Top Banner
HYPEREMESIS GRAVIDARUM (PERNICIOUS VOMITING ) INTRODUCTION The wait to bring a new life surfacing out of our body is that all of us must aspire to experience at least once in our life time. This period is called pregnancy. Responsibilities & growing concern for the new life now plays a significant role as we set foot on the path that transmutes one from a woman into a mother. Among these is our duty to the life i.e. yet to be & how we can give of ourselves, in body & spirit, to form & nurture the new life that we seek to bring into existence. Giving life is powerful. It is vital therefore, that we prepare our body to become a suitable environment for the baby to grow in while staying happy & healthy emotionally & mentally as well. Pregnancy an incredible journey. A women body has a great deal to do during pregnancy. Sometimes the changes takes place will cause irritation & discomfort & on occasions they may seem quite alarming. Pregnant women may have many health
52
Welcome message from author
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Page 1: Pernicious Vomiting

HYPEREMESIS GRAVIDARUM(PERNICIOUS VOMITING)

INTRODUCTION

The wait to bring a new life surfacing out of our body is that all of us

must aspire to experience at least once in our life time. This period is called

pregnancy. Responsibilities & growing concern for the new life now plays a

significant role as we set foot on the path that transmutes one from a woman

into a mother. Among these is our duty to the life i.e. yet to be & how we can

give of ourselves, in body & spirit, to form & nurture the new life that we seek

to bring into existence. Giving life is powerful. It is vital therefore, that we

prepare our body to become a suitable environment for the baby to grow in

while staying happy & healthy emotionally & mentally as well. Pregnancy an

incredible journey.

A women body has a great deal to do during pregnancy. Sometimes the

changes takes place will cause irritation & discomfort & on occasions they

may seem quite alarming. Pregnant women may have many health complaints

of varying degrees throughout their pregnancies. One such common complaint

that pregnant women are plagued with is morning sickness, (that is mild form

of nausea & vomiting), which is particularly observed during the first

trimester of pregnancy.

The cause is usually unknown. Most researchers believe it’s a

combination of the many physical changes taking place in the body such as the

higher levels of hormones during early pregnancy. Normal nausea & vomiting

may be an evolutionary protective mechanism. It may protect the pregnant

Page 2: Pernicious Vomiting

women & her embryo from harmful substances in food, such as pathogenic

micro organisms in meat products & toxins in plants, with the effect being

maximal during embryogenesis (the most vulnerable period of pregnancy).

This is supported by studies showing that women who had nausea &

vomiting were less likely to have miscarriage & still births. Some researchers

have found that women who are more likely to have nausea from birth control

pills, migraines or hormone replacement therapy. A continuous spectrum of

the severity of nausea & vomiting ranges leads to severe disorders of

hyperemesis Gravidarum.

Pernicious vomiting of pregnancy: Medically known as Hyperemesis

gravidarum, this is excessive vomiting in early pregnancy. Hyperemesis

Gravidarum is a severe form of morning sickness, with unrelenting, excessive

pregnancy-related nausea and/or vomiting that prevents adequate intake of

food and fluids. Hyperemesis is considered a rare complication of pregnancy

but, because nausea and vomiting during pregnancy exist on a continuum,

there is often not a good diagnosis between common morning sickness and

hyperemesis.

MEANING

Hyperemesis gravidarum is the Latin for excessive vomiting in

pregnancy. Hyper means "over"; emesis means "vomiting"; and gravidarum

means "pregnant state." Nausea & vomiting of pregnancy commonly termed

‘morning sickness’ is a common phenomenon in pregnancy, occurring in about

70% of pregnancies.

Page 3: Pernicious Vomiting

DEFINITION

Excessive nausea & vomiting that start between 4 & 16 weeks gestation &

requiring intervention are known as Hyperemesis gravidarum.

Ammula Radha Ramana Sree

Hyperemesis gravidarum is a severe type of vomiting of pregnancy which has

got deleterious effect on the health of the mother, &/or incapabilities her in

day to day activities

D.C.Dutta

Hyperemesis Gravidarum (HG) is defined as a severe form of nausea and

vomiting in pregnancy

Hyperemesis Education and Research Foundation (HER)

Hyperemesis gravidarum (hyperemesis) is defined as excessive nausea and

vomiting in pregnancy starting before the 22nd week of gestation, which

might lead to nutritional deficiencies and weight loss.

BMJOURNALS

INCIDENCE

Nausea & vomiting affect over 50% of pregnancies

Affecting 0.3-3% of all pregnant women. It is associated with

dehydration

Most cases are mild & resolves with time, approximately 1 in every

1000 pregnant women requires hospitalization

Maternal age less than 2 years

Page 4: Pernicious Vomiting

Approximately 60,000 cases of HG are reported annually in the United

States; however, this statistic only reflects those women treated in

hospitals (HER, 2006).

ETIOLOGY

The etiology & pathogenesis of nausea & vomiting of pregnancy is still not

clear & various postulates have been put forth

1. Endocrine-hCG has been postulated to be the cause. This is probably

why Hyperemesis is more common in pregnancies with high hCG levels

like hydatidiform mole & multiple pregnancy. Estrogen has also been

implicated & it is observed that women who have vomiting while using

the combined oral contraceptive pill are likely to have Hyperemesis

2. Infection-Helicobacter Pylori is a gram negative bacillus that has been

associated with the development of peptic ulcer where similar

symptoms are seen.

