Hyperemesis Gravidarum1

HYPEREMESIS GRAVIDARUM

ARYA. K. A

MORNING SICKNESS Nausea and vomiting of pregnancy

( NVP) is commonly called “morning sickness”.

Common phenomenon (70% of all pregnancies)

Usually starts from 6th to 8th week (sometimes it may be one of the earliest symptoms leading to suspicion of pregnancy)

Usually passes off by 12th week , sometimes persist throughout pregnancy.

Mild in first trimester, with a frequency of once or twice in the morning and of small quantity.

Does not affect the patients health.

HYPEREMESIS GRAVIDARUM Excessive vomiting in pregnancy.

Characterised by severe nausea and intractable vomiting sufficient to interfere with nutrition.

Seen in 0.5 % of pregnancies.

Increased frequency in vomiting and weight loss.

The primary stimulus arises from placenta or may be triggered by a placental product.

The stimulus is increased in a. molar pregnancy b. multiple gestations

The response of the mother to this stimulus is determined partly by her susceptibility.

Susceptibility specific to hyperemesis gravidarum includes receptor abnormalities increasing sensitivity to placental product.

A strong genetic component may also influence.

The aetiology and pathogenesis of hyperemesis is still not clear, but various postulates have been put forward.

1. Endocrine2. Infection3. Upper gastrointestinal dysmotility4. Psychological5. Other postulates

1. ENDOCRINE hCG Hyperemesis is more common in

pregnancies with increased hCG levels like hydatidiform mole and multiple pregnancy.

Estrogen It is observed that women who have

vomiting while using combined oral contraceptive pill, are likely to develop hyperemesis in pregnancy.

INFECTION Helicobacter pylori, a gram negative

bacteria, associated with the development of peptic ulcer where similar symptoms are seen.

This organism has been isolated in severe hyperemesis

UPPER GASTROINTESTINAL DYSMOTILITY During pregnancy oesophageal, gastric ,

and small bowel motility are impaired as a result of smooth muscle relaxation induced by high levels of progesterone.

This dysmotility could be a factor contributing to the nausea and vomiting of pregnancy.

PSYCHOLOGICAL one of the oldest theories postulated.

OTHER POSTULATESa) liver dysfunctionb) altered lipid metabolismc) immunological theory

PATHOLOGY 1. METABOLIC CHANGES

Starvation causes depletion of glycogen stores and mobilization of fat stores. This leads to increased production of ketone bodies which are excreted through the kidneys and breath.

At the same time , there is increased tissue protein metabolism which leads to increased blood urea nitrogen.

If prolonged, hypoglycemia, hypoproteinemia and hypovitaminosis can supervene.

In severe cases, hepatic dysfunction may supervene.

2. BIOCHEMICAL Vomiting and dehydration can lead to

hyponatraemia, hypokalaema and hypochloraemia.

3. HAEMATOLOGICAL Haemoconcentration can also occur as a

result of dehydration.

SYMPTOMS

SIGNS

CLINICAL FEATURES

VOMITING INCREASED IN FREQUENCY WITH RETCHING

UNABLE TO RETAIN FOOD OLIGURIA, CONSTIPATION, EPIGASTRIC PAIN

SYMPTOMS

ANXIOUS SUNKEN EYES DRY TONGUE KETOTIC ODOUR OF BREATH NON ELASTIC SKIN TACHYCARDIA HYPOTENSION WEIGHT LOSS ICTERUS

SIGNS