 4th and 7th week of pregnancy, peaks in approximately the 9th week and resolve by 20th week in approximately 90% of women.
In many cases it resolves by the end of the first trimester
7% have symptoms before the time of first missed period.
20% continue to have symptom through out their pregnancy

4. Associations common to nausea and vomiting of pregnancy:
Family history
Female gender of fetus
History of migraine
Multiple gestation
Down syndrome
Molar gestation

5. Hyperemesis gravidarum
Hyper means ‘over’, Emesis means ‘vomiting’ and Gravidarum means ‘pregnancy’.
HG can be diagnosed when there is protracted NVP with the triad of more than 5% prepregnancy weight loss, dehydration and electrolyte imbalance.
It affects ~ 1-3 % of pregnant woman.
It occurs more in multiple and molar pregnancy.

6. Hyperemesis Gravidarum
NVP
Hyperemesis Gravidarum
Common
Rare
Confined to meals
Repeated throughout day
severe and persistent
Does not affect general condition
Affects general condition
weight loss, dehydration, nutritional deficiencies, electrolyte imbalance, and possible liver damage
Resolves around 12 weeks
even without treatment
Progressive course even fatal unless effective treatment
Often persists for the duration of pregnancy
Rarely needs hospitalization
Always requires hospitalization
Need oral fluid
Need enteral or parenteral fluid

7. Etiology and pathophysiology:
The pathogenesis is poorly understood and the etiology is likely to be multifactorial
hormonal effect: mainly hCG and to lesser extend estradiol.
This is the most accepted theory and proved by the higher frequency in the conditions where the hCG is high, such as in:
early in pregnancy
vesicular mole and
multiple pregnancy

8. cytokines: The consistent finding has been an increased concentration of TNF_α which is involved in regulation of hCG production, suggesting a possible link to hCG – hormones hypothesis
genetic factor: the siblings of patients affected by NVP are ,more likely to be affected.
psychological factor may play a role.

9. Symptoms of Severe Nausea
The patient cannot retain anything in her stomach, vomiting occurs through the day and night even without eating.
Thirst, constipation and infrequent urination.
In severe cases, vomitus is bile and/ or blood stained.
Finally, there are manifestations of Werniche’s encephalopathy as drowsiness, nystagmus and loss of vision then coma.

10. A common associated symptom is Ptyalism- (the inability to swallow saliva), an increased olfactory and gustatory aversion and change in the taste sensitivity.

11. Signs Manifestations of starvation and dehydration include:
Loss of weight
Sunken eyes
Dry tongue dry mucous membranes, and inelastic skin
Gums covered with sores
Breath acetone smell
Late, slight jaundice
Pulse: rapid and weak
Blood pressure: low
Temperature: slight rise

12. Remember that:
NVP begins before weeks’ gestation. Symptoms that begin after this gestational age are due to other causes.
Abdominal pain is not a prominent feature of NVP.
Fever is not present in NVP, but is characteristic of many other disease associated with nausea and vomiting.

13. Risk associated with it:
Fetal growth restriction. Women with severe NVP or HG who have continued symptoms into the late second or the third trimester should be offered serial scans to monitor fetal growth.
Maternal hyponatraemia leading to central pontine myelinolysis.
Thiamine deficiency leading to Wernicke’s encephalopathy.

14. Investigation
Pack cell volume (PCV):This may be elevated because of volume depletion.
General urine examination (GUE) including testing for ketones and specific gravity.
Serum electrolytes.
Renal function test (RFT)
Liver function test (LFT)
Thyroid function test (TFT)
Ultrasound to exclude molar or twin pregnancy

15. Differential Diagnosis:
Other pathological causes should be excluded by clinical history, focused examination and investigations.
Other pathological causes of nausea and vomiting include peptic ulcers, cholecystitis, gastroenteritis, hepatitis, pancreatitis, genitourinary conditions such as urinary tract infection or pyelonephritis, metabolic conditions, neurological conditions and drug-induced nausea and vomiting.

16. Treatment
The management of nausea and vomiting of pregnancy depends on the severity of the symptoms. Treatment measures range from dietary changes to more aggressive approaches involving hospitalization, or even total parenteral nutrition (TPN).

17. Most women with nausea and vomiting in pregnancy can be successfully managed in primary care. Judicious assessment enables recognition of women whose symptoms are severe and intractable despite treatment with oral antiemetics, who are unable to maintain oral hydration and have ketonuria, and who therefore require referral to hospital
Exclude other causes of nausea and vomiting:
Urinary tract infection
Thyrotoxicosis
Cholecystitis

18. Admission to hospital for sever cases
Adequate rehydration (normal saline + K) sufficient to correct tachycardia, hypotension, ketonuria and return electrolyte level to normal. This is the most important component of management.

19. Antiemetic drugs
Cyclizine.
Stemetil 5 mg,8 hourly orally or 12.5 mg, 8 hourly IV, IM
Metoclopramide 10 mg, 8 hourly orally, or 10 mg, 8 hourly IV, IM
Promethazine.

20. Combinations of different drugs should be used in women who do not respond to a single antiemetic.
For women with persistent or severe HG, the parenteral or rectal route may be necessary and more effective than an oral regimen.
Women should be asked about previous adverse reactions to antiemetic therapies. Drug-induced extrapyramidal symptoms and oculogyric crises can occur with the use of phenothiazines and metoclopramide. If this occurs, there should be prompt cessation of the medications.

21. Oral → 25 - 50 mg, 8 hourly IV → 100 mg in 100 ml N.S., 60 min
Prophylactic thiamine:
Oral → mg, 8 hourly
IV → 100 mg in 100 ml N.S., 60 min
Steroid treatment: For women with severe hyperemesis gravidarum who do not improve despite conventional treatment with IV fluid & regular antiemetics, a trial of corticosteroid may be considered.
Ondansetron(5HT3 antagonist) may also have a role in exceptional cases but clear evidence of safety in first trimester is still awaited.

22. Iron supplementation better to be avoided.
In the severest cases, total parenteral nutrition is given , but this is very rare.
In the very worst cases, termination of pregnancy may be considered.

23. General advice: Eat small frequent meals (6 meals)
Separate fluid from solid by consuming fluid in between meals
Brushing teeth after eating may help prevent symptoms.
Avoid lying down immediately after eating .
Rest after meals. Sit up in a chair for about an hour after meals.
Avoid these foods: Fatty, greasy, or fried – Spicy or hot –– foods with strong odors, like broccoli, cabbage, fish, etc.
Eat easily digested starches such as rice, potatoes, cereal and bread.
Pick low fat protein foods: lean beef, skinless chicken, eggs, and boiled beans.

24. Emotional Support
A woman’s quality of life can be adversely affected by NVP and HG and practitioners should address the severity of a woman’s symptoms in relation to her quality of life and social situation
It is important that these women receive appropriate support from family members and medical and nursing staff.
Consultation is indicated if a pregnant woman is depressed, domestic violence is suspected, or evidence of substance abuse or psychiatric illness exists.