Guidelines for the Management of Hyperemesis Gravidarum

Hyperemesis gravidarum is persistent vomiting in pregnancy which causes weight loss (> 5% of body wt ) and ketosis. Untreated or inadequately treated it may lead on to Wernicke’s encephalopathy, central pontine myelinosis and maternal death.

Clinical Features

Though the common clinical presentation is in the 1st trimester of pregnancy a certain number of patients may present in the second trimester. Other problems must be ruled out before a confident diagnosis of hyperemesis gravidarum is made.

• Pregnancy and persistent nausea/vomiting.
• Dehydration
• Tachycardia
• Postural Hypotension
• Weight loss
• Hematemesis
• Mental changes of confabulation and retrograde amnesia in severe cases
• Abdominal Pain is NOT a common feature and its presence should alert the examiner to the differential diagnosis.

Common Differential diagnosis

PREGNANCY RELATED

• Multiple Pregnancy
• Molar Pregnancy

Non Pregnancy Related

• UTI
• Hepatitis
• Thyrotoxicosis
• Hyperparathyroidism
• Diabetic ketoacidosis
• Addison’s ds
• Appendicitis
• Cholecystitis
• Pancreatitis

Clinical History and Examination

• Establish LMP and pregnancy status
• Establish duration and amount of vomiting
• Ask about urine output and dysuria
• Clinically look for jaundice, goitre, and evidence of thyroid problems
• Clinical examination of chest and abdomen to rule out other causes of persistent nausea and vomiting
• Look for evidence of dehydration
• Does the uterus correspond to dates?

Investigations (5)

• Urine
• Ketones – to be checked daily
• MSU
• Bloods
• U & E s – check daily

Hyponatremia, Hypokalemia and low serum urea are the usual findings. Adjust IV fluid cationic balance accordingly.
Please check Serum Calcium to rule out hyperparathyroidism

• LFTs – baseline
• Elevated aminotransferases and bilirubin are common in upto 50% of patients.
• FBC – baseline
• Thyroid function tests – baseline
• Pelvic Ultrasound Scan
• To diagnose pregnancy and to rule out multifetal and molar pregnancies.
• Body weight – twice a week
  

  Treatment (1,5)

  Any patient unable to maintain adequate hydration at home should be admitted to the hospital and investigated.

  Discontinue any medications that may aggravate symptoms like iron supplements and antibiotics.

  Discontinue oral intake.

  Maintain input/output chart

  IV fluids – N Saline /Hartmans

  Fluid and electrolyte regimes should be adapted daily and titrated against the U&E results.

  KCL may be added on according to the U & E results

  DO NOT USE Double strength saline

  Avoid solutions containing dextrose esp if hyponatremia exists.

  Antiemetics – Cyclizine 50 mg tds PO/IV/IM
  Prochlorperazine – 5-12.5 tds PO/PR/IM
  Metoclopramide – 10mg tds PO/IM

  The oculogyric crisis may occur – Manage with PROCYCLIIDINE 5 mg IM/IV

  Thiamine – Routine supplementation
  25 – 50 mg TDS PO if she can tolerate orally
  – 100mg in 100ml N Saline infusion over 1 hr weekly.

  H2 receptor antagonists – Ranitidine and omeprazole are useful in some patients, particularly with associated hematemesis

  Thromboprophylaxis – Low Molecular wt Heparin
  TED stockings

  Corticosteroids – Discuss with Consultant first (3)

  Useful in intractable hyperemesis.

  • Hydrocortisone 100mg IV BD
  • followed by 40 mg prednisolone daily.
  • Then maintenance of 5-10 mg daily to continue until symptom amelioration.
  • Screen for diabetes.

  Total Parenteral Nutrition – In severe cases.(4)

  • Discuss with consultant first.
  • Psychological support from nursing and medical staff.

  Subsequent Management

  • Oral fluids may be re introduced once the symptoms have lessened in severity.
  • Dietary advice
  • Small frequent helpings of food to be taken when symptoms are less severe must be encouraged.
  • Patient may be discharged with oral antiemetics.

  References

  1. James et al Evidence based obstetrics 2nd ed 233 -234
  2. Jewell D interventions for nausea and vomiting in pregnancy Cochrane database issue 4
  3. Safari HR Theefficacy of methylprednisolone in the treatment of hyperemesis gravidarum am j obstet gynec 179 921-924
  4. Subramanium R et al TPN and steroids in the management of hyperemesis gravidarum Aust NZJ obst Gynec 1998;39;339- 41
  5. Nelson Piercy Hyperemesis Gravidarum – a review Obst & Gynecol (RCOG UK) vol 5 ; 4 2003

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