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MRCOG PART 2 SBAs and EMQs

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Essay 270- Hyperemesis

Posted by N K.
(a) How would you confirm the diagnosis of hyperemesis gravidarum? [7 marks]
It is mainly a diagnosis by exclusion. A detailed history, examinations and investigations are necessary to confirm this diagnosis.
From history I will find out the onset, duration and severity of the symptom. Onset after 9weeks may be suggestive of other causes. I will enquire about associated symptoms such as abdominal pain, urinary symptoms, fever which may point towards infective causes such as Urinary tract infections, cholecystitis, and appendicitis or even hepatitis. Symptoms of constipation (intestinal obstruction) or diarrhoea (gastroenteritis) should be excluded. A personal or even strong family history of hyperemesis will make this diagnosis more likely. Asian ethnicity is more prone to hyperemesis. Drug history is essential as some antibiotics or iron supplements can cause this condition.
Grave’s disease may present for the first time in pregnancy with hyperemesis. Pre pregnancy and present symptoms suggestive of hyperthyroidism should be evaluated. Thyroid functions may be elevated in pregnancy; however thyroid antibodies will be specific for Grave’s disease.
Twin pregnancy and molar pregnancy needs to be excluded. Utreine fundus will be more than the gestational age on abdominal palpation. However an Ultra sound scan is necessary to confirm this.

(b) How would you assess the severity of the condition? [4 marks)
Severity can be subjectively assessed from the history by severity of symptoms such as severe vomiting and unable to eat or drink or keep any thing in.
It is vital to assess the degree of hydration on examination by skin and mucosal dryness, reduced urine out put and concentration, and decreased sweating. Severe dehydration may affect the level of consciousness of the patient.
In observations pulse rate and respiratory rates may be raised and orthostatic hypotension may be observed. Urine analysis is essential to look for ketonuria and increased specific gravity. Full blood count may be useful to assess the haematocrit which will be raised and serum urea and electrolyte is essential to look for any imbalance ( hyponatraemia, reduced urea). Metabolic hypochloraemic acidosis may be seen, unless the condition is severe where metabolic acidosis is observed.

(c ) The woman has severe hyperemesis. Justify your management [9 marks].

Hyperemesis is intractable severe nausea and vomiting arising early (6-8wks) in pregnancy resulting in loss of more than 5% of body mass and ketosis. If untreated can cause severe maternal and foetal morbidity. The patient needs to be admitted in the hospital in case of severe hyperemesis until stabilisation.
The main stay of the management is correct the dehydration and alleviate the symptoms. Dehydration can be corrected by IV fluids mainly 0.9% normal saline or Hartmann’s. Higher concentration saline solutions should be avoided even in case of hyponatraemia as rapid correction can cause central pontine myelinosis. Dextrose should also be avoided as this won’t correct hyponatraemia and may precipitate Wernick Korsakoff encephalopathy. Potasium chloride may be necessary with every bag of fluid. Fluids should be infused quickly initially. It may be ideal to keep the patient nil orally for the first 24 hours as oral intake may precipitate further vomiting.

IV or IM (or even PR) antiemetics should be given regularly until can tolerate orally. First line antiemetics are Cyclizine, Promethazine, Metachlopromide or Prochlorperazine. These are not teratogenic and some of them can cause drowsyness (cyclizine and promethazine) and extra pyramidal side effects (Metachlopramide, Prochloperazine). If still intractable, Ondansetrone may be considered. Long term safety profile in pregnancy is not available. Treatment with corticosteroids have shown dramatic improvement is some studies. Hydro cortisone 100mg Bd followed by 40 mg predniselone . Can be tailed off to 5-10mag daily after 20 weeks. Some people may need it until delivery. This is not teratogenic, but has to watch out for infections and gestational diabetes when on long term high dose therapy.
Stop any antibiotics or iron tablets if on any. May benefit from thiamine IV or orally if tolerated, as prophylaxis for Wernick-Korsakoff encephalopathy. Thrombo prophylaxis is essential with LMWH prophylactic dose and correctly fitted compression stockings. Antacids such as Ranitidine or omeprazole may be useful in reducing gastric symptoms.
Some severe cases may reaquire parentral nutrition if all the above measures fail.

Initial weighing followed by regular weighing is essential to check for rate of body mass loss. Fluid balance chart should be maintained to asses input and out put. Reagular full blood count (haematocrit), Ureal and electrolytes are essential to assess hyponatraemia, alkalosis and acidosis if present. Liver function tests and Thyroid functions tests are not done routinely.
Lots of emotional support and reassurance is needed throughout treatment. When stabilised, should be discharged on oral antiemetics with food and intake advice. Regular follow up is essential.
Posted by San S.
a)Hyperemesis gravidarum is vomiting in pregnancy as a physiological hence diagnosis after ruling out other underlying pathology and causeof vomiting. Hence, it is important to enquire about the severity of vomiting, and other associated symptoms. Feeling feverish with contact or family members with vomiting and diarrhoea may indicate food poisoning or gastroenteritis. Other systemic symptoms e.g.rigors and abdominal pain may indicate appendicitis or urinary tract infection. Symptoms and signs of tachycardia, intolerance to heat, vomiting which are common symptoms in pregnancy may be similar to hyperthyroidism.
On examining a patient with hyperemesis gravidarum, she may be tachycardic, apyrexial with a soft, non-tender abdomen. Her may be pyrexial with right iliac fossa pain or guarding with appendicitis with raised inflammatory markers (WCC and CRP). Raised inflammatory markers, suprapubic pain, dysuria and leucocytes in urinalysis may suggest urinary tract infection. TSH may be low in hyperthyroidism although thyroid function tests may be deranged in hyperemesis as well.
b)In severe hyperemesis, she could clinically be dry with signs of tachycardia, hypotension/postural hypotension, with slow capillary refill time. Her buccal mucosa may appear dry and she may have ketotic smelling breath.
Her urine may appear concentrated and with high concentration of ketones on urine dipstix.
c)I would admit this patient, gained iv access for rapid rehydration with Hartmanns solution or normal saline. Blood should be taken for FBC, CRP to rule our co-existing infection, U&Es to assess renal function, TFTs and LFTs as this may be deranged in severe hyperemesis and there may be coexisting hyperthyroidism.
She should have daily bloods, weight and abdominal girth measurements and urinalysis to asess response to treatment.
She should be given antiemetics e.g.cyclizine, chlorpromazine, metoclopramide which are safe in pregnancy parentallly for symptomatic control. Vitamin B12 may be commenced when she tolerates oral intake as it is effective in preventing hyperemesis gravidarum. Should she not response to conventional antiemetics, steroids may be used after discussion with senior obstetrician or endocrinologist.
USS should be arranged to rule out molar and multiple pregnancy that could cause severe hyperemesis in pregnancy.
Posted by Shachi M.
(a) How would you confirm the diagnosis of hyperemesis gravidarum?
Diagnosis is confirmed by history, examination and investigations.
A history of excessive vomiting, with onset in early pregnancy, in absence is any other cause is suggestive of hyperemesis gravidarum. Vomiting associated with dysuria, loin pain, frequency could be due to urinary tract infection. The presence of jaundice, right hypochondrial pain, pale stools could suggest vomiting secondary to liver disease. If associated with heart burn and epigatric pain, it might suggest gastritis or peptic ulcer. A previous history of recurrent urinary tract infections, peptic ulcer, liver disease and current medication is important.
A thorough general examination should be carried out to check for pallor, jaundice and signs of dehydration. Urine should be dipped to rule out urinary tract infection, and check for ketonuria.
A mid stream urine should be performed if dipstick shows presence of leucocytes, protein or nitrates.
A full blood count , liver function tests and renal function tests should be done to aid diagnosis.

