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DEFINITION:
Hyperemesis gravidarum(HG) means "excessive vomiting during pregnancy ".
HG has been technically defined as more than three episodes of vomiting per day such that
weight loss of 5% or three kilograms has occurred and ketones are present in the urine. HG is
the severe form of normal vomiting of pregnancy (NVP), which affects about 0.3–3.6% of
pregnant women. The aetiological theories for NVP and HG range from the fetoprotective and
genetic to the biochemical, immunological and biosocial.
RISK FACTORS: PRESENTATION:
. TREATMENT GOALS
Determine the severity of disease and correct dehydration.
Reduce symptoms by changing her diet and begin medication, in a step- wise approach.
Prevent serious complications including electrolyte imbalance, vitamin deficiency (eg,
Wernicke encephalopathy) and weight loss.
Minimize the fetal effects of hyperemesis and its treatment.
DIAGNOSIS:
Typically starts between the 4th and 7th weeks of gestation, peaks in 9th week ninth
week and resolves by the 20th week in 90% ofwomen.
Protracted vomiting with the triad of more than 5% prepregnancy weight loss
dehydration and electrolyte imbalance.
An objective and validated index such as the Pregnancy-Unique Quantification of
Emesis (PUQE) score and Rhodes index can be used to classify the severity of NVP.
INITIAL ASSESMENT:
Look for -hyponatraemia, hypokalaemia, low serum urea, raised haematocrit and ketonuria
with a metabolic hypochloraemic alkalosis.
Urea and serum electrolyte levels should be checked daily
The biochemical thyrotoxicosis resolves as the HG improves
Liver function tests are abnormal in up to 40%, most likely transaminases being raised.
Ultrasound to confirm viability, for gestational age, as well as to rule out multiple pregnancy or
trophoblastic disease.
Unless there are other medical reasons for an urgent scan, this can be scheduled later.
DIFFERENTIAL DIAGNOSIS:
In presence of severe abdominal/epigastric pain
Peptic ulcers, cholecystitis,
Gastroenteritis, hepatitis, pancreatitis, Serum amylase
genitourinary conditions such as urinary tract Abdominal ultrasound, and possibly
Infection or pyelonephritis, Esophageal gastro duodenoscopy,
Metabolic conditions,
Neurological conditions and Rarely- testing for H. pylori antibodies
Drug-induced nausea and vomiting.
MANAGEMENT:
Women with mild symtoms (no dehydration) should be managed in the community with
antiemetics, support, reassurance, oral hydration and dietary advice
Inpatient management : should be considered if there is at least one of the following:
Inability to tolerate oral antiemetics
Ketonuria and/or weight loss (> 5% of body weight), despite oral antiemetics
Confirmed or suspected comorbidity (such as UTI and inability to tolerate oral
antibiotics).
Recommended antiemetic therapies and dosages
First line Second line Third line
Cyclizine 50 mg PO, IM or Metoclopramide 5–10 mg Corticosteroids:
IV 8 hourly 8 hourly PO hydrocortisone 100 mg
Prochlorperazine 5–10 mg twice daily IV
Metoclopramide 5–10 mg
Convert to prednisolone
6–8 hourly PO; 12.5 mg 8 8 hourly PO, IV or IM
40–50 mg daily PO,
hourly IM/IV; 25 mg PR/day (maximum 5 days’
Gradually tapered to
Promethazine 12.5–25 mg duration) lowest maintenance dose
4–8 hourly PO, IM, IV or PR Domperidone 10 mg
8 hourly PO; 30–60 mg 8
Chlorpromazine 10–25 mg
hourly PR
4–6 hourly PO, IV or IM; or
Ondansetron 4–8 mg
50–100 mg 6–8 hourly PR
6–8 hourly PO; 8 mg over
15 minutes 12 hourly IV