3. Upper gastrointestinal dysmotility- during pregnancy esophageal,

gastric, & small bowel motility are impaired as a result of the smooth

muscle relaxation induced by the high levels of progesterone. This

dysmotility could be a factor contributing to the nausea & vomiting of

pregnancy

4. Psychological-this is one of the oldest theories postulated in the

pathogenesis of Hyperemesis.

5. Other postulates

Liver dysfunction

Altered lipid metabolism

Immunological

Page 5: Pernicious Vomiting

Whatever may be the cause of initiation of vomiting, it is probably aggravated

by the neurogenic element. Unless it is not quickly rectified,

MORNING SICKNESS vs. HYPEREMESIS GRAVIDARUM

Morning Sickness Hyperemesis Gravidarum

Nausea sometimes accompanied by 

vomiting 

Nausea accompanied by severe

vomiting

Nausea that subsides at 12 weeks or

soon after 

Nausea that does not subside

Vomiting that does not cause severe

dehydration

Vomiting that causes severe

dehydration

Vomiting that allows you to keep

some food down

Vomiting that does not allow you

to keep any food down

Page 6: Pernicious Vomiting

PATHOLOGY

There is no specific morbid anatomical findings. The changes in the various

organs as described by Sheehan are the generalized manifestations of

starvation & severe malnutrition.

Liver: there is centrilobular fatty infiltration without necrosis

Kidneys: usually normal with occasional findings of fatty change in the

cells of first convoluted tubule which may be related to acidosis

Heart-a small heart is a constant finding. There may be subendocardial

hemorrhage

Brain: a small hemorrhages in the hypothalamic region giving the

manifestation of Wernicke’s encephalopathy. The lesion may be related

to vitamin B1 deficiency

Metabolic, biochemical & circulatory changes: the changes are due to the

combined effect of dehydration & starvation consequent upon vomiting

1. Metabolic changes- starvation causes depletion of glycogen stores &

mobilization of fat stores. This leads to increased production of ketone

bodies, which are excreted through the kidneys & the breath. At the

same time, there is increased tissue protein metabolism, which leads to

increased blood urea nitrogen. If prolonged, hypoglycemia,

hypoproteinaemia & hypovitaminosis can supervene.

2. Biochemical-vomiting & dehydration can lead to hyponatraemia,

hypokalemia & hypochloraemia

3. Hematological- haemoconcentration can also occur as a result of

dehydration

Page 7: Pernicious Vomiting

PATHOPHYSIOLOGY

Etiology:Unknown

Predisposing Factor:-woman

Precipitating Factor:-pregnancy

Adverse reaction to the hormonal changes

of pregnancy

Increased level of beta HCG

Increased level of estrogen & progesterone

Decreased gastric motility

Immune response to fragments of chorionic villi that enter the maternal bloodstream; immune response

to the “foreign” fetus.

Loss of 5% or more of pre-pregnancy body

weight.

Dehydration

Metabolic imbalances

Difficulty with daily activities

Food leaving the stomach more slowly

Page 8: Pernicious Vomiting

Effect of Severe Vomiting

CLINICAL FEATURES

Nausea & vomiting of pregnancy tends to begin at 4-6 weeks, peaks at 8-

12 weeks & usually resolves by 20 weeks.

Abdominal pain

Nausea & vomiting

Hypersalivation

Difficulty in breathing

Page 9: Pernicious Vomiting

Low birth infants

Disorientation

Delusions

Nystagmus

Jaundice

Anaemia

Rapid pulse

Low blood pressure

Dry tongue

Hypovilaemia

GI disturbances

Sunken eyes

Loss of skin elasticity & dry

Lips cracked

Morning sickness

Coffee coloured vomitus

Anxious appearance

Ketotic odour of breath

Tachycardia

Hypotension

Upto 5% weight loss

In sever cases icterus

INVESTIGATIONS

1. Urinalysis

Oliguria

Page 10: Pernicious Vomiting

Dark colour

Increased specific gravity

Ketone bodies

Acidic pH

2. Hematological & biochemical

Raised haemocrit

Raised blood urea

Electrolytes may be abnormal

Abnormal liver function tests

3. Ultrasound

Confirms viable intrauterine pregnancy

Rules out molar pregnancy & multiple pregnancy

Differential diagnosis

Liver dysfunction

Peptic ulceration

Sever gastro-esophageal reflux

Psychological problems

COMPLICATIONS

Electrolyte imbalance

Liver dysfunction & jaundice

Renal abnormalities’

Stress ulcers in the stomach

Mallory-Weiss tears in the esophagus & esophageal rupture

Pneumothorax & pneumomediastinum

Page 11: Pernicious Vomiting

Complications due to vitamin deficiency

- Wernicke’s encephalopathy due to thiamine deficiency

- Korsakoff’s psychosis

- Peripheral neuritis

- Vitamin K deficiency & bleeding disorders

IUGR for the fetus

MANAGEMENT

The principles in the management are:

To control vomiting

To correct the fluids, electrolytes & other metabolic disturbances

promptly & effectively

To prevent or to detect at the earliest, the ominous complications

that may arise.

Morning sickness can be treated by reassurance & simple dietetic

regulation

Fatty acid rich rood is better avoided

Food should be composed of CHO, fruits & vegetable.

Toasts, biscuits, jelly are recommended

Sticks of barley sugar provide a palatable medium of easily assimilable

glucose. Bowel movement should be regular

I. MEDICAL INTERVENTIONS

1. Control of dehydration through IV fluids – often 1 to 3 liters of dextrose

solution with electrolytes and vitamins, as needed. Bicarbonate may be

given for acidosis.