(b)How would you assess the severity of the condition?
The signs of severe hyperemesis are, inability to tolerate solid or liquid food, signs of dehydration on general examination (tachycardia, hypotension, dry tongue, delayed capillary refill), negative fluid balance on input output chart, presence of ketones in urine and raised urea and creatinine in serum.

c ) The woman has severe hyperemesis. Justify your management [9 marks].
A woman with severe hyperemesis should be treated as an inpatient. She should have intravenous fluids at least 250-125mls per hour to begin with, followed by maintenance fluids. As there is risk of hypokalemia, potassium should be supplemented with fluids. Some women will need vitamin B1 supplementation.
A full blood count , liver function tests and renal function tests should be performed.
Antiemetics like cyclizine (50mg TDS oral/im/iv), stemetil (oral/im/pr), maxolon (10mg oral/im/iv) are safe in pregnancy. If there is no response, then ondensetron can be prescribed.
An input output chart should be maintained and pulse and blood pressure should be checked regularly (2-6 hourly, depending upon severity. TEDS stockings should be provided to minimise the risk of thromboembolism. If the patient is at hig risk of thromboembolism (high BMI, age more than 35 years, previous thromboembolism ) then can be prescribed low molecular weight for thromboprophylaxis.
When the patient is stable, she should have a pelvic ultrasound scan to check for viability of pregnancy and to rule out multiple pregnancy and molar pregnancy.
Posted by Priti T.
a]Hyperemesis Gravidarum is the severe vomitting occuring in early pregnancy[peak 8-12weeks]requiring hospital admission.It affects 3-10/1000 pregnancies.It is basically a diagnosis of exclusion,which can be confirmed by taking history,doing physical examination and investigations.

We take the detail history of urinary symptoms like frequency,haematuria,pain in flanks to rule out UTI/Pyelonephritis;history of epigastric pain,or pain lower abdomen with vomitting ,haematemesis,fever,drug ingestion like iron[ferrous sulphate] to rule out peptic ulcer,acute appendicitis,intestinal obstruction,pancreatitis,diabetic ketoacidosis or hepatitis.Accordingly patient is examined physically to assess hydration;abdominal examination for the tender points and the bowel sounds.
She should be be investigated in detail.FBC -which shows raised haematocrit due to dehydration,U&E -which shows low blood urea,hyponatraemia,hypokalemia;MSU with dipstix for the blood,proteins,ketones,nitrites,glucose,culture&senstivity to rule out UTI/Ketosis.LFT may be raised slightly and hepatitis should be excluded.TFTs may be raised and hyperthyroidism should be ruled out.Serum Amylase will be raised in acute pancreatitis.USG is done to confirm the viability and the dating of pregnancy ai 9 weeks and at the same time multiple/molar pregnancy may be ruled out.

b]Severity of Hyperemesis Gravidarum can be assessed by the loss of skin turger,sunken eyes,rapid pulse,postural hypotension[dehydration],ketonuria,electrolyte imbalance of hyponatremia and hypokalemia with low blood urea and raised haematocrit;abnormal LFTs and raised TFTs.

