1. HYPEREMESIS
GRAVIDARUM

2. Dr. Niranjan Chavan
MD, FCPS, DGO, DFP, MICOG, DICOG, FICOG
Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H
Chairperson, FOGSI Oncology and TT Committee (2012-2014)
Treasurer, MOGS (2017- 2018)
Chair and Convener, FOGSI Cell- Violence against Doctors (2015-2016)
Chief Editor, AFG Times (2015-2017)
Editorial Board, European Journal of Gynecologic Oncology
Editor of FOGSI FOCUS, MOGS, AFG & IAGE Newsletters
Member, Managing Committee, IAGE (2013-2017)
Member, Oncology Committee, AOFOG (2013 -2015)
Recipient of 6 National & International Awards
Author of 15 Research Papers and 19 Scientific Chapters
Course Co-Ordinator, of 11 batches, of MUHS recognized Certificate Course of
Basic Infertility Management Including Endoscopy (BIMIE) at LTMGH

3. INTRODUCTION
• Nausea and Vomiting of Pregnancy diagnosed when onset is in the first
trimester of pregnancy and other causes of nausea and vomiting have been
excluded.
• Hyperemesis Gravidarum is defined as protracted Nausea and Vomiting of
Pregnancy with the triad of
• > 5% pre pregnancy weight loss
• Dehydration and
• Electrolyte imbalance.

4. INCIDENCE
• The incidence of women with severe symptoms
vary from 0.3 to 3 % of pregnancies.
• In a prospective study published in 2016 which
included 800 patients,
• 57 % reported nausea and
• 27 % reported both nausea and vomiting
• by 8 weeks of gestation. *
Hinkle SN, Mumford SL, Grantz KL, et al. Association of Nausea and Vomiting During Pregnancy With
Pregnancy Loss: A Secondary Analysis of a Randomized Clinical Trial. JAMA Intern Med 2016; 176:1621.

5. RISK FACTORS
• Multiple gestation
• Hydatidiform mole
• Non-use of multivitamins before 6 weeks of
gestation or during the peri-conceptional period
• Heartburn and acid reflux
• Nulligravida
• Nonpregnant women who experience nausea
and vomiting related to oestrogen-based
medication

6. RISK FACTORS
• Motion sickness
• Migraine
• Female fetus
• Family history of Hyperemesis
Gravidarum
Smoking and Alcohol are
protective factors.

7. PATHOGENESIS
Psychological
Factors
Hormonal changes
Abnormal
Gastrointestinal
Mobility
H.Pylori

8. PATHOGENESIS
Psychological
Factors
Conversion or
Somatization
Disorder
Response to
Stress

9. PATHOGENESIS
HORMONAL CHANGES
• Estrogen
• Progesterone
• Beta hCG
• These hormones relax smooth muscle and thus slow
gastrointestinal transit time and may alter gastric
emptying.
• Relax the lower oesophageal sphincter

10. In a 2014 systematic review and meta-analysis of 26 epidemiological studies
published in American Journal of Obstetrics & Gynaecology, a significant
association was found between H. pylori infection and
hyperemesis gravidarum/nausea and vomiting of pregnancy compared with
asymptomatic controls (OR 3.21)

11. NATURAL COURSE
• Mean onset of symptoms  five to six weeks of gestation
• Peak  nine weeks
• Subsides by 16 to 20 weeks of gestation
• 60 % become asymptomatic six weeks after onset of nausea.
• Persisted symptoms till third trimester 15 to 20 %
• Persisted symptoms till delivery  5 %

12. CLINICAL PRESENTATION
• Nausea and vomiting
• Weight loss (> 5% of pre pregnant weight or >3 kg)
• Ketonuria
• Orthostatic hypotension
• Physical signs of dehydration
• Ptyalism (Hyper salivation)

13. DIAGNOSTIC SCORING SYSTEM
• The Motherisk – PUQE (Pregnancy
Unique Quantification of Emesis) scoring
system
• Rhodes score
• Modified PUQE Score (symptoms over the
course of the entire first trimester)
Assess the symptoms for past
12 hours

15. RHODES INDEX: none: 0, mild: 1-8, moderate: 9-16, severe: 17-24, great: 24-
32.

16. MODIFIED PUQE SCORE
Mild NVP 3–6
Moderate 7–12 and
Severe NVP/HG ≥13

17. INVESTIGATIONS
• Electrolyte Imbalance: hypokalemia
hypochloremia
hypomagnesaemia
• If Mg2+ < 0.8 mEq/L  resistance to parathormone  Hypocalcemia
• Hematocrit: due to hemoconcentration
• Liver Function Test : ALT & AST (in 50%)
: bilirubin (do not rise > 4)
• Serum amylase and lipase (10 to 15 %)
• Thyroid Function: Mild hyperthyroidism due to raise B – hCG: Transient
Biochemical Hyperthyroidism is is defined as a free T4 index higher than the upper
range of normal, or a thyroid-stimulating hormone (TSH) level less than 0.4 mU/L.

18. DIFFERENTIAL DIAGNOSIS
• Multiple gestation
• Hydatidiform mole
• Preeclampsia, HELLP, and acute fatty liver of
pregnancy (late onset)
• Pancreatitis
• Migraine
• Hyperparathyroidism in pregnancy
• Cannabinoid hyperemesis syndrome

20. MANAGEMENT

21. As per ACOG Practice Bulletin No. 189: Nausea And Vomiting Of
Pregnancy. 2018
Nausea & Vomiting of Pregnancy (NVP) should be treated according
to the severity
• Nausea alone
• Vomiting without dehydration
• Vomiting with dehydration.

