Hyperemesis gravidarum is defined as severe, persistent nausea and vomiting during pregnancy leading to dehydration, electrolyte imbalance, ketosis, loss of more than 5% pre-pregnancy weight and can even result in mortality.
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Infant of a Diabetic Mother — Pathophysiology and Management

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Epidemiology

  • Nausea and vomiting is seen in up to 90% of all pregnant women. However, the prevalence of nausea and vomiting that requires hospital admission ranges from 0.3%-2%.
  • The condition begins at 9-10 weeks, peaks at 11-13 weeks and resolves in the second trimester. It is more common in urban areas and it has no racial predilection.

Etiology and risk factors of hyperemesis gravidarum

Common associations of HEG include:

  1. Elevation in the levels of placental human chorionic gonadotropin (HCG) hormone typically causes nausea and vomiting during the first trimester of pregnancy. In most women, the symptoms tend to diminish after the first trimester.
  2. Multiple gestations as the annoyances of pregnancy are more accentuated.
  3. Female fetus.
  4. OCPs intolerance in the pre-pregnancy state.
  5. Nulliparity.
  6. Low socio-economic states.
  7. Hydatiform mole (trophoblastic disease).

Reduced risk has been associated with smoking and maternal age greater than 30 years.

Clinical presentation of HG

  • Excessive and persistent nausea and vomiting
  • Fatigue
  • Excessive salivation
  • Dizziness
  • Insomnia
  • Olfactory dysfunction
  • Dysgeusia
  • Anxiety
  • Lability of moods
  • Diminished ability to concentrate

Diagnosis of HG

Physical examination

Physical examinations include non-specific findings unless the pregnant woman has abdominal pain or bleeding. A physical examination should evaluate orthostatic blood pressure changes, signs of dehydration (dryness of mucous membranes, poor skin turgor, collapsed neck veins and mental status changes), and cardiac, pulmonary, abdominal and neurologic organ systems.

Laboratory tests

  • Pregnancy test: Urine and serum HcG to confirm pregnancy
  • Complete blood count with differential and hematocrit
  • Urinanalysis for ketones
  • Serum electrolytes and serum ketones
  • Liver transaminases and Bilirubin levels
  • Serum amylase and lipase levels
  • Free thyroxine and thyroid stimulating hormone levels
  • Serum calcium levels
  • Abdominal ultrasonography to confirm gestational sac and its age and to exclude multiple gestations, trophoblastic disease, and appendicitis

Management of HG

In mild cases

Conservative management with reassurance, dietary modifications and moral support is recommended. Alternative therapies like acupressure and hypnosis can also be considered.

This is the first line therapy instituted for non-severe cases.

In severe cases

Pharmacotherapy:

  • Doxylamine/pyridoxine is currently the only medication approved by FDA for the treatment of Hyperemesis gravidarum.
  • Other medications that may provide relief include antihistamines, phenothiazine antiemetics (e.g. metoclopramide), ondansetron and steroids.

Termination of pregnancy.

  • Medical termination of pregnancy is only indicated in cases of severe refractory hyperemesis gravidarum with a high risk to maternal life.
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