c] Severe Hyperemesis requires in patient admission and management of dehydration and ketosis.Patient is rehydrated with Na and K containing fluids like normal saline and Hartmann\'s solution.Daily urine output and serum electrolytes is used to monitor the fluid regimen.Dextrose containing fluids are avoided as they aggravate hyponatremia and cause thiamine deficiency precipitating Wernicke\'s Encephalopathy.Thiamine therapy is given to avoid this risk.
Patient is weighed twice weekly to monitor the progress.
Simple anti emetics like cyclizine,domperidone,metoclopromide,promethazine,perchloperazine are effective and safe in the first trimester of pregnancy.Ondansetrone is 5HT3 antagonist with a limited experiance of use in the treatment of hyperemesis.Severe Refractory cases of hyperemesis are treated with corticoids,oral prednisolone or intravenous hydrocortisone,but they have side effects like hypergycemia,acidity.Non pharmacological measures like ginger and P6 Accupressure may be useful in some cases.
Once patient is settled she is advised about the oral nutrition of taking small frequent meals and avoiding the spicy foods.Psycological support is given to the mother that the condition carries minimal risk to the foetus of low birth weight only and the nausea/vomitting resolves by 12 weeks or maximum 16-20 weeks;but there is 50% risk of recurrence in the next pregnancy.
Very severe intractable cases not responding to the above therapy may be advised TOP[termination of pregnancy].
Posted by Asma kamal K.
(a)Hyperemesis gravidarum is the diagnosis of exclusion. Detail history, examination and investigation to rule out other pathologies is very important. I will ask her about the duration and progression of the symptoms, weight loss, weather she is able to tolerate any thing by mouth,is she producing any urine.
To rule out urinary tract infection I will ask her about fever ,rigors,loin pain,supra pubic pain, dysuria, frequency, urgency, burning micturation and hematuria.In examination I will specifically look for tachycardia, raised temperature, renal angle tenderness, supra pubic tenderness. I will do Urine dipstix for nitrite, hematuria, and WBC esterase and MSU for culture.
To rule out gastroenteritis I will ask her about associated diarrhea, tranismus, crampy abdominal pain. I will send her full blood count for WBS count (infection) and if the history suggest I will send her stool for microscopy and detail examination.
To rule out gastric ulcer I will ask her any previous history of acid peptic disease , gastro esophegial reflux, retro sternal burning, melena . I will look for epigartric tenderness.If the history suggest I will ask for anti bodies against helicobector pylori and upper gastro-intestinal endoscopy.
To rule out hyperthyroidism iwill ask her about heat intolerance tachy cardia tremors,examine her for the presence goiter, fine tremors and will investigate her throid function test.
To rule out molar pregnancy I will ask her about any previous history of molar pregnancy, any history of bleeding or passage of grapes like vesicle per vaginum. I will do per speculum examination to look for any bleeding and ask for ultra sound pelvis, which will also tell me about the site viability and number of pregnancy and will rule out any ovarian accident.
To rule out hepatitis I will ask her about any history of viral hepatitis or chronic liver disease, any associated right hypochondric pain or jaundice. In examination I will look for jaundice right hypochondric pain and hepatomegaly.I will ask for LFTs and if history suggest I will ask for viral markers and ultra sound hepatobiliary tree.
To rule out intestinal obstruction I will ask about the content and the colour of the vomitus, any associated abodominal distension,is she able to pass stool and or flatus. I will specifically look for distended abdomen,percussion notes and bowel sounds.if the history suggest then I will ask for ultra sound abdomen.
To rule out any CNS or vestibular cause I will ask her about any associated head ache, blurred or double vision, vertigo dizziness and seizures.I will examine her pulse, blood pressure and optic fundi (rasied intracranial pressure) and request an ENT examination.
To rule out pancreatitis I will ask for sever abdominal pain,look for abdominal guarding rigidity or tenderness and if the history and examination suggest I will ask for serum amylase,Calcium(decrease) and blood sugar random(raised).
If all the above are excluded and there is only history of hyperemesis, generalized weakness and weight loss. I will ask her about any history of hyperemesis in the previous pregnancies (if relevent) and will confirm the diagnosis.
(b) Severity of the condition can be assessed by the history examination and investigation. In history excessive force full vomiting with fresh bleeding in the vomitus and severe retrosternal pain may indicate Mallory weiss tear. Rapid weight loss with muscle wasting indicating malnutrition. Diplopia, ataxia peripheral neuropathies will indicate thiamine deficiency. Pain and swelling in the limbs will indicate venous thromboembolism(VTE). On examination and tachycardia orthostetic hypotention , low JVP,loss of skin turger(dehydration) anemic(Vit B12 deficiency) confused and convulsing patient(electrolyte imbalance). Patient with abnormal ocular movements, sixth nerve palsy(wernickes encehalopaty) and painfull swollen limb are all symptoms and sign of severity. On investigation raised hemoglobin and hematocrit(Hemoconcentration) hyponatrimea, hypokalemia,metabolic alkalosis, ketone in urine are all the indicators of severity of the disease.
(c)Severe hyperemesis gravidarum if untreated or not treated properly will lead to maternal morbidity and mortality and perinatal mortality. Mild cases can be managed on day care bases but moderate to severe cases in which a patient cannot tolerate oral fluid, severly dehydrated,significant weight loss (3 kg or more)malnutrition,acidotic or infected should be offered in patient care. Aim of the management is to prevent complications like dehydration, malnutrition,severe electrolyte imbalance,VTE, Mallory weiss tears, wernickes encephalopathy.she will be kept nil peroral till the vomiting subsides. This patient will need multidisciplinary care involving consultant obstetrician ,medical specialist, ITU specialist(if needed), dietician psychologist and social support group.
To correct dehydration intravenous 0.9% NACL or ringer lactate will be given. Though she will be hyponatremic but it will not be corrected too rapidly i.e with double strength saline because it will cause central pontine myelinolysis which will lead to spastic duadruplagia, pseudobulbar palsy and impaireand conciousness. Dextrose solution will be avoided as will further worsen hyponatremia and will precipitate wernickes encephalopathy which will lead to korsakoffs psychosis and death. Hypokalemia will be corrected. Anti emetics like dopamine antagonist, phenothiazine anti-cholinergics and anthistamine can be given. Patient usually prefer non oral preparations like per rectal domperidne and subcutaneous metaclopramideazine. patient who do not respond to conventional anti emetics odansterone and corticosteroids can be given. Thromboprphylaxis with deterrent stockings and low molecular weight heparin till she is admitted. Patient should be reassured that usually this problem settles down after 16-18 weeks and has no bad effect on the growing fetus. Dietry advice like small and frequent meals, avoidance of spicy food and drugs which irritate GI tract helps in many cases.Maternal surveillance will be done with twice weekly weight , ketonuria,urea and electrolyte estimation.
Patient will need psychological support and encouragement as social or psychological pressures may be the causes behind her problem. Rarely in very severe intractable cases termination of pregnancey may be offered or requested by the patient which should be respected.Patient who respond to treatment will be discharged home with oral antemetics,corticosteroids(if needed) and dietery advise and regular follow up antenatal visits. fetal surveillance will require frequent growth scaning as hyperemesis is associated with IUGR. Patient will need i.v corticosteroid in labour if she will be long term steroids. Postnatally her nutrition status will be revised again and she will be informed about the recurrence risk of 50%. Proper advice regarding contraception will be given to her.
Posted by Manoj M.
Hyperemesis is diagnosis of excusion.A detailed history must be taken to find out the symptoms, and the correlation with her last menstrual period. Additional symptoms like dysuria, loss of appetite, pale coloured stools can point towards a urinary tract infection and hepatitis respectively. Associated abdominal pain, shoulder tip pain, location and the severity can point towards gastrointestinal causes and cholecystitis. History of hyperthyroidism needs to be taken as hyperemesis can mimic hyperemesis. A urinary dipstick may show signs of infection, ketosis, however urinary tract infection may also be superimposed on hyperemesis. Examination for signs of acute abdomen to rule out surgical causes, renal angle tenderness, signs of hepatomegaly will point towards surgical causes. Blood investigations for full blood count and C- reactive protein to rule out sepsis needs to be done. Elevated liver function tests may be present with hepatitis, cholecystitis or obstructive jaundice as well as hyperemesis. However, checking for Hepatitis antigens and an ultrasound of the abdomen can rule out obstructive jaundicae and gall stones. Thyroid function tests to asess if evidence of hyperthyroidism, however the blood picture may be very much similar in hyperthyroidism amd hyperemesis. An ultrasound of the pelvis to confirm pregnancy, the number of fetuses as twin pregnancy can cause a higher degree of hyperemesis. Molar pregnancy which can causes hyperemesis can also be ruled out with an ultrasound, if in doubt a grossly elevated HCG level can confirm this.
B. The severity of the condition can be assessed when symptoms do not settle with oral or parenteral anti emetics. Signs of severe hypovolemia like raised dry skin, pulse rate, low blood pressure and oliguria should be looked for. Low blood urea, deranged electrolytes like hypokalemia, hyponatremia inspite of treatment will give the severity of the condition. Derangement of liver function tests can also occur in severe disease. Signs of vitamin deficiency like wernicke\'s encephalopathy can develop with severe hyperemesis. Weight loss of more than 6 kilograms suggests severity of the problem.
C. The management must be multidisciplinary with a team of obstetrician, medical input and dietician in severe disease. The aim would be to control symptoms and prevent secondary complications. Intravenous fluids, with potassium supplementation if necessary with strict input and output chart to identify early renal compromise and ensure hydration. Regular parenteral antiemetics like cyclizine, stemetil and metaclopramide can be given. Polydrug therapy can be beneficial. Ranitidine can be given to reduce acidity. Daily check of renal and liver functions to assess progress and if necessary request medical input. If vomiting is intractable and the electrolytes are deranged, hydrocortisone can be given parenterally, howvever gradually withdrawn after response. Thromboprohylaxis in the forms of TED stockings and low molecular weight heparin can be given in prohylactic doses. Dietician should be involved to ensure nutrition and fortified food can be given, however if patient is unable to eat then total parenteral nutrition is to be considered. Parenetal multivitamin in the form of pabrinex to prevent vitamin deficiency especially Vitamin B1 and folic acid. Emotional and social support to be given to patient as this can be extremely stressful for her and her family. She should also be reassured that the medications are safe for her and her fetus.
Posted by Srivas  P.
a) It is a diagnosis of exclusion. Significant vomiting in 1st trimester associated with >5% loss in weight could be due to Hyperemesia Gravidarum. Other cause which may cause excess vomiting like UTI, Hepatitis, appendicitis, cholecystitis, small bowel obstructions have to be ruled out before making tentative diagnosis of HG.

Her menstrual history should be taken and USG done do pregnancy dating and also rule out hydatiform mole and Multiple pregnancy as cause for this excessive vomiting.

Hepatitis will present with deranged LFT, Liver tenderness, hepatosplenomegaly and jaundice and possibly positive hepatitis antigens. LFT like S. Aminotranferase and S Bilirubin may also be deranged in 50% cases of HG though the levels are likely to be lower than with Hepatitis. Appendicitis may present with acute pain abdomen, tenderness at Mc Burney’s point and symptoms of vomiting and diarrhea. USG may reveal an appendicular mass. Any Gall bladder enlargement or stones may suggest cholecystitis. Urinary infection should be ruled out by urine M/E and culture. Increased urinary Specific Gravity and ketonuria could be seen in hyperemesis.

b)Significant weight loss more than 10-20% of body weight indicates severity of HG. She may present with marked hypotension and severe ketoacidosis. Severe malnutrition and resultant thiamine deficiency may precipitate Wernicke’s encephalopathy which may also be associated with fetal death in 40% cases.

The fetus in mothers with severe and refractory hyperemesis may have lower birth weight.
Thyroid function tests also may provide a useful index of severity of HG, as it correlates with the degree of hyperthyroidism, with possibility of refractoriness to treatment and repeated admissions.

c)It is a potentially life threatening condition. Senior input and hospital protocol should be followed in management.

Woman with severe HG should be admitted and started on Intravenous drip to correct to dehydration and severe ketosis as she is unlikely to be able to retain oral fluids. Anti emetics like ranitidine, omeprazole should be started to simultaneously to encourage oral rehydration while drugs that may cause vomiting should be discontinued temporarily.

She should be investigated for serum electrolytes levels as she may have hyponatremia and hypokalemia which needs urgent correction. This needs to be monitored on a daily basis to maintain serum electrolytes. TFT should be done to assess severity of HG. Monitoring should also involve daily weight, pulse, B.P, Fluid balance chart.

