Hyperemesis gravidarum

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Significant nausea and vomiting associated with pregnancy and is the most common indication for hospital admission during the first part of pregnancy.

A pregnancy complication characterized by severe nausea, vomiting, weight loss, and possibly dehydration.

The incidence of HG is 0.3–1.5%.

Individuals may experience vomiting many times a day and feeling faint.

A small percentage rarely vomit, but the nausea still causes most of the same issues that hyperemesis with vomiting does.

Tends to occur in the first trimester of pregnancy and lasts significantly longer than morning sickness.

Considered more severe than morning sickness.

Symptoms usually improve after the 20th week of pregnancy but may last the entire pregnancy duration.

Some experience severe symptoms until they give birth to their baby, and sometimes even after giving birth.

Risk factors include: First pregnancy, multiple pregnancy, obesity, prior or family history of hyperemesis gravidarum, trophoblastic disorder, history of an eating disorder.

Infection with Helicobacter pylori, increased thyroid hormone production, low age, low body mass index prior to pregnancy, multiple pregnancies, molar pregnancies, and a past history of hyperemesis gravidarum have been associated with its development.

Other potential causes should be excluded including urinary tract infection and high thyroid levels.

Frequency about 1% of pregnant women.

Estimated to affect 0.3–2.0% of pregnant women.

After preterm labor, hyperemesis gravidarum is the second most common reason for hospital admission during the first half of pregnancy.

Diagnosis is usually made based on clinical findings.

Technically defined as more than three episodes of vomiting per day, weight loss of 5% or three kilograms, and ketones are present in the urine.

Can be associated with serious health problems in the mother or baby: Wernicke’s encephalopathy, coagulopathy and peripheral neuropathy.

Treatment includes drinking fluids, bland diet, electrolyte-replacement,, thiamine, and a higher protein diet.

Some patients require intravenous fluids.

Hospitalization may be necessary.

Medications include pyridoxine, metoclopramide, prochlorperazine, odansetron.

Psychotherapy may be beneficial.

Death very rare.

Higher risk of premature birth.

Some women choose to have an abortion due to HG.

Severe symptoms may result in:

Loss of 5% or more of pre-pregnancy body weight

Dehydration

Ketosis.

Constipation

Nutritional disorders, such as vitamin B1 (thiamine) deficiency, vitamin B6 (pyridoxine) deficiency or vitamin B12 (cobalamin) deficiency.

Metabolic imbalances such as metabolic ketoacidosis or thyrotoxicosis.

Physical and emotional distress.

Difficulty with activities of daily living

HG symptoms can be aggravated by odors, hunger, fatigue, prenatal vitamins, oral iron and diet.

It is proposed as an adverse reaction to the hormonal changes of pregnancy, with elevated levels of beta human chorionic gonadotropin (β-hCG), and increase in maternal levels of estrogens.

Elevated levels of beta human chorionic gonadotropin (β-hCG) explain why hyperemesis gravidarum is most frequently encountered in the first trimester as β-hCG levels are highest at that time and decline afterward.

Estrogen decreases intestinal motility and gastric emptying leading to nausea/vomiting.

A diagnosis of exclusion.

Common testing include creatinine and electrolytes, liver function tests, urinalysis, and thyroid function tests.

Hematocrit levels are usually raised due to hemoconcentration.

An ultrasound scan may be needed to know gestational status and to exclude molar or partial molar pregnancy.

Management includes oral rehydration and dry bland diet.

Antiemetic medications and intravenous rehydration may be required

Supplementation of electrolytes and thiamine (Vitamin B1) must be considered.

After IV rehydration frequent small liquid or bland meals may be tolerated, and treatment focuses on managing symptoms to allow normal intake of food.

A number of antiemetics are effective and safe in pregnancy, but there is limited evidence to suggests the use of medications to treat hyperemesis gravidarum is beneficial.

Ondansetron may be beneficial in HG.

Ondansetron May be associated with cleft palate,

Metoclopramide is relatively well tolerated.

Evidence for the use of corticosteroids is weak.

Refractory patients may require nutritional support.

Complications of inadequate treatment include: anemia, hyponatremia, Wernicke’s encephalopathy,
kidney failure, coagulopathy,, Mallory-Weiss tears,[11] hypoglycemia,, malnutrition, pneumomediastinum,, deconditioning, deep vein thrombosis, pulmonary embolism, and post-traumatic stress disorder, vasospasms of cerebral arteries, depression are possible consequences.

The fetus may be effected due to electrolyte imbalances caused by HG in the mother.

Infants of women with severe hyperemesis tend to be of lower birth weight, small for gestational age, and born before 37 weeks gestation.

There is no significant difference in the neonatal death rate in infants born to mothers with HG, but children born to mothers with undertreated HG have a fourfold increase in neurobehavioral diagnoses.

Vomiting is a common, affecting about 50% of pregnant women, with another 25% having nausea.

4-5 times more common in multiple gestation than in singletons.

Occurs in 8-23% of cases of hydatidiform mole.

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