Page 12: Pernicious Vomiting

2. Vomiting that persists after initial fluid and electrolyte replacement is

treated with an antiemetic taken as needed; antiemetics include:

a. Vitamin B6

o Drug classification: Vitamins & Minerals (Pre & Post Natal) /

Antianemics

o Indications: Treatment & prevention of metabolic disorders;

multivitamin & mineral deficiency states; treatment & prophylaxis

of Fe-deficiency anemias.

o Dosage: 10 to 25 mg every 8 hours

o Special precautions: Should be taken on an empty stomach (Best

taken between meals. May be taken w/ meals to reduce GI

discomfort.).

b. Doxylamine (Aldex, Unisom)

o Drug classification: Antihistamines

o Mechanism of action: Doxylamine competes with histamine for H1-

receptor sites on effector cells; blocks chemoreceptor trigger zone,

diminishes vestibular stimulation, and depresses labyrinthine

function through its central anticholinergic activity.

o Indications: For hypersensitivity reactions and insomnia;

Doxylamine has been approved for used in pregnancy-associated

nausea and vomiting

o Dosage: Oral: Adults: One tablet 30 minutes before bedtime; once

daily or as instructed by healthcare professional (can be taken in

addition to vitamin B6)

Page 13: Pernicious Vomiting

o Contraindications: Hypersensitivity to doxylamine or any

component of the formulation

o Side effect: Sedation

o Adverse reactions: Cardiovascular: Palpitation, tachycardia ;

Central nervous system: Dizziness, disorientation, drowsiness,

headache, paradoxical CNS stimulation, vertigo; Gastrointestinal:

Anorexia, dry mucous membranes, diarrhea, constipation,

epigastric pain, xerostomia; Genitourinary: Dysuria, urinary

retention; Ocular: Blurred vision, diplopia

o Special precautions: May impair ability to drive and operate

machinery. Angle-closure glaucoma, urinary retention, prostatic

hypertrophy or pyloroduodenal obstruction; epilepsy; hepatic

impairment. Elderly. Lactation.

o Pregnancy Considerations: Doxylamine has been approved for used

in pregnancy-associated nausea and vomiting.

c. Promethazine (Metagon, Phenerzin)

o Drug classification: Antihistamines

o Mechanism of action: Blocks postsynaptic mesolimbic

dopaminergic receptors in the brain; exhibits a strong alpha-

adrenergic blocking effect and depresses the release of

hypothalamic and hypophyseal hormones; competes with

histamine for the H1-receptor; muscarinic-blocking effect may be

responsible for antiemetic activity; reduces stimuli to the brainstem

reticular system.

Page 14: Pernicious Vomiting

o Indications: Symptomatic relief of allergy e.g. hay fever, urticaria,

premed; emergency treatment of anaphylactic reactions; sedation;

motion sickness.

o Dosage: Deep IM injection/slow IV injection/infusion Nausea &

vomiting 12.5-25 mg 4 hourly. Max: 100 mg/day. Other indications

25-50 mg. Max: 100 mg. Rate of infusion: Not >25 mg/min.

o Contraindications: Hypersensitivity to promethazine or any

component of the formulation (cross-reactivity between

phenothiazines may occur); coma; treatment of lower respiratory

tract symptoms, including asthma.

o Side Effects: Extra pyramidal symptoms, sedation

o Special precautions: Avoid extravasation or inadvertent intra-

arterial inj. Induction of & recovery from anesthesia. Patients w/

acute porphyria. Allergy to Na metabisulfite.

Appropriate administration: Not for Subcutaneous or intra-arterial

administration. I.M. is the preferred route of parenteral

administration. I.V. use has been associated with severe tissue

damage; unintentional intra-arterial administration/infiltration has

been associated with severe tissue necrosis and loss of digits/limb.

In some institutions, I.V administration may be avoided or specific

administration techniques may be used to minimize risk.

Discontinue immediately if burning or pain occurs with I.V.

administration.

o Pregnancy Considerations: Teratogenic effects were not observed

in animal studies. Crosses the placenta. May be used alone or as an

adjunct to narcotic analgesics during labor.

Page 15: Pernicious Vomiting

d. Metoclopramide (Biclomet, Clomitene, Reglomar)

o Drug classification: Antiemetics

o Mechanism of action: Blocks dopamine receptors and (when given

in higher doses) also blocks serotonin receptors in chemoreceptor

trigger zone of the CNS; enhances the response to acetylcholine of

tissue in upper GI tract causing enhanced motility and accelerated

gastric emptying without stimulating gastric, biliary, or pancreatic

secretions; increases lower esophageal sphincter tone.

o Indications: Relief of nausea & vomiting associated w/ radiation

therapy, malignant disease, labor, infectious diseases & uremia.

Control of post-op vomiting & assist in intestinal intubation.

o Dosage: Adult 10 mg TID, 15-20 yr 5-10 mg TID. Max: 0.5 mg/kg

body wt.

o Contraindications: Hypersensitivity to metoclopramide or any

component of the formulation; GI obstruction, perforation or

hemorrhage; pheochromocytoma; history of seizures or

concomitant use of other agents likely to increase extra pyramidal

reactions.

o Side Effects: Tardive dyskinesia (black-box warning)

o Special precautions: May cause drowsiness so avoid activities

which require high levels of concentration. May mask symptoms of

a serious disease. Discontinuation of therapy: Abrupt

discontinuation may (rarely) result in withdrawal symptoms

(dizziness, headache, nervousness).