First she must have intravenous rehydration with normal saline or Hartmann’s solution. Double strength saline solution should be avoided as rapid reversal of hyponatremia can cause central pontine myelinosis. Solutions containing dextrose should also be avoided because they do not contain enough sodium and may precipitate Wernicke’s encephalopathy. Thiamine supplementation should be given to all patients with severe HG to prevent Wernicke’s encephalopathy. This can be by daily tablets after initial intravenous supplementation. She should also have Vit B12 and Vit B6 supplementation as prolonged hyperemesis can cause deficiency of these vitamins.

Complications of excessive vomiting like Mallory–Weiss tears of the esophagus may sometimes occur, causing haematemesis and these need surgical referral and management.

If the woman has prolonged hospitalization and extended bed rests she should receive thromboprophylaxis with LMWH till the condition is under control. Wearing TDS stockings is also helpful in preventing VTE.

If vomiting still does not come under control and she needs repeated admissions, she may benefit by Corticosteroids given as I/V hydrocortisone and later maintained by prednisolone 5-10mg daily, up to 20 weeks pregnancy. In cases of refractory HG uncontrolled on any treatment regime, termination of pregnancy could be the best alternative. This is likely to be very distressing to the woman. Careful counseling with woman and partner may help them make this difficult decision.
Posted by hoping ..
A healthy 23 year old woman is referred by her midwife because of possible hyperemesis gravidarum at 9 weeks gestation. (a) How would you confirm the diagnosis of hyperemesis gravidarum? [7 marks] (b) How would you assess the severity of the condition? [4 marks] (c ) The woman has severe hyperemesis. Justify your management [9 marks].
Hyperemesis is associated with considerable morbidity and sometimes maternal mortality. Vomitings in early pregnancy is common form of presentation and tend to occur after fourth week of gestation. Absence of diarrhoea and abdominal cramps rule out gastroenteritis. Urinary tract infection could present with vomitings thus urinary symptoms should be enquired. History of thyroid dysfunction or associated symptoms of menstrual irregularity pre pregnancy, unexplained weight loss or gain should be asked to rule out thyroid problems.Patient should be asked about number of vomitings and any haematemesis as it is associated with high morbidity and requires urgent investigations and management. If she can manage any oral intake or not should be checked as if it is severly restricted she would need inpatient management. Her pulse and blood pressure should be examined to check for hypovolemia. Her tongue AND SKIN TURGOR help in assesing dehydration. Neck should be examined for thyroid pathology. Patients consciousness and neurological examination for wernickes encephalopathy should be checked. This includes gait and eye examination. If she appears acidotic or altered conciousness, arterial blood gases should be done to ruleout acidosis. Her urine should be tested for ketonuria to asses dehydartion. Urine should also be tested for protein,leucocytes , blood and nitrites as these may indicate infection. Bloods should be sent for full blood count to check for anaemia and haematocrit. Liver function should be checked as hyperemesis may cause severe hepatic dysfunction.Urea and electrolytes should be requested to diagnose and treat hypokalemia and also detrmine renal function because with severe dehydration renal failure can occur. Thyroid function tests should only be done if history suggests probability. these should be interpretated carefuly as undergo physiological alteration in pregnancy with hyperthyroid picture in prepregnancy.
Severity of condition is detrmined by symptoms and biochemical parameters. Excessive vomiting and when patient unable to tolerate any oral intake can rapidly deterirate patients condition. Haemetemesis indicate severe hyperemesis due to bleeding from oesophaegeal or upper gastric vessels. Loss of skin turgor and low volume pulse with tachycardia indicate severity of dehydration. Any signs of wernickes encephalopathy or Korsakoff\'s psychosis also indicate severe hyperemesis. Biochemical parameters of deranged liver function and electrolytes are associated with severe disorder. High urea and creatinine levels indicate renal compromise.
Severe hyperemesis requires inpatient management and thus pateint should be offered admission. Intravenous access should be obtained and crystalloids commenced at rate of 200-250 mls hourly. Dextrose should be avoided because of risk of osmosis and further loss of circulating volume. Potassium supplements should be given as guided by levels. Antiemetics like cyclizine, prochlorperazine are effective in reducing vomitings and are not teratogenic . Metoclopramide and Ondansetrone may also be considered if first line not effective. Steroids are effective and should be considered if hyperemesis is unresponsive to other treatments. Daily Fluid balance should be recorded and observed to aid in estimating required fluids and early detection of renal compromise or fluid overload. Liver and renal function tests should be repeated regularly depending upon derangement until stable. Vitamin supplements especially thiamine and folic acid should be administered . Alternative measures like acupuncture and ginger also appear to be effective. Severe hyperemesis is associated with increased risk of thrombosis thus prophylactic antocoagulation with compression stockings and heparin should be given. Ultrasound to rule out molar pregnancy and multiple pregnancy should be arranged. Patient should be counselled and supported throughout as psychological morbidity can be significant. Parentral nutrition or nasogastric tube feeding should be considered if persisiting hyperemesis limiting nutritional intake.
Rarely termination of pregnancy is required when condition severe and unresponsive .
Posted by Farina A.
a)Hypermesis gravidarum is the diagnosis of exclusion. Patient should be enquired for other GIT symptoms like diahrea, hematemesis, malaena or bleeding P/R. History of jaundice and nausea vomiting before pregnancy may indicate liver disease. Gastritis is usually an with epigastic pain and heart burn, which relieves on eating. Acute pancreatites may present with severe epigastic pain with nausea and vomiting and acute cholecystitus may have the same picture with a positive murphy’s sign. Acute pyelonephiritis should slow signs and symptoms of UTI like burning micturation and renal angle tenderness. Acute gynaecological emergencies like twisted ovarian cysts and ectopic pregnancies may present with vitally unstable patient with diagnostic sonographic findings. Rarely Addisons disease and hypercalcemia during pregnancy may present with these features. The investigations required are liver function tests which may not be deranged, however alkaline phosphatase is markedly raised in obstructive jaundice. Serum amylase is raised in pancreatitis, very low serum Na concentration may indicate Addison’s disease and low ca levels are found in hypercalcemia. Diabetics kelodiedosis in known diabetics may present with nausea vomiting and epigastric pain and should be ruled out by checking blood glucose.

b)Severity of the disease can be assessed by examining the state of hydration, hypotension and ketotic breath. A urine analysis may show ketones and serum electrolysis are low in persitent vomiting.

c)Severe hyperemesis is managed by replacing fluids and electrolytes and prescribing I/V antiemetics. Rehydration should be done with caution by Hartman’s solution. Rapid rehydration by
5% dextrose may lead to Wernick’s encephalopately and rapid rehydration with hypertonic saline is associated with pontine myelinosis. . Antihistamine like Cyclezine and promatheazine, Phenothazides like prochlorprazine and chlorpromazine and dopamine, receptor antagonist like metachorpromide and domperiodine all are safe during pregnancy.H2 receptor blocking agents like omeprazole can be given for dyspeptic symptoms and 5HT3 selective serotonin receptor antagonists like ondansetron can be used as second line therapy. Finally in intractable cases, steroids are indicated with I/V hydrocortisone 100mg BD
or methylperdnisolone 40-50mg daily in divided doses. These patients are at risk of vitamin deficiency like vitamins B1, B6 and B12. Thiamine defiency should be rapidly reversed as it is associated with wernickes encephalopathy. Once retrograde amenesia ,inability to confabulate and learn ensues, the recovery rate is about 50% and complications include pontine myelinosis and presents with spastic paraplegia. Psuedobulbar palsy and impaired conciousness. Thromboprophylaxis is indicated in view of dehydration. Prolonged severe vomiting is associated with mallory wiese ulcers and may result in oesophageal rupture and pnemothorax which should be managed in conjunction with a chest physician. In severe intractable cases total parenteral nutrition is indicated and termination of patient can be done as a last resort.
Posted by Drxyz A.
a) I shall take detailed history about gastritis, uti, hepatitis and previous history of hyperemesis gravidarum. I shall ask about the duration of the symptoms and severity. As hyperemesis gravidarum is the diagnosis of exclusion so other causes of persistent vomiting will be ruled out by history, examination and investigations.

