Hyperemesis gravidarum is severe nausea and vomiting during pregnancy that can lead to dehydration and weight loss. The document discusses the epidemiology, risk factors, clinical presentation, diagnosis, and management of hyperemesis gravidarum. Treatment involves intravenous rehydration, nutritional supplementation, antiemetic medications like pyridoxine and doxylamine, and hospital admission for severe cases. Outcomes of untreated hyperemesis gravidarum can include complications like esophageal rupture, Wernicke's encephalopathy, and maternal mortality in rare cases.

1. Hyperemesi
s
Alsaleh Yassin Mahmoud
gravidarum
Security Force Hospital

2. ُ ْ َ َ
‫ ووصينا النسان بوالديْه إحسانا حملته‬ :‫قال تعالى‬
َ ْ ِ َ ِ َ
َ
َّْ َ َ
‫أ ُمه كرها ووضعته كرها‬
ْ ُ ُ َْ َ َ َ
ْ ُ ُ ّ
And we have commended unto man
kindness toward parents. his mother bear
him with reluctance, and bring him forth with
.reluctance

3. Objectives
 Introduction.
 Epidemiology.
 Clinical picture.
 Investigation.
 Treatment.
 outcomes.

4. Introduction
Nausea and vomiting in pregnancy is extremely
common.
The nausea and vomiting associated with
pregnancy usually begins by 9-10 weeks of
gestation, peaks at 11-13 weeks, and resolves in
most cases by 12-14 weeks.
Normal nausea and vomiting may be an
protective mechanism—it may protect the
pregnant woman and her embryo from harmful
substances in food.

5. Definitions
Motion sickness:
Nausea felt by pregnant woman on getting up in
the morning.
Emesis gravidarum:
actual vomiting in the morning.
Hyperemesis gravidarum:
Vomiting not confined to morning but repeated
throughout the day until it affect the general
condition of the patient.

6. Epidemiology
Incidence:
Of all pregnancies, 0.3-2% are affected with HEG .
more common in westernized industrialized
societies and urban areas than rural areas.
Race: No clear racial predominance is noted for
HEG

7. Risk factors
Previous pregnancies with HEG
Greater body weight
Multiple gestations
Trophoblastic disease
Nulliparity
The risk of HEG appears to decrease with
advanced maternal age.
Cigarette smoking is associated with a
decreased risk for HEG.

8. Aetiology
Unknown.
Hormonal.
Psychological.
Vestibular and olfaction
Hepatic dysfunction .
Lipid alterations .
Other (H.pylori infection)

9. Aetiology cont.
Hormonal:
Women with hyperemesis gravidarum often have
high hCG levels that cause transient
hyperthyroidism.
High human chorionic gonado trophin (hCG)
stimulate the chemo receptor trigger zone in the
brain stem including vomiting center.
Evidence by High hCG in :
Early pregnancy.
Vesicular mole.
Multiple pregnancy.

10. Aetiology cont.
H . pylori infection:
1-The incidence of H.pylori sero positive in
patients with hyperemesis gravidarum (HG) is
high in comparison with non-HG pregnant
women .
ive
t
ni
efi ion
o d lat
 no one was able to demonstrate correlation
or
t
N re
cH. pylori and the
between seropositivity for
fa
or
c
le
time of onset or tduration of HG symptoms.
l ip
 Although H.M u
pylori infection may be an
importantm factor in exacerbating HG, it may
not represent the sole cause of the disease.

12. Diagnosis
History.
Examination.

13. Clinical picture (symptoms)
Vomiting through day and night
ptyalism
dizziness
Sleep disturbance
Hyperolfaction
Dysgeusia
Depression
Anxiety
Irritability
Mood changes
Decreased concentration

14. Clinical picture (sign)
Signs:
Dehydration.
Weight loss.
Sunken eye
Dry mouth.
Mild fever.
Hypotension.

15. CRITERIA
HEG
Persistent vomiting
weight loss greater than 5%
Dehydration
Electrolyte abnormalities

16. Differential Diagnosis














Gastrointestinal disorders
Gastroenteritis
Biliary tract disease
Hepatitis
Intestinal obstruction
Peptic ulcer disease
Pancreatitis
Appendicitis
Genitourinary tract
disorders
Pyelonephritis
Uremia
Degenerating uterine
leiomyoma
Torsion
Kidney stones
Metabolic disorders
Diabetic ketoacidosis
Porphyria
Addison’s disease
Hyperthyroidism
Neurologic disorders
Pseudotumor cerebri
Vestibular lesions
Migraine headaches
Central nervous system
tumors
 Pregnancy-related
conditions
 Nausea and vomiting of
pregnancy
 hyperemesis gravidarum











18. Investigations
Urinalysis: for ketones and specific gravity .
Serum electrolytes :
-low Na or K.
-hyperchloremic metabolic alkalosis or acidosis.
LFT: Elevated transaminase levels .
TSH,free thyroxine :HEG is associated with
hyperthyroidism

19. Investigations cont
Urine culture: UTI can be associated with
nausea and vomiting.
Hematocrit: This may be elevated.
Hepatitis screening: hepatitis A, B, or C may be
confused with HEG.