Page 16: Pernicious Vomiting

o Pregnancy Considerations: Teratogenic effects were not observed

in animal studies; however, there are no adequate and well-

controlled studies in pregnant women. Crosses the placenta;

available evidence suggests safe use during pregnancy.

e. Ondansetron (Emodan, Zofran)

o Drug classification: Antiemetics

o Mechanism of action: Hypersensitivity to ondansetron, other

selective 5-HT3 antagonists, or any component of the formulation.

o Indications: Prevention of nausea and vomiting associated with

moderately- to highly-emetogenic cancer chemotherapy;

radiotherapy; prevention of postoperative nausea and vomiting

(PONV); treatment of PONV if no prophylactic dose of

ondansetron received. Unlabeled/Investigational use:

Hyperemesis gravidarum; breakthrough treatment of nausea and

vomiting associated with chemotherapy

o Dosage: Treatment of hyperemesis gravidarum (unlabeled use): 8

mg administered over 15 minutes every 12 hours or 1 mg/hour

infused continuously for up to 24 hours; 8 mg oral every 12 hours

o Contraindications: Hypersensitivity to ondansetron, other

selective 5-HT3 antagonists, or any component of the formulation

o Side effects: Constipation, diarrhea, headache, fatigue

o Special precautions: May cause drowsiness so avoid activities

which require high levels of concentration. May mask symptoms

of a serious disease. Discontinuation of therapy: Abrupt

Page 17: Pernicious Vomiting

discontinuation may (rarely) result in withdrawal symptoms

(dizziness, headache, nervousness).

o Pregnancy considerations: Teratogenic effects were not observed

in animal studies; however, there are no adequate and well-

controlled studies in pregnant women. Use of ondansetron for the

treatment of nausea and vomiting of pregnancy (NVP) has been

evaluated. Additional studies are needed to determine safety to

the fetus, particularly during the first trimester. Based on

preliminary data, use is generally reserved for severe NVP

(hyperemesis gravidarum) or when conventional treatments are

not effective.

f. Prochlorperazine (Compazine)

o Drug classification: Antipsychotics, Antivertigo

o Mechanism of action: Prochlorperazine is a piperazine

phenothiazine antipsychotic which blocks postsynaptic

mesolimbic dopaminergic D1 and D2 receptors in the brain,

including the chemoreceptor trigger zone; exhibits a strong alpha-

adrenergic and anticholinergic blocking effect and depresses the

release of hypothalamic and hypophyseal hormones; believed to

depress the reticular activating system, thus affecting basal

metabolism, body temperature, wakefulness, vasomotor tone and

emesis.

o Indications: Management of nausea and vomiting; psychotic

disorders, including schizophrenia and anxiety

Page 18: Pernicious Vomiting

o Dosage: Adult: PO Prevention of nausea and vomiting As maleate

or mesilate: 5-10 mg 2-3 times/day. Nausea and vomiting as

maleate or mesilate: 20 mg, may repeat if needed. Vertigo As

maleate or mesilate: 15-30 mg/day in divided doses. May reduce

gradually to 5-10 mg/day. IM Nausea and vomiting as mesilate:

12.5 mg, may repeat via PO if needed.

o Contraindications: Hypersensitivity to prochlorperazine or any

component of the formulation (cross-reactivity between

phenothiazines may occur); severe CNS depression; coma

o Side effects: Extra pyramidal symptoms, sedation

o Special precautions: Extra pyramidal syndrome, hypotension,

epilepsy, impaired hepatic, renal, CV, cerebrovascular or

respiratory function, glaucoma. May impair ability to drive or

perform tasks requiring mental alertness or physical

coordination. Parenteral use in children is not recommended.

History of jaundice, parkinsonism, diabetes mellitus,

hypothyroidism, myasthenia gravis, paralytic ileus, prostatic

hyperplasia or urinary retention. Regular eye examinations are

recommended in patients on long-term treatment.

o Pregnancy Considerations: Crosses the placenta. Isolated reports

of congenital anomalies, however, some included exposures to

other drugs. Jaundice, extra pyramidal signs, hyper-/hyporeflexes

have been noted in newborns. Available evidence with use of

occasional low doses suggests safe use during pregnancy.

Prompt hospitalization is mandatory to prevent complications

Page 19: Pernicious Vomiting

1. Supportive treatment with IV crystalloids & correction of dehydration

ketosis, electrolyte deficit & acid base imbalance is vital. Oral feeding is

stopped to provide rest to the gastrointestinal tract. Most patients

respond & slowly an oral diet can be reintroduced, beginning with fluids

& then low fat solids. If Hyperemesis is prolonged, parenteral vitamins

should be given, especially B vitamins due to the possibility of

Wernicke’s encephalopathy in severe cases

2. Antiemetics like doxylamine 10mg orally or twice a day, alone or in

combination with vitamin B6 (10-30mg) is considered as first line

pharmaco therapy. Metachlopramide 10mg orally upto 4times a day can

also be given. Both these drugs are FDA category B drugs

3. Pyridoxine or B6 has been shown to be effective in the management of

nausea in early pregnancy but may not be very effective in intractable

vomiting

4. Methylpredisolone has been found to be effective in severe

Hyperemesis probably by a direct effect on the vomiting centres of the

brain. The dosage is 20mg orally twice daily. It should only be used

when all other causes are excluded & the risks are clearly explained to

the patient. There is a marginal increase of congenital malformations

with first trimester use of steroids in experimental animals & so if used,

should be after 8weeks in refractory cases

5. Life style & diet changes. General advice is to avoid offensive foods &

odours; eating of small frequent meals; a high protein, low fat, low

carbohydrate diet; & avoiding iron supplements. She should be asked to

take whichever foods appeal to her. Reassurance & explanation will go a

long way

Page 20: Pernicious Vomiting

6. Alternative therapies like psychotherapy, acupressure & medical

hypnosis can be tried

7. Termination of pregnancy is very rarely needed as a last resort, to be

considered only in severe cases when there is a danger to life.