On general physical examination I shall take the vital signs and assess the hydration of the patient. On abdominal examination I shall look for the liver enlargement

I shall check urine with dipstick for ketones in urine will be +ve in hyperemesis gravidarum. leukocites and nitrates will be +ve in UTI

I shall send blood for i) CBC to see the hematorit which will be raised in hyperemesis gravidarum, ii) U&E to see the urate and electrolyte levels because urate will be high and Na and K will be low in hyperemesis gravidarum. iii) LFT as 50% of patient with hyperemesis gravidarum have deranged liver function. iv) Thyroid function test because in 66% cases with hyperemesis gravidarum have abnormal TFT.

USG for molar pregnancy or twin pregnancy.


b) Severity of the condition is assessed by seeing the general condition of the patient. Hydration level of the patient. Degree of ketonurea. Patient\'s inability to retain fluids or food. if the patient is suffering from hemtaemesis. B1 vitamin deficiency due to hyperemesis can lead to wernicke\'s encephalopathy in which patient will be confused, have diplopia, ophthalmoplegia and nystagmus. Severe hyoponatremia can present as lethargy and seizures. Malnutrition can cause weight loss of the patient and if more than 5% loss can cause low birth weight baby. If the patient is not responding to the treatment than termination of the pregnancy is recommended.
.
c) For severe hyperemesis I shall admit the patient. Keep her NPO. Send her blood for CBC, U&E, Blood sugar, LFT, RFT. I shall check urine for ketons. I shall give IV fluids but not dextrose as it will precipitate Vit B1 deficiency. the fulids will include NaCl or Ringer Lactate. If needed replacement of K. I shall give IV anti-emetics like cylizine, promethazine and phenothyazine on regular basis. If patient not relieved by this than i shall give Ondansitron whcih is a strong anti-emetic. Proton Pump inhibitors (omeprazole) in case of dyspepsia. If all these treatments fail to control the condition than prednisolone or IV Hydrocortisone will be given. Thromboprophylaxis will be given. Psychotherapy consulation will be done. If the condition does not resolve quickly the steroids will be discontinued gradually. With the help of dietician enteral feeding will be started to correct the malnutrition state. With enteral nutrition there is risk of aspiration. although enteral nutrition is cost effective but in very severe cases total parenteral nutrition is necessary. With TPN there is risk of thrombosis and phlebitis. If all the above measures fail than termination of the pregnancy will be considered.
Posted by g.b. D.
a)
Severity can be assessed by clinical examination and investigations.
A history of not being to able to retain any foods, intractable vomitings are suggestive of severe case. General examination for pallor, icterus and signs of dehydration should be done. Loss of skin turgor, sunken eyes, dry and coated tongue is associated with severe dehydration. Urine dipstick for sugar proteins and ketones will show ketonuria.
Cbc and hematocrit will show hemoconcentration due to dehydration. Renal function tests with be deranged with high urea and electrolytes will show hypernatremia and hypokalemia in severe cases.liver function tests will be mildly raised.
In very severe cases the patient may feel giddy and confused. There is a risk of pontine myelinosis due to hypernatremia and wernicke’s encephalopathy due to vit B12 deficieny which may manifest with CNS signs.



b)
There is a risk of myelinosis wernickes encephalopathy and thrombosis in severe hyperemesis due to hemoconcentration .this risk is more if she is obese and previous history of thrombosis and varicose veins and in bed for long hours due to these vomitings.
These patients should be admitted and monitered closely for signs of dehydration, intake output chart, signs of giddiness or confusion ,and urinary dipstick for ketones 8 hrly.
cbc electrolytes and rfts should be done 24- 48 hrly depending upon the clinical condition.hydration should be maintained with iv fluids . normal saline should be used. Dextrose containing crystalloids may precipitate wernickes encephalopathy. 2.5 to 3 lit of fluids can be given in a day. Any hypokalemia should be treated with addition of 20 meq of kcl in the infusion according to deficit.
Parenteral Amti emetics like metoclopramide, cyclizine, stemitil and H2blockers can be used. They are safe in pregnancy. In uncontrolled cases may use ondensetron (5HT3 antagonists).they have not shown to be of any harm in the trials though not routinely recommended in pregnancy. In intractable cases steroids can be used. However they are associated with significant maternal and fetal side effects- especially teratogeneisis at this gestation- and cannot be recommended for a long time.
As the patient is not able to tolerate foods, she can be kept nil per orally for one or two days till her symptoms settle and parenteral nutrition is given till then. Im inj of vit B12 or multivitamin injections can be given weekly to overcome deficiency.Folic acid supplemetation should be given . general advise of leg exercises in bed, TED stockings should be given. If high risk then thromboprophylaxis with lowmolecular wt heparin should be considered.

