Pregnancy usually comes with a considerable amount of nausea and vomiting as part of the phenomenon called morning sickness. When there is excessive vomiting occurring in the early part of pregnancy, it is called Hyperemesis Gravidarum. Hyperemesis is a complication of pregnancy characterised by severe nausea and vomiting, weight loss and possible dehydration. Hyperemesis is more severe than morning sickness and can be experienced more during the early pregnancy and gets better usually after the 20th week but can also last through out the pregnancy in rare cases.
Hyperemesis Gravidarum has been technically defined as more than three (3) episodes of vomiting per day such that weight loss of 5% or 30kg has occurred and ketones are present in the urine. Hyperemesis can cause volume depletion, electrolyte imbalance, nutritional deficiencies and even maternal death, therefore it is considered as an obstetric emergency with requires serious attention. It is important to rule out other possible causes of vomiting like malaria, high thyroid levels, urinary tract infection, gastritis, peptic ulcer disease, hepatitis, hypoglycemia, acute appendicitis, bowel obstruction, ovarian cysts e.t.c.
Hyperemesis is a common experience and should not be underestimated by either the woman or the healthcare givers. It is important to reassure the woman and her spouse when Hyperemesis occurs and management commenced depending on the severity of the presentation.
What causes Hyperemesis Gravidarum?
Hyperemesis is often of no known cause, however some theories explain that Hyperemesis results from an adverse reaction of the body to the hormonal changes in pregnancy, particularly elevated levels of beta human chorionic gonadotropin (hCG) levels. Hyperemesis has also been explained to occur as a result of high estrogen and progesterone levels acting on smooth muscles and causing decreased intestinal motility and gastric emptying, hence the nausea and vomiting experienced by pregnant woman in addition to the pressure effects of pregnancy in the abdominal cavity.
Certain risk factors have been linked with the occurrence of Hyperemesis and include
- First time pregnancy
- Multiple gestation
- Previous history of Hyperemesis
- Family history of Hyperemesis
- History of eating disorders
- Molar pregnancy
What are the signs and symptoms of Hyperemesis Gravidarum?
- Vomiting through out the day
- Inability to eat or drink anything for fear of vomiting
- Weight loss of > 5% of pre-pregnancy weight
- Sleep disturbance
- Mood changes
- Decreased concentration
The signs of Hyperemesis that can be picked up by healthcare givers include
- Patient appears miserable
- Dehydration (dry skin, dry tongue and sunken eyes)
- Pulse rapid and thready
- Low blood pressure as a result of hypovolemia
- Deep and fast breathing
Diagnosis of Hyperemesis Gravidarum
The diagnosis of Hyperemesis is one of exclusion. Other possible causes must be ruled out first before concluding on the diagnosis. This can be done through
- Proper history taking and physical examination of patient of presenting signs and symptoms.
- Lab investigations are necessary and include full blood count, malaria tests, urinalysis and culture, suckling test, liver function test, thyroid function test, blood urea and electrolytes.
- Imaging studies usually ultrasound scan are used to determine gestational age and rule out molar pregnancy or multiple pregnancy. CT scan or MRI can also be used if appendicitis is suspected to be the cause of vomiting.
How to manage Hyperemesis Gravidarum
The management is dependent on the severity of the presentation but the management objectives of Hyperemesis are to stop vomiting, correct dehydration, treat present shock and other underlying conditions.
Management may require hospital admission if severe but can also be given at outpatient.
- Dry bland food and oral rehydration are the first line treatment for Hyperemesis.
- Mild cases can be treated with antiemetics like oral promethazine or metoclopramide to stop vomiting.
- More severe vomiting will warrant hospitalisation for resuscitation with intravenous fluids and injectible antiemetics with vitamin supplementation.
Complications of Hyperemesis Gravidarum
Possible complications that can arise as a result of Hyperemesis during pregnancy include
- Wernicke’s encephalopathy
- Kidney failure
- Low birth weight
- Preterm delivery
Medscape : “Hyperemesis Gravidarum”
Wikipedia : “Hyperemesis Gravidarum”