Obstetrics/ Dr. Aseil
1
Nausea &
vomiting of
pregnancy
Nausea and vomiting of pregnancy (NVP)
is the most common medical problem in pregnancy.
It occurs in approximately 70-80% of pregnancies and is most marked at
the 1
st
trimester but not confined to it.
It is usually most severe in the morning (Morning Sickness) but can occur
at any time and may be precipitated by cooking odors and strong sharp
smells.
The pathogenesis of NVP is poorly understood and the etiology is likely to be
multifactorial
The nausea probably results from relaxation of smooth muscle of stomach
by rapidly rising serum levels of steroids and hCG during the first trimester.
Emotional tension may play a role in the severity of nausea and vomiting.
Common in urban than in rural women.
More in house wife, more in alcoholic women ,more common in women
over 35y & in women with history of infertility
Obstetrics/ Dr. Aseil
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Clinical features of nausea & vomiting of pregnancy.
-
Nausea & vomiting 1-2 times per day .
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Normal pulse rate , blood pressure & urinary output
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No evidence of dehydration.
-
Usually the patient treated as outpatient.
Hyper emesis gravidarum
severe intractable vomiting through out the day following every meal &
the patient cannot maintain any fluid in stomach.
It affects 0.3-2% of pregnancies.
It disturbs nutritional intake &metabolism, causes physical & psychological
debilitation & is associated with adverse pregnancy outcome.
Clinical features of hyperemesis
1-Persistent vomiting
2- Dehydration.
3- Ketosis
4- Electrolyte disturbances.
5- Weight loss
6- Oliguria
7- Hypotension & tachycardia
Aetiology& Pathophysiology
.
Unknown &various putative mechanisms like high levels of hCG,
Oestrogen&thyroxine are associated
Obstetrics/ Dr. Aseil
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Risk factors of hyper emesis gravidarum
1-Multiple gestations.
2- Gestational trophoblastic disease
3- Triploidy
4- Trisomy 21 syndrome (Down’s syndrome)
5- Hydropsfetalis (Rh iso – immunization)
Recent study suggests that chronic infection with Helicobacter pylori may play
a role in hyper emesis gravidarum.
Differential diagnosis of persistent vomiting in pregnancy
1- Gastrointestinal disorders:Gastroenteritis, biliary disease, hepatitis,
intestinal obstruction, pancreatitis, appendicitis.
2- Genitourinary tract disorders: Pylonephritis, uremia, red degeneration of
fibroid, torsion ovarian cyst, renal stones
3- Metabolic disorders: Diabetic ketoacidosis, Addison's disease,
Hyperthyroidism
4- Neurologic disorders :Pseudo tumor cerebri, vestibular lesions, migraine,
CNS tumors
5- Pregnancy related conditions : Preeclampsia, acute fatty liver of
pregnancy.
6- Drug toxicity or intolerance
Maternal & fetal outcomes
Women with morning sickness have been noted to have nearly normal
pregnancy outcome
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Fewer miscarriages, preterm deliveries, and stillbirths
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Fewer instances of fetal low birth weight ,growth restriction & mortality
Obstetrics/ Dr. Aseil
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While Hyper emesis gravidarum has been associated with increases in
pregnancy adverse outcomes & complications including:
- Renal failure.
- Acute fatty necrosis of liver & liver failure.
- Spleen a avulsion.
- Esophageal rupture.
- Mallory-weiss tears.
- Pneumothorax.
- peripheral neuropathy (B6 deficiency), psychosis , Wernick’s
encephalopathy coma &death.
- Preeclampsia .
Increase in fetal growth restriction & mortality.
Treatment of NVP
A- Non pharmacological therapy , Dietary measures :
* Frequent small meals
* Avoid smells & food texture that cause nausea
* Solid foods should be bland testing &audor, high in carbohydrate& low
in fat.
- Emotional support
Alternative therapies, such as ginger supplementation and acupuncture
may be beneficial
B- Pharmacological therapy
* Antiemetic drug:
• Pyridoxine ( B6 ) &Doxylamine .
• Prochlorperazine& chlorpromazine.
• Metochlopramide( plasil ).
* Antihistamines:
• Meclizine, Diminhydrinate, Diphenhydramine
Obstetrics/ Dr. Aseil
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Management of hyperemesis gravidarum
1- Hospitalization .
2- No food by mouth for 48 hours .
3- Replacement of fluid & electrolyte correction ( glucose saline & potassium)
4- thiamine supplementation.
5- Take sample of urine for : Color, ketone bodies, specific gravity, RBC &
WBC , proteinurea.
6- Blood test for electrolytes( Na, K & CL) & Blood sugar ( hypoglycemia )
7- Liver function tests.
8- Clotting factors, PT& PTT.
9- Renal function test.
10-After 48 hour start solid food rich in carbohydrates .
11- Antiemetic drugs such as phenothiazines (like stemetil ) can be given in
form of injections
12- Corticosteroids:Methyleprednesolone in a dosage 16 mg tds, followed by
tapering over two weeks is a worthwhile treatment for a woman with
refractory hyper emesis gravidarum.
13- Total parenteral nutrition ( TPN ).
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90% of cases will improve.
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10% of cases will deteriorate in spite of our management & the only
treatment will be termination of pregnancy
Indications of termination of pregnancy in hyperemesis gravidarum :
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Jaundice.
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Renal failure.
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Psychosis .
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Polyneuritis.