c)
In cases where symptoms are still uncontrolled with all these measures ,the dyselectrolytemia and abnormal renal functions persists , may consider option of TOP.
Once vomitimgs settle and there is no ketonuria may shift to oral antiemetics and dietary advise of liquids and short frequent meals. She should be advised to avoid foods that trigger nausea and ptylism.
Continued support from staff and family with the resuring scan findings can help to recover early.distractions with music and outings may help.
Posted by Atashi S.
a)Hyperemesis gravidarum is a diagnosis of exclusion. Careful history, clinical examination and investigation is to be done to exclude other cause of vomiting. I will assess the patient whether the vomiting is severe or not by asking her regarding weight loss, urine output, and its effect on quality of life. I will ask her about the presence of fever, chills and rigor, loin pain, supra pubic pain, dysurea, frequency and urgency which is indicative of urinary tract infection. Any history of epigastric pain and abdominal burning followed by vomiting is to be asked which is suggestive of peptic ulcer disease. History of taking oral iron preparation is to be noted which may cause gastric upset and vomiting. History of presence of similar condition in her previous pregnancy is to be noted. Degree of dehydration is to be noted. Temperature is to be measured, pulse is to be recorded to detect trachycardia, BP is to be recorded to detect hypotension. Jaundice is to be looked for. Any tenderness in the hepatic area, right illiac fossa, epigastric tenderness need to be assessed. Any enlargement of thyroid gland is to be looked for. Midstream Specimen of Urine is to be tested to rule out urinary tract infection. Full blood count to detect any infection. Urea and electrolyte to detect electrolyte imbalance like hypochlorimic alkalosis. Liver function test to rule out hepatitis. Thyroid function test to exclude hyper thyroidism. Ultrasonography is to be done for accurate dating, to exclude molar pregnancy and multiple pregnancy. Serum amylase is to be done to exclude pancreatitis. When all other cause is excluded then diagnosis is confirmed.b) Condition is likely to be severe if there is sign of severe dehydration,  presence of severe hypotension and trachycardia, presence of fever, small dark colour urine with high specific gravity, weight loss of 3 kg or more, presence of electrolyte imbalance like hypokalamea, hyponatremea, hypochloremic alkalosis and raised liver enzyme on investigation, presence of neurological abnormality like diplopia, ataxia, confusion and abnormal ocular movement. c) As the condition is severe, patient need to be admitted in the hospital. Parental nutrition is to be started with 0.9% sodium chloride or ringer lactate solution. Dextrose containing fluid need to be avoided as it may be dangerous as hyponatremea is worsen and can precipitated wernicks encephalopathy. Anti emetic drug should be given like cyclizine / metroclopramide / prochlorperazine / domperidone - can all be used. Ondansetron can be used but has limited experience regarding safety in pregnancy. If condition fail to improve then I V corticosteroid is to be given. Thiamine therapy should be considered to prevent neurological symptoms. Fluid input / output chart should be maintained to monitor progress. Weight should be taken twice weekly. Drug like ferrous sulphate if taken should be stopped immediately. Thrombo prophylaxis should be given to the patient with low molecular weight heparin and correctly fitted compression stockings. Regular investigation to assess the improvement of the condition include FBC, U and E, LFT. Explanation of the condition, reassurance and psycological support should be offered to the patient. This condition is not associated with adverse pregnancy outcome. It will usually resolve after 16 to 20 weeks. In refractory cases, sometimes termination of pregnancy should be offered.
Posted by O O.
A-Hyperemesis Gravidarum (HG) is a diagnosis of exclusion. In this healthy woman it is diagnosed with symptoms of persistent vomiting which causes weight loss ( more than 5 % body mass index) and ketonuria. That s why history taking for number of vomiting times and relation to food and the response to anti emetic treatment should be taken, as well as history of HG in previous pregnancy as it is likely to recur.
.. Urine analysis for ketones and increased specific gravity should be done to confirm diagnosis and might be positive for nitrites., leucocytes and proteins which indicate urinary tract infection(UTI), MSU should be send for culture and sensitivity in all patients with HG to exclude UTI and ultrasound scan to exclude molar or multiple pregnancy
B-the severity of the condition is assessed by history suggestive of possible complications as history of haematemesis which might indicate Mallory Weiss oeophageal tear, profound loss of weight, and symptoms of neurological manifestations of vitamin B deficiency ( wernicks encephalopathy) as diplopia, and ataxia Examination for signs of dehydration as dry tongue tachycardia and postural hypotension by checking blood pressure while patient is upright and flat, and signs of muscle wasting and vitamin deficiency as confusion in vitamin B1 deficiency and peripheral neuropathy in vitamin B6 deficiency .
Investigations done should include U & Es as the patient is liable to hypokalemia and hyponatremia and liver function tests which could raised aminotransferase an bilirubin in severe disease, full blood count which usually shows increased haematocrit value.
C-in case of severe HG proper treatment should be applied to improve outcome and to avoid complications .
The patient should be admitted to hospital for observation, and weekly weight checking and daily investigations mentioned above to detect mentioned complications and to guide treatment.
Immediate starting of intravenous hydration using normal saline or Hartman solution and avoiding double strength saline which might cause pontine myellinolysis as well as dextrose which might precipitate Wernick encephalopathyand aggrvate hyponatremia.
Thiamine is advisable to decrease chance of Wernicks encephalopathy .
Potassium chloride should be added to fluid bags according to K level.
Antiemetics should be given orally , rectally or IV according to patient ttolerance and choice from cyclizine, promethazine, prochlorpazine, metoclopromide, domipridone and chloropromazine and they are not teratogenic. Although Ondanosterone is effective safety data are still being collected. Ranitidine and protone pump inhibitor can be used successfully.
Corticosteroid therapy should be considered if not responding to conventional management and it is safe and effective
If .resistant to treatment, total parental nutrition or termination of pregnancy can be done.
Emotional support from nursing and medical staff and knowledge that symptoms will improve during pregnancy is helpful in itself.
This patient is at increased risk of venous thromboembolism so. Needs TED stocking ,and to encourage mobilization , and to consider thrmobrophylaxis as enoxaparin or tinzaparin.
OA
Posted by O O.
A-Hyperemesis Gravidarum (HG) is a diagnosis of exclusion. In this healthy woman it is diagnosed with symptoms of persistent vomiting which causes weight loss ( more than 5 % body mass index) and ketonuria. That s why history taking for number of vomiting times and relation to food and the response to anti emetic treatment should be taken, as well as history of HG in previous pregnancy as it is likely to recur.
.. Urine analysis for ketones and increased specific gravity should be done to confirm diagnosis and might be positive for nitrites., leucocytes and proteins which indicate urinary tract infection(UTI), MSU should be send for culture and sensitivity in all patients with HG to exclude UTI and ultrasound scan to exclude molar or multiple pregnancy
B-the severity of the condition is assessed by history suggestive of possible complications as history of haematemesis which might indicate Mallory Weiss oeophageal tear, profound loss of weight, and symptoms of neurological manifestations of vitamin B deficiency ( wernicks encephalopathy) as diplopia, and ataxia Examination for signs of dehydration as dry tongue tachycardia and postural hypotension by checking blood pressure while patient is upright and flat, and signs of muscle wasting and vitamin deficiency as confusion in vitamin B1 deficiency and peripheral neuropathy in vitamin B6 deficiency .
Investigations done should include U & Es as the patient is liable to hypokalemia and hyponatremia and liver function tests which could raised aminotransferase an bilirubin in severe disease, full blood count which usually shows increased haematocrit value.
C-in case of severe HG proper treatment should be applied to improve outcome and to avoid complications .
The patient should be admitted to hospital for observation, and weekly weight checking and daily investigations mentioned above to detect mentioned complications and to guide treatment.
Immediate starting of intravenous hydration using normal saline or Hartman solution and avoiding double strength saline which might cause pontine myellinolysis as well as dextrose which might precipitate Wernick encephalopathyand aggrvate hyponatremia.
Thiamine is advisable to decrease chance of Wernicks encephalopathy .
Potassium chloride should be added to fluid bags according to K level.
Antiemetics should be given orally , rectally or IV according to patient ttolerance and choice from cyclizine, promethazine, prochlorpazine, metoclopromide, domipridone and chloropromazine and they are not teratogenic. Although Ondanosterone is effective safety data are still being collected. Ranitidine and protone pump inhibitor can be used successfully.
Corticosteroid therapy should be considered if not responding to conventional management and it is safe and effective
If .resistant to treatment, total parental nutrition or termination of pregnancy can be done.
Emotional support from nursing and medical staff and knowledge that symptoms will improve during pregnancy is helpful in itself.
This patient is at increased risk of venous thromboembolism so. Needs TED stocking ,and to encourage mobilization , and to consider thrmobrophylaxis as enoxaparin or tinzaparin.
OA
Posted by Ephia Y.
Confirmation of diagnosis starts with history of when the vomiting started, any specific time of day and any history of vomiting in a previous pregnancy. Inquiry is made as to whether she is able to retain any fluids or solids at all, increased salivation, visual disturbances, history of heartburn.

Examination involves checking hydration, jaundice, ketotic breath, hepatosplenomegaly, size of uterus which may be large for dates in case of molar or multiple pregnancy. Pulse, blood pressure, temperature are checked. Any confusional state noted due to risk of Wernicke\'s encephalopathy.

Investigations include urineanalysis for ketones and any evidence of UTI. A full blood count identifies haemoconcentration, Liver function test to note any rise in bilirubin or liver enzymes and urea and electrolytes for any hyponatraemia or hypokalemia associaed with severe vomiting and any rise in creatinine and urea in severe dehydration.Urea is normally low in hyperemesis. A thyroid function test will help identify undiagnosed hyperthyroidism and an ultrasound examination will identify number of pregnancies or molar pregnancy. Hyperemesis is a diagnosis of exclusion.

Severity will be assessed by history of prolonged vomiting , inability to keep food and liquid down, severe dehydration with urinary suppression, severe ketosis evident in urineanalysis, abnormal liver and kidney function, confusion or ocular disturbances such as diplopia suggestive of Wernicke\'s encephalopathy.

Management involves hospitalization and correction of dehydration. 0.9% sodium chloride solution and Hartmann\'s are fluids of choice. Potassium is added to correct hypokalaemia. Dextrose containing fluids are not used as they cause hypokalaemia or may precipitate wernicke\'s encephalopathy. Fluid balance charts are maintained and infusion titrated accordingly.