ALTERNBATIVE & COMPLIMENTARY THERAPIES IN HYPEREMESIS

GRAVIDARUM

The aim of the treatment is to restore proper balance & stop nausea &

vomiting

Traditional Chinese medicine

Stimulation of the acupuncture point p6 (neiguan), this point is

located on the inner arm, just above the wrist. Has been shown in

multiple trials to be effective in reducing nausea & vomiting.

The intensity & duration of the sickness has a direct relationship to

the state of the woman’s digestive system(spleen & stomach

meridians) before conception.

The effects of the acupuncture calm the digestive system, decrease

fatigue, decrease nausea & vomiting.

Homeopathic approaches

It can be an excellent choice for treatment of Hyperemesis because

small tasteless pills are dissolved under the tongue with little chance

of inducing nausea & vomiting

Page 21: Pernicious Vomiting

Sepia is the remedy most helpful for ordinary nausea & vomiting of

pregnancy. It is indicated when nausea is intensified by the smell or

thought of foods &/or when the woman is regarded as irritable,

emotional & selfish because of her need to be alone & quite.

Phosphorus is very effective for ailments of pregnancy & is

recommended when there are complaints related to an overactive

imagination with exaggerated fears, burning pains & thirst for cold

drinks.

Hypnotherapy

When emotional factors are implicated in the cause of Hyperemesis,

the use of hypnosis with positive suggestions can be helpful.

It involves the removal of fears of hypnosis, along with an

explanation of the role of the vomiting center in the brain & how it

works, coupled with a general discussion about the value of good

nutrition in pregnancy

Herbal therapy

The cutaneous application of wild yam cream has been anecdotally

reported to reduce nausea & vomiting

Dandelion root tea calms & strengthens the stomach, improves the

appetite, & supports the liver.

An infusion of ginger (in small amounts), chamomile, peppermint,

catnip, fennel, red raspberry, or lemon balm can also help.

Cranial Sacral & polarity therapy

Page 22: Pernicious Vomiting

Cranial sacral & polarity therapies can be used together energetically

to normalize the adaptational processes of the body.

If anxiety or any other emotional issues are at the root of the

sickness, these therapies allow the body, mind & spirit to integrate &

relax in a nurturing environment

DIETARY MANAGEMENT

Eat frequent small meals every two to three hours

Speak to a dietitian about ensuring the nutritional adequacy of your diet

during pregnancy and nutrition strategies to improve nausea and

vomiting symptoms

Eat dry crackers 15 minutes before getting out of bed in the morning

Do not skip meals needlessly

Drink fluids half an hour before a meal or half an hour after a meal.

Avoid drinking with your meal to prevent becoming overfull

Drink about eight glasses of liquid during the day to avoid dehydration

Try eating cold food rather than hot food (cold foods have less odour)

Avoid spicy foods

Avoid foods high in fat

Protein-containing snacks are helpful (e.g. yoghurt and fruit; wholegrain

crackers with sliced cheese)

Sugar free mineral waters or soda waters can assist in settling nausea

Herbal teas containing peppermint or ginger or other ginger-containing

beverages may ease nausea

If odours bother you while cooking, try to improve ventilation in your

kitchen area

Page 23: Pernicious Vomiting

NURSING DIAGNOSIS

Fluid volume deficit related to

Altered nutrition less than body requirements related to

Acute pain related to nausea & vomiting

Activity intolerance related to weakness due to inadequate nutrition

Risk for sleep pattern disturbance related to nausea & persistent

vomiting

Risk for maternal / fetal injury related to severe complications of

Hyperemesis

Risk for ineffective individual or family coping result emotional status &

hospitalization

Page 24: Pernicious Vomiting

NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:hypersalivationnausea & vomitingObjective:-Irritated-(+) nausea and vomiting-(+) hypersalivation-(+) dry skin-Vital signs taken as follows:BP: 90/70CR: 80bpmRR: 22cpmT: 37°C

Deficient fluid volume related to hyperemesis gravidarum as manifested by hypersalivation, vomiting and dry skin.

After the shift of nursing interventions, the patient will decreased the possibility in vomiting, hypersalivation decreased and skin becomes moisturized. And irritability will diminish.

-Established rapport to the patient and to the S.O.-Monitored vital signs and recorded.-Monitored IVF drip and its patency.-Maintained quiet environment.-Provided comfort measures.-Administered and documented medications (METOCLOPRAMIDE) given as ordered by the physician.-Encouraged patient to increase oral fluid intake.-Encouraged patient to eat dry toast foods.

-To gather information.-For Baseline data.-To prevent overload of the fluid. And IVF can help for the hydration of the patient.-For relaxation of the patient.-To prevent irritation/ discomfort of the patient.-To provide wellness to the patient. And to prevent patient from vomiting.-For hydration of the patient.-Dry toast foods inhibit the urge of vomiting and at the same time the patient will be refilled to prevent gastric ulcer.