20. Investigations cont
Imaging Studies:
Obstetric ultrasonography : evaluate for multiple
gestations or trophoblastic disease.
upper abdominal ultrasonography to evaluate the
pancreas and/or biliary tree
In rare cases, abdominal CT scan may be
indicated if appendicitis is under consideration.

22. Management
1-Admission:
2-Intravenous Fluids:
Normal saline or lactated Ringer’s solution is the
mainstay of intravenous fluid therapy.
It should be given by infusion over 2-3 hours.
thiamine (vitaminB1).
3-Enteral or Parenteral Nutrition.

23. Management cont
DIETARY AND LIFESTYLE CHANGES
 Separating solids and liquids.
 Eating small, frequent meals consisting of bland




foods.
Avoiding fatty foods such as potato chips.
Avoiding drinking cold or sweet beverages.
Eliminate pills with iron
High protein snacks are helpful.

24. Management cont
5 - PHARMACOLOGICAL THERAPIES:
 Vitamins Pyridoxine (Nestrex)
 Essential for normal DNA synthesis and play a
role in various metabolic processes
(Diclectin) combination of doxylamine with of
pyridoxine (vitamin B6)
A - Safe in pregnancy
at a dose of 10-12.5 mg PO qd/bid.

25. Management cont
Antiemetics :
a.DOPAMINE ANTAGONISTS:
Useful in the treatment of symptomatic nausea
- phenothiazines (i.e., chlorpromazine,
perphenazine, prochlorperazine, promethazine,
trifluoperazine)
- blocking postsynaptic mesolimbic dopamine
receptors through anticholinergic effects and
depressing reticular activating system
- C - Safety for use during pregnancy has not been
established.

26. Management cont
Metoclopramide:is an upper gastrointestinal
motility stimulant.
Blocks dopamine receptors and (when given in
higher doses) also blocks serotonin receptors in
chemoreceptor trigger zone of the CNS
Metoclopramide is safe to be used for
management of NVP, although evidence for
efficacy is more limited
B - Usually safe but benefits must outweigh the
risks

27. Management cont
SEROTONIN 5-HT3 ANTAGONISTS.
 Ondansetron (Zofran) :
blocking serotonin, both peripherally on vagal
nerve terminals and centrally in the
chemoreceptor trigger zone
In general, 5-HT3 antagonists may be safe to use
during the first trimester, but the data are scant.

28. Management cont
Antihistamines :
Meclizine (Antivert) , Diphenhydramine
(Benadryl)
Appears to be as efficacious as pyridoxine
Causes sedation; caution must be used in
performing tasks which require alertness

29. Management cont
Corticosteroids:
Methylprednisolone (Medrol, Solu-Medrol)
Recent studies revealed a small but significantly
increased risk of oral clefting associated with first
trimester exposure to corticosteroids.

30. Management cont
A doxylamine/ pyridoxine combination should be
the standard of care since it has the greatest
evidence to support its efficacy and safety.
Other drugs may also be used, primarily
dimenhydrinate, in conjunction with the
doxylamine/pyridoxine combination.
If possible, corticosteroid use should be avoided
in the first 10 weeks .

31. Management cont
Other modalities:
(antidepressent):
- Selective serotonin re-uptake inhibitors
- Tricyclic antidepressants (TCAs)
Helicobacter pylori eradication.
ACUPUNCTURE.
Stimulation of the P6 point, located three-fingers’
breadth proximal to the wrist, has been used for
treat nausea and vomiting
Ginger (Zingiber officinale)

33. outcomes
Esophageal rupture or perforation
Pneumothorax and pneumomediastinum
Wernicke encephalopathy or blindness
Hepatic disease
Seizures, coma, or death
HEG is self-limited and, in most cases, improves
by the end of the first trimester. However,
symptoms may persist through 20-22 weeks of
gestation and, in some cases, until delivery.

34. Referances
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JG. Hyperemesis gravidarum, a literature review.
Hum Reprod Update. 2007 Mar-Apr;13(2):207.
Sahakian V, Rouse D, Sipes S, Rose N, Niebyl J.
Vitamin B6 is effective therapy for nausea and
vomiting of pregnancy: a randomized, doubleblind placebo-controlled study. Obstet Gynecol
1991;78:33-6.
Leathem A. Safety and efficacy of antiemetics
used to treat nausea and vomiting in pregnancy.
ClinPharm 1986;5:660-8.

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Miklovich L, van den Berg BJ. An evaluation of
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drugs. Am J Obstet Gynecol 1976;125:244-8.

36.  Harrington RA, Hamilton CW, Brogden RN,
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Metoclopramide. An updated review of its
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 Park-Wyllie L, Mazzotta P, Pastuszak A, Moretti
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37.  Nageotte MP, Briggs GG, Towers CV, Asrat T.
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 Aselton P, Jick H, Milunsky A, Hunter JR, Stergachis
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