Antiemetics are commensed in a stepwise manner. Antihistamines such as promethazine and cyclizine are usually first line and have least side effects and no evidence of teratogenicity. Phenothiazines are tried as second line and can cause drowsiness. Metoclopramide has extrapyramidal side effects. Ondansetron can be used if no response to standard antiemetics. There is no record of teratogenicity. If she continues to vomit despite these measures then corticosteroids are used. If used they need to be weaned off.

Thiamine is supplemented in severe hyperemesis to prevent Wernicke\'s encephalopathy.

Thromboprophylaxis in the form of compression stockings and prphylactic low molecular weight heparin is started due to haemoconcentration and immobilisation as they increase risk of thrombosis.

If vomiting is intractable and not responding to rehydration and antiemetics, dieticians need to be involved especially if the patient requires total parenteral nutrition.

If any causes such as hyperthyroidism, dyspepsia or molar pregnancy identified further treatment is directed to the cause.


Posted by Sam M.
A healthy 23 year old woman is referred by her midwife because of possible hyperemesis gravidarum at 9 weeks gestation. (a) How would you confirm the diagnosis of hyperemesis gravidarum? [7 marks] (b) How would you assess the severity of the condition? [4 marks] (c ) The woman has severe hyperemesis. Justify your management [9 marks].
a
Hyperemesis gravidarum is a condition resulting from excessive vomiting .this leads to dehydration and weight loss necessitationg hospital admission for further management.this is a disease of exclusion mainly seen in first half of pregnancy. diagnosis will be based on history examination and investigations .onset of vomitings .for how long and frequency the number in 24 hrs and duration episode ,relationship to specific time of the day or meal, symptoms of git disturbances as ,diarrohea,abdominal pain, fever ,right iliac fossa pain with fever clinical signs of tenderness rebound tenderness and ,guarding for appendicitis, frequency urgency burning micturation dysuria haemeturia,loin to groin pain for uti,past or recent history of epigastria pain radiating to back and felt better change in posture of pancreatitis,symptoms of hyperthyroidism as tachycardia ,sweaty hands, weight loss and ,clinical throid enlargement ,any eye singns,signs of wernicks encephalopathy ,history of diabetes and its complications as diabetic ketoacidosis, history of peptic ulcer ,I will ask her for her dating scane done so far and if done ,any evidence of molar pregnancy or multiple pregnancy, I will ask for her last weight done and now do it again to asses weight loss.
.it is said that raised hcg levels and thyroid harmones are responsible for this condition ,but no direct relation with levels of these harmones had been found, investigations to rule out other conditions responsible for excessive vomiting will be based on history and examination, as blood complete examination ,blood group rh factor urea and electrolytes, urine for microscopy and culture, thyroid function tests ,liver function test ,serum amylase level, amylase level, if dating scane not done then ultrasound for dating pregnancy ,to specifically look for molar pregnancy and multiple pregnancy. history of psychological disturbances is also important. if all other causes are ruled out and she has fluid and electrolyte imbalance and weight loss confirm hyperemesis gravidarum
b.
severity will be assessed by severity of her symptoms ,clinically dehydrating ,weight loss if very severe stupor and coma, fluid and electrolyte imbalance metabolic alkalosis ,hypokalemia as excessive potassium lost in urine, ,urine will be acidic high density ,until rehydration done and bicarbonate will started appearing in urine making it alkaline,
c
she needs emergency hospital admission if severe form is causing dehydration ,inability to oral intake and malnutrion with weight loss.and after history and examination and relevant investigations ,other causes will be excluded, blood pressure, temperature and pulse will be checked her weight assessment will be done .blood will be sent for complete examination ,urea electrolytes ,live function test, mid stream urine specimen for ketones and microscopy ,ultra sound for dating and exclude molar pregnancy and multiple pregnancy. she will be given fluids not rich in dextrose to avoid wernicke’s encephalopathy, they can even worse hyponaetremia ,to control vomiting metoclopramide , cyclizine will be given ,thiamine can also be given ,avoid any thing by mouth until vomitings controlled then started will small ,spice free meals so that no GIT irritation occurs, in severe cases steroids can be given ,termination of pregnancy if intractable vomiting not controlled by any measure and patient conditions deteriorates and she agrees for that. she needs to have antenatal frequent follow up and weight assessment on regular basis. she will be councelled that this condition is usually limited to first half of pregnancy but there is recurrence risk round 40 to 50 % is still there
Posted by H P.
(a)Hyperemesis gravidarum(HG) presents as vomiting in the first trimester associated with dehydration and weight loss and which is severe enough to require admission. HG is a diagnosis of exclusion so other causes of vomiting should be ruled out. A history of dysuria, increased urinary frequency, and fever and urine dipstix positive for nitrites, protein and leucocytes points to urinary tract infection. To confirm, I will send a mid stream urine specimen for culture and sensitivity. I would enquire for other gastrointestinal symptoms and abdominal pain. Vomiting with right iliac fossa pain and high white blood cell count is suggestive of acute appendicitis. Right hypochondriac pain and tenderness, pale stools and jaundice suggest hepatitis. A history of heart burn and reflux suggests peptic ulcer disease. A history of epigastric pain radiating to back and high serum amylase levels points to pancreatitis. Ultrasound of the abdomen will help to arrive at diagnosis if gastrointestinal cause is suspected. If urine is positive for glucose and ketones and if her blood glucose levels are high, diabetic ketoacidosis should be ruled out. HG is associated with hyperthyroidism. I would enquire about symptoms of heat intolerance, palpitations and look for midline neck swelling, tachycardia and eye signs. HG has 50% recurrence rate so I will ask about similar symptoms in her previous pregnancies. Sympathetic enquiry may reveal psychosocial factors which are known to be associated with hyperemesis. Twin or molar pregnancy on ultrasound should be ruled out. Blood investigation showing increased hematocrit, low sodium and potassium, hypochloraemic alkalosis, low blood urea and slightly raised liver enzymes help to confirm diagnosis of hyperemesis.
(b) A history of inability to retain any liquids orally and persistent vomiting uncontrolled with oral emetics with ketonuria and ketotic breath suggests severe HG. Severity can be assessed by the degree of dehydration, electrolyte imbalance, weight loss of more than 5% body weight and complications. Loss of skin turgor, dry mucosa, reduced sweating and decreased urine output with tachycardia and postural hypotension suggests severe dehydration. The resulting haemoconcentration may lead to venous thrombo-embolism. Severe electrolyte imbalance in the form of low potassium and/or sodium and metabolic hypochloraemic alkalosis, if untreated are life threatening. Severe hyponatremia may present as lethargy and seizures. Associated thiamine deficiency which may be precipitated by infusion of dextrose containing fluids will lead to (Wernicke’s encephalopathy) diplopia, ataxia, confusion and abnormal ocular movements. In severe cases, vomiting may cause Mallory-Weiss tears in the oesophagus and hemetemesis.
(c) Management requires hospital admission. Senior obstetrician, physician and dietician should be involved. Blood should be sent for complete blood count, urea and electrolytes and baseline liver function tests. Rehydration should aim to correct electrolyte imbalance. Initially Hartmann’s solution and 0.9% sodium chloride solution should be given intravenously with added potassium( K+ 20 Meq in each pint) to correct hypokalemia. Avoid dextrose containing fluids as thiamine deficiency may precipitate Wernicke’s encephalopathy. I will start parenteral emetics like cyclizine, prochlorperazine, promethazine, metoclopramide, or domperidone according to availability and response. Urea and electrolytes repeated 24-48 hourly to monitor progress. Oral diet should be gradually started with advice to avoid spicy food and having regular small meals. Thiamine and pyridoxine deficiency should be corrected. Concurrent infection should be treated. Thromboprophylaxis in the form of well fitted compression stockings should be given. LMWH should be started if she has any high risk factor for thromboembolism. Weight should be checked twice weekly. Continuous weight loss may necessitate parenteral nutrition. I will arrange ultrasound for dating and ruling out twin or molar pregnancy. She will need early evacuation in case of molar pregnancy. Drugs with GI side effects like ferrous sulphate are avoided. Ginger and wrist acupressure should be offered. Emotional support and counseling is very important. I will inform her that most cases will resolve spontaneously by16-20 weeks and it is not associated with poor pregnancy outcome. If other treatments fail, corticosteroids (oral prednisolone/ iv hydrocortisone) for short duration may be useful. In refractory cases, termination of pregnancy may be offered.