Goal met: After the shift of nursing interventions the patient was able to perform changes in her status.

Page 25: Pernicious Vomiting

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:The patient verbalizes irritability pain

Objective:-9/10 pain scale-Irritable-Grimacing-Guarding behavior-Vital signs taken as follows:BP: 90/70CR: 80bpmRR: 22cpmT: 37°C

Acute pain related to hyperemesis gravidarum as manifested by verbal report and guarding behavior.

After 4 hours of nursing intervention, the patient will relieve from pain.The patient can perform activities (sitting, standing, walking and etc.) comfortably.Pain scale will decelerate to 5/10.

-Established rapport to the patient and to the S.O.-Monitored vital signs and recorded.-Monitored IVF drip and its patency.

-Maintained quiet environment.

-Provided comfort measures.-Positioned the patient to her comfortable state.-Massage patient.

-Instructed S.O. not to leave the patient.

-To gather information.

-For Baseline data.-To prevent overload of the fluid.

-For relaxation of the patient.

-To lessen the pain felt by the patient.

-To decreased pain.

- To alleviate suffering from perceived pain. -To prevent from fall.

Goal met: After 4 hours of nursing intervention the patient was relieved from pain, can do things comfortably and report pain scale to 5/10.

Page 26: Pernicious Vomiting

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:The patient verbalizes that orthopneaObjective:-Irritated-Orthopnea-Alterations in depth of breathing-Nasal flaring-Vital signs taken as follows:BP: 90/70CR: 80bpmRR: 22cpmT: °C

Ineffective breathing pattern related to pain as evidenced by orthopnea, alterations in depth of breathing and nasal flaring.

After 3 hours of nursing intervention the patient will be able to breathe properly.

-Established rapport to the patient and to the S.O.-Monitored vital signs and recorded.-Monitored IVF drip and its patency.

-Maintained quiet environment.-Provided comfort measures.-Positioned patient to orthopneic position.

-Provided air to patient.-Instructed S.O. to massage chest and back of the patient.

-To gather information.

-For Baseline data.

-To prevent overload of the fluid.

-For relaxation of the patient.-To prevent irritation/ discomfort of the patient.-Helps in the breathing pattern of the patient. It helps the patient to breathe properly.-For proper ventilation.

-It helps the patient’s breathing pattern.

Goal met: After 3 hours of nursing intervention the patient can perform proper breathing pattern and can breathe properly.

Page 27: Pernicious Vomiting

Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:Objective:-Irritability-Facial tension-Trembling-Restlessness-Vital signs taken as follows:BP: 100/80CR: 89bpmRR: 22cpmT: 37°C

Anxiety related to perceived proximity of death as manifested by the verbal report, irritability, facial tension, trembling, and restlessness.

After 3 hours of nursing intervention the will no longer feel the proximity of death.

-Established rapport to the mother.-Monitored vital signs and recorded.-Monitored IVF drip and its patency.

-Maintained quiet environment.-Provided comfort measures.

-Provided calm and peaceful setting.

-Encouraged patient to pray to God.

-Taught patient and S.O. about the condition of the patient.

-To gather information.

-For Baseline data.-To prevent overload of the fluid.

-For relaxation of the patient.

-To prevent irritation/ discomfort of the client.-Promotes relaxation and ability to deal with situations.-For the patient be filled with faith and hope.

-For them to be clarified about the situation of the patient.

Goal met: After 3 hours of nursing intervention, the patient was filled with hope.

Page 28: Pernicious Vomiting

II. NURSING INTERVENTIONS

1. Maintaining fluid volume

a. Establish an IV line, and administer IV fluids as prescribed.

b. Monitor serum electrolytes, and report abnormalities.

c. Medicate with antiemetics as prescribed. Administer

intramuscularly (IM) or by rectal suppository to avoid loss of dose

through vomiting.

d. Maintain NPO status except for ice chips until vomiting has

stopped.

e. Assess intake and output, urine specific gravity and ketones, vital

signs, skin turgor, and fetal heart tones as indicated by condition.

2. Encouraging adequate nutrition

a. Advice the woman that oral intake can be restarted when emesis

has stopped and appetite returns.

b. Begin small feedings. Suggest or provide bland solid foods; serve

hot foods hot and cold foods cold; do not serve lukewarm.

oAvoid greasy, gassy, and spicy foods.

oProvide liquids at times other than meal times.

c. Suggest or provide an environment conducive to eating.

oKeep room cool and quiet before and after meals.

oKeep emesis pan handy, yet out of sight.

3. Strengthening coping mechanisms

a. Allow patient to verbalize feelings regarding this pregnancy.

Page 29: Pernicious Vomiting

b. Encourage patient to discuss any personal stress that may have a

negative effect on this pregnancy.

4. Allaying fears

a. Explain the effects of all medications and procedures on maternal

as well as fetal health.

b. Accentuate the positive signs of fetal well-being.

c. Praise mother for attempts at following nutritious diet and

healthy lifestyle.

5. Patient education and health maintenance

a. Educate the woman about proper diet and nutrition in pregnancy.

b. Educate the woman about health weight gain in pregnancy.

c. Educate the woman on the need for child care during the periods

of severe nausea and vomiting.

d. Encourage the woman to move slowly, avoiding quick changes of

position. Quick changes in position can cause vertigo and then

nausea and vomiting.

e. Educate the woman on the need to take antiemetics during the

nausea phase before vomiting occurs.

f. Educate the woman on tips to assist with hyperemesis

gravidarum:

oEat dry toast or crackers before rising from bed or anytime

nausea begins.

oGet fresh, outside air daily; lie down in a semi-prone

position.