23. MANAGEMENT OF NAUSEA ALONE
• Diet changes : small meals every 2 hrs
avoid triggers
add ginger to diet
• Pyridoxine: 10 to 25 mg orally every 6 - 8 hours; the
maximum 200 mg/day.
• Doxylamine succinate and pyridoxine:each tablet
contains doxylamine 10 mg and pyridoxine 10 mg, 2 – 4
tabs/day
• Acupuncture or acupressure – P6 acupressure wristbands
• Hypnosis

25. MANAGEMENT OF VOMITING
WITHOUT DEHYDRATION
• Antihistaminic (H1 antagonists): Diphenhydramine,
Meclizine, Dimenhydrinate
• Dopamine Antagonist: Metoclopramide, Promethazine,
Prochlorperazine
• Serotonin Antagonist: Ondansetron, granisetron,
and dolasetron
• Acid-reducing agents: antacids, H2 blockers, proton pump
inhibitors

26. MANAGEMENT OF VOMITING
WITH DEHYDRATION
• IV Fluid & Electrolyte Correction
• Vitamins & Mineral
• Antiemetics
• Diet therapy

27. IV Rehydration and Electrolyte
Correction
2 L intravenous Ringer's lactate infused
over 3 – 5 hrs
Isotonic saline if serum Na+ levels
>120 mEq/L
Dextrose 5 % in 0.45 % saline with 20
mEq KCl at 150 mL/hour to patients with
normal K- levels
Urine output of at
least 100 mL/hour
Serum K +  3.0 to 3.4 mEq/L.
Treatment is usually started with 10 to
20 mEq of K+ given 2 - 4times per day
(20 to 80 mEq/day)

28. VITAMINS & MINERALS
• THIAMINE: 100mg IV for 3 days
• FOLIC ACID: 0.6mg daily
• VITAMIN B6: 25mg in 1 litre fluid daily
• MVI: 10 ml with IV Fluid
• MAGNESIUM : 2 g (16 mEq) magnesium sulfate infused
as a 10 percent solution over 10 to 20 minutes, followed
by 1 g (8 mEq) in 100 mL of fluid per hour.

29. CLASS DRUG DOSE SIDE EFFECTS FDA
CATEGORY
Antihistaminics Diphenhydramine 25 – 50 mg QID B
Meclizine 25 mg QID Cleft palate B
Dimenhydrinate 25 mg QID, MAX
400mg
B
Dopamine
antagonist
Metochlopramide 10mg PO/IV/IM 30
min before each meal
Metoclopramide-induced
tardive dyskinesia
B
Promethazine (H1 +
Dopamine
antagonist
12.5 – 25mg
PO/PR/IV every 4
hours
Sedation
Dystonia
Lower seizure threshold
C
Prochlorperazine 10 mg PO QID
25 mg PR BD
QT prolongation
Urinary retention
Extrapyramidal
symptoms
C
5-
hydroxytryptamine-3
(5-HT3) serotonin
receptor antagonist
Ondensetron 4mg PO/IV QID Headache
Constipation
QT prolongation
Serotonin syndrome
B
Granisetron Can be given
transdermal
Same as ondensetron B

30. REFRACTORY CASES
• The ACOG suggests consideration of testing for H. pylori infection in
patients who are unresponsive to standard therapy.
• CORTICOSTEROIDS: methylprednisolone (16 mg) IV/ 8 hours for
48 to 72 hours
Hydrocortisone 100mg IV BD for 2 – 3 days
After IV, Prednisolone 40mg for 1 day 20 mg for 3 days  5mg for
7 days
• Parenteral Nutrition : continued till the women is able to take
1000kcal/day per oral

31. CONCLUSION
• Nausea and vomiting in pregnancy is the most common indication for
hospitalization in 1st trimester.
• Severity of NVP should be evaluated using PUQE score and treated accordingly.
• Diet changes, avoidance of the trigger and Doxylamine + Pyridoxine is the 1st line of
therapy
• PUQ> 13 with dehydration should be treated with IV rehydration, electrolyte
correction and ondansetron.
• Refractory cases might require corticosteroids and parenteral nutrition.

32. REFERENCES
• Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 189: Nausea And
Vomiting Of Pregnancy. Obstet Gynecol 2018; 131:e15.
• The management of nausea and vomiting of pregnancy and hyperemesis gravidarum, Green Top
Guideline No 69, June 2016
• Sartori J, Petersen R, Coall DA, Quinlivan J. The impact of maternal nausea and vomiting in
pregnancy on expectant fathers: findings from the Australian Fathers' Study. J Psychosom Obstet
Gynaecol 2017; :1.
• Matthews A, Haas DM, O'Mathúna DP, Dowswell T. Interventions for nausea and vomiting in early
pregnancy. Cochrane Database Syst Rev 2015; :CD007575.
• Tan A, Lowe S, Henry A. Nausea and vomiting of pregnancy: Effects on quality of life and day-to-
day function. Aust N Z J Obstet Gynaecol 2017.
• Heitmann K, Nordeng H, Havnen GC, et al. The burden of nausea and vomiting during pregnancy:
severe impacts on quality of life, daily life functioning and willingness to become pregnant again -
results from a cross-sectional study. BMC Pregnancy Childbirth 2017; 17:75.