Posted by Iffat ara M.
a):As hyperemesis gravidarum is the persistent vomiting with onset in first trimester with inability to maintain adequate hydration, fluid and electrolyte balance and nutritional status. Diagnosis is made by exclusion. So urinary tract infections, gastroenteritis, pancreatitis,pepticulceration, hepatitis, diabetic ketoacidosis, appendicitis, hyperthyroidism, hypercalcemia or addison disease(rare) should be excluded. I would ask the effect of vomiting on life. How sever are the symptoms. About weight loss in recent period which is usual up to 20% in HEG. Then I will examine her thoroughly, see for signs of dehydration with postural hypotension and tachycardia,mascle wsting and ketosis. I would request following investigation FBC, urea and electrolytes, LFTs. serum calcium to rule out hypercalcaemia, TFT to exclude hyperthyroidism. Arterial blood gases are rarely carried out and test for metabolic hypochloremic alkalosis.urinalysis Is used to test for ketonuria and increase specific gravity of urine. Pelvic ultra sonography to confirm the gestational age and to exclude multiple pregnancy or molar pregnancy.
b): severity of condition would be assessed By assessing the degree of dehydration. I will check for blood pressure, pulse, postural, hypotension, ketosis and ketone urine. I will look for any sign & symptoms of maternal complications which include electrolyte imbalance especially hyponetremia which causes lethargy, seizures and respiratory arrets, I will look for anaemia and peripheral neuropathy due to vit B12 +B6 deficiency. See for Wernick’s encephalopathy due to deficiency of thiamin (B1) others risks include Mallory-Weiss tear. thromboemblism, malnuetrition , abnormal liver enzymes and jaundice .
c):Regarding management, early and aggressive treatment is essential. Treatment is supportive while awaiting spontaneous resolution. So first of all exclude other causes of vomiting assess then degree of dehydration .For rehydration Start I/V fluid(normal saline or hartmen solution) avoid dextro solution as it aggravate the risk of wernick’s and encephalopathy.Avoid double strength saline to correct the hyponatraemia as it may result the central pontine myelinolysis. Weight the patient twice weekly to monitor progress, Consider thiamine therapy. Dietary advice, usually avoid spicy food and eat small regular meals. Avoid drugs with Gastrointestinal side effects such as ferrous sulphate. Provide psychiatric and emotional support . Reassure women that most cases of nausea & vomiting in pregnancy will resolve spontaneously by 16 to 20 weeks & they are not associated with poor pregnancy out come.
Cyclizine/metachlopramide/prochlorprezine/promethazine/domperidone can all be used in first trimester. Non pharmacological treatment like ginger & P6(wrist) acupressure should also be offered. Limited experience with ondansetron (5Ht3-selectine serotonin antagonist).
H2 receptor blocker may be used for dyspeptic symptoms. Corticosteroids( oral prednisolone /IV hydrocortisone) have been shown to be useful if other treatment have failed. Thomboprophylaxis should be considered. Some patients may request Termination of pregnancy /TOP may be recommended in very severe Cases.
Indications for admission in hospital severe dehydration and inability to tolerate oral fluid.
Sever electrolyte abnormality, Acidosis, Infection, Malnutrition, Weight loss,
(Continues weight loss may require enteral feeding or parenteral nutrition).
Posted by J P.
a.Hyperemesis gravidarum is mainly a diagnosis by exclusion. I would like to rule out other possible causes, like urinary tract infection, gastroenteritis, peptic ulcer, pancreatitis, appendicitis and intestinal obstruction. I would ask for symptoms suggestive of the above possible causes and exclude it.Historynof burning micturition and suprapubic pain to rule out urinary tract infection and any past history of peptic ulcer will be enquired.History of upper abdominal pain ,fever and jaundice may suggest hepatitis.The patient presenting at 9 weeks suggest possibility of hyperemesis as this usually presents by 8-12 weeks of pregnancy.I will also request for Ultrasound if not done before to rule out multiple pregnancy or gestational trophoblastic disease. Liver function tests to rule out hepatitis and mid stream urine assay for blood and nitirtes will be done .Thyroid function test to rule out hyperthyroidism will be done as it may be co existent or the cause of vomiting.
b.The severity of the condition is assessed by limitation of daily activities of the patient. I will enquire about any limitation to such degree as unable to eat, drink and requires hospitalisation with weight loss more than 3 kg. Hydration status and ketones in Urine will also determine the severity. Associated complications like elecrolyte disturbance, Wernicke’s Encepalopathy, Mallary weiss tear will be enquired and if present will indicate the severity.
c.Severe hyperemesis gravidarum causes significant physical and psychological morbididty to the mother. Hence I will have a sympathetic approach to the patient. I will admit the patient after explaining the severity of the condition and reassuring that the symptoms will resolve as the pregnancy progresses beyond 16 weeks. I will look for the hydration status of the patient and vitals like pulse and blood pressure.Initially the patient may need intravenous fluids like Hartman solution or normal saline. I will also administer intravenous thiamine to prevent Wernicke’s encephalopathy. Antiemetic will be required as intravenous mode such as cyclizine , premethazine for the control of vomiting. Cortico steroids may be necessary in some cases if routine antiemetics have not controlled vomiting.. I will request for mid stream urine test to rulr out urinary tract infection,full blood count to anaemia and blood urea, electrolytes for base line assessment.Patient will be monitored with weekly weight, urinary ketones.Stict intake output chart will be maintained. I will request for ultrasound to reassure.the patient about the well being of baby and to rule out multiple pregnancy and gestational trophoblastic disease if not done before.I will be vigilant to look for electrolyte disturbances and other complications. Once the patient is stabilised she may be advised to start oral fluids at small and frequent intervals and avoiding spicy food. I will ensure adequate psychological and emotional support . Risk of thromboprophylaxis to be assessed. In rare cases of severe hyperemesis not responding to supportive management termination of pregnancy can be offered.
Posted by Sabahat S.
a) Diagnosis of hyperemesis is based on history examination and relevant investigation. I will ask about onset and duration of her symptom of vomiting. Onset during pregnancy in the absence of other associated conditions like infections and drugs etc is suggestive of hyperemesis. Clinical examination will be done to assess state of hydration, pulse, B.P. The findings will vary according to the severity of vomiting. An USS will be arranged to confirm singleton pregnancy and exclude multiple gestation or molar pregnancy as both of which are associated with excessive vomiting. Laboratory investigations will include FBC, U&E, and LFT, urine for ketons, to access the degree of biochemical derangement.
b) Severity of the disease will be assessed by her clinical condition and biochemical markers. Frequent vomiting with intolerance of any food or fluid, malnutrition, loss of around 5% of her prepregnancy weight is suggestive of severe hyperemesis. It will have psychological impact on her as well. Clinical examination will be done to assess degree of hydration and vital sign and weight. Signs of dehydration as dry mucous membrane, with hypotension and tachycardia will indicate severe hyperemisis.Further information regarding severity of disease will be taken by laboratory investigations.FBC will demonstrate high haematocrit, measurement of urea & electrolytes will demonstrate hyponatraemia, hypokalaemia low s.urea. LFTs may reveal mildly elevated liver enzymes and bilirubin. Urine dipstick will show presence of various degrees of ketonuria which correlates with the degree of hypovalaemia and dehