1. HYPEREMESIS GRAVIDARUM

2. 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

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

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

5. 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

6. 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

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

8. 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

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

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

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

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

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

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

15. 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

16. 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

17. DIAGNOSIS
Pregnancy is to be confirmed first
USG

18. 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

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

20. 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

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