Page 30: Pernicious Vomiting

oDrink spearmint or peppermint tea.

oTake vitamin B6 50-100mg daily.

oAvoid food odors.

oEat smaller, frequent meals.

HEALTH EDUCATION

Drink lots of fluids to avoid dehydration.

Drink small amounts of fluid often.

Small frequent feeding rather than having heavy meals.

Increase oral fluids and food intake at the time of the day when you feel

least nauseated.

Avoid fatty, hot and spicy foods.

Avoid foods with smell that makes you feel nauseated.

Early morning nausea may be helped by eating dry crackers before

getting out of bed.

Avoid having empty stomach.

Lie down when nauseated.

Have enough rest and sleep.

JOURNAL ABSTRACT

1. Hyperemesis gravidarum is a miserable condition for patients and a

frustrating one for the staff caring for them. While nausea and vomiting are

common and expected in early pregnancy, the syndrome of hyperemesis

gravidarum, which can be defined as persistent vomiting starting in the first

trimester, is relatively uncommon. A study in 1992 found that among 9,088

Page 31: Pernicious Vomiting

pregnancies 35 had hyperemesis of sufficient severity to require intravenous

rehydration (Spiller, 1992).

2. Dodds, Linda PhD; Fell, Deshayne B. MSc; Joseph, K S. MD, PhD; Allen,

Victoria M. MD, MSc; Butler, Blair MD conducted a study on Outcomes of

Pregnancies Complicated by Hyperemesis Gravidarum with an objective

to evaluate maternal and neonatal outcomes among women with hyperemesis

during pregnancy. A population-based retrospective cohort study was

conducted among women with singleton deliveries between 1988 and 2002.

Hyperemetic pregnancies were defined as those requiring one or more

antepartum admissions for hyperemesis before 24 weeks of gestation.

Severity of hyperemesis was evaluated according to the number of antenatal

hospital admissions (1 or 2 versus 3 or more) and according to weight gain

during pregnancy (< 7 kg [15.4 lb] versus ≥ 7 kg). Maternal outcomes

evaluated included weight gain during pregnancy, gestational diabetes,

gestational hypertension, labor induction, and cesarean delivery. Neonatal

outcomes included 5-minute Apgar score of less than 7, low birth weight,

small for gestational age, preterm delivery, and perinatal death. Logistic

regression was used to generate adjusted odds ratios for all outcomes, and the

odds ratios were converted to relative risks. The results of this study suggest

that the adverse infant outcomes associated with hyperemesis are a

consequence of, and mostly limited to, women with poor maternal weight

gain.

3. Levine MG, Esser D conducted a study on Total parenteral nutrition

for the treatment of severe hyperemesis gravidarum: maternal

Page 32: Pernicious Vomiting

nutritional effects and fetal outcome. The purpose of this study was to

examine the nutritional state of pregnancy complicated by hyperemesis

gravidarum and the effects of total parenteral nutrition on maternal nutrition

and fetal outcome when given during the first trimester of pregnancy. Using a

standard method of indirect calorimetry, the basal metabolic expenditure and

adjusted metabolic expenditure were determined, and appropriate calories

were calculated for each patient. The patients were then started on total

parenteral nutrition. Follow-up indirect calorimetry studies showed improved

nutritional status, with return of anabolic parameters. The results of this

study support the conclusion that total parenteral nutrition given during the

first trimester is a safe and effective method of nutritional support.

4. Fell, Deshayne B. MSc; Dodds, Linda PhD Joseph, K S. MD, PhD; Allen,

Victoria M. MD, MSc; Butler, Blair MD conducted a study on Risk Factors for

Hyperemesis Gravidarum Requiring Hospital Admission During

Pregnancy with an objective to identify risk factors for hyperemesis

requiring hospital admission during pregnancy. Data from a population-based

cohort of all deliveries in Nova Scotia, Canada between 1988 and 2002 were

obtained from the Nova Scotia Atlee Perinatal Database. Women with 1 or

more antepartum admissions for hyperemesis were compared with women

with no admissions for hyperemesis. Relative risks (RRs) and 95% confidence

intervals (CIs) were estimated using logistic regression and used to determine

a set of independent risk factors for hyperemesis. The results shows that the

overall rate of admission for hyperemesis was 0.8% (n = 1,301) among

157,922 deliveries. In the adjusted analysis, hyperthyroid disorders (RR 4.5,

95% CI 1.8–11.1), psychiatric illness (RR 4.1, 95% CI 3.0–5.7), previous molar

Page 33: Pernicious Vomiting

pregnancy (RR 3.3, 95% CI 1.6–6.8), preexisting diabetes (RR 2.6, 95% CI 1.5–

4.7), gastrointestinal disorders (RR 2.5, 95% CI 1.8–3.6), and asthma (RR 1.5,

95% CI 1.2–1.9) were all statistically significant risk factors for hyperemesis,

whereas maternal smoking and maternal age older than 30 were associated

with decreased risk. Compared with singleton male pregnancies, singleton

female pregnancies, pregnancies with multiple male fetuses, and male and

female combinations were associated with statistically significant increased

risk of hyperemesis. Although hospitalization for hyperemesis occurs in less

than 1% of pregnant women, this translates to a large number of hospital

admissions. The factors associated with hyperemesis are primarily medical

and fetal factors that are not easily modifiable, but identification of these

factors may be useful in determining those women at high risk for developing

hyperemesis.

5. Jennifer L.   Bailit , MD, MPH, conducted a study on Hyperemesis

gravidarium: Epidemiologic findings from a large cohort . the Objective of

this study was undertaken to quantify the frequency, clinical course, charges,

and outcomes of hyperemesis gravidarum. California birth certificate data

linked with maternal and neonatal hospital discharge data in 1999 were used

(N = 520,739). Hyperemesis was defined by ICD-9 codes. The frequency,

estimated charges, and demographic characteristics associated with

hyperemesis patients were assessed. Maternal and neonatal perinatal

outcomes were compared by maternal hyperemesis status. Results shows that

Hyperemesis complicated 2,466 of 520,739 births. The average length of stay

was 2.6 days and the average charge was $5,932. Singleton hyperemesis

infants were smaller (3,255 vs 3,380 g; P < .0001 and more likely to be small

Page 34: Pernicious Vomiting

for gestational age (29.21% vs 20.8%; P < .0001). Hyperemesis occurs in 473

of 100,000 live births and is associated with significant charges. Infants of

mothers with hyperemesis have lower birth weights and the mothers are

more likely to have infants that are small for gestational age.

6. Golberg, Deborah MD, CCFP; Szilagyi, Andrew MD, FRCPC; Graves, Lisa

MD, CCFP conducted a study on Hyperemesis Gravidarum and

Helicobacter pylori Infection: A Systematic Review. The objective of the

study is to systematically review studies examining the relationship between

hyperemesis gravidarum and Helicobacter pylori (H pylori) infection. A 1966

to January 2007 search using MEDLINE/PubMed, EMBASE, and Web of

Science included MeSH terms: Helicobacter pylori, Helicobacter infections,

hyperemesis gravidarum, and the text words nausea, vomit, pregnancy, and

Helicobacter. References of selected papers were examined for additional

relevant studies. They evaluated studies investigating a relationship between

hyperemesis gravidarum and H pylori infection. Studies were included in

which the diagnosis of hyperemesis gravidarum was made at or before entry

into the study, and H pyloridiagnosis was made by serum antibody sample,

gastric biopsy, saliva test, or stool sample. The search produced 169 titles; 22

were reviewed in further detail. Fourteen case-control studies met established

criteria, involving 1,732 participants and controls tested for H pylori infection.

Studies were evaluated according to patient demographics and study

methodology (case definition, exclusion criteria, H pylori testing). An estimate

of the odds ratios with 95% confidence intervals was calculated by using a

random effects model for dichotomous variables with review article software.

Ten studies showed a significant association between hyperemesis

Page 35: Pernicious Vomiting

gravidarum and H pylori infection. Odds ratios varied from 0.55 to 109.33;

three results were less than 1.0. Tests for heterogeneity applied to several

subgroups were considerable with values above 75% for all groups. An

association between hyperemesis gravidarum and H pylori infection is

suggested by this systematic review. However, the considerable heterogeneity

among studies highlights study limitations.

SUMMARY

Excessive vomiting of pregnancy incapacitating the day-to-day activities

&/or deteriorating the health of the mother is called Hyperemesis

gravidarum. It is rare now a days (1 in 1000). It is common in first birth &

limited to early pregnancy. The exact cause is not known but once vomiting

starts, probably neurogenic elements aggravate the state. The morbid

pathological changes are due to starvation. The clinical manifestations are due

to the effect of dehydration, starvation & keto-acidosis. Management consists

of hospitalization, sympathetic but firm handling of the patient, antiemetic

drugs, replacement of fluids by infusion, correction of electrolyte imbalance &

supply of glucose to protect the liver & vitamin supplement. Intractable

Hyperemesis gravidarum in spite of therapy is rare these days. Termination of

pregnancy is rarely indicated

Page 36: Pernicious Vomiting

BIBLIOGRAPHY

TEXTBOOK REFERENCE

1. Sheila Balakrishnan. Textbook of Obstetrics. 1st edn. 2007. Paras Medical

Publisher, Hyderabad. Pg.No-170-173

2. Ammula Radha Ramana Sree. Handbook of Obstetrical Nursing. 1st edn.

2007. Frontline publications, Hyderabad. Pg.No- 268-271

3. Elizabeth Stepp Gilbert. Manual of High Risk Pregnancy & Delivery. 4th

end. 2007. Elsevier publications. Newdelhi. Pg.no-109-111

4. Annamma Jacob. A Comprehensive textbook of midwifery. 2nd edn. 2008.

Jaypee publications. Newdelhi. Pg.no-289-290

5. D.C.Dutta. textbook of Obstetrics including Perinatology &

Contraception. 6th end. 2004. Central publications. Pg.no-156-158

6. D.K.James, P.J.Steer, C.P.Weiner, B.Gonik. High risk pregnancy

management options. 3rd edn. 2007. Elsevier publications. .pg.no-1045-

1048

NET REFERENCE

1. https://www.thieme-connect.com/ejournals/abstract/ajp/doi/10.105

5/s-2000-9424

2. http://www.nursingcenter.com/prodev/ce_article.asp?tid=866194

3. http://www.nursingtimes.net/nursing-practice-clinical-research/

hyperemesis-gravidarum-a-short-case-study/200677.article

4. http://www.obgyn.net/educational-tutorials/article/16247

5. http://www.netce.com/coursecontent.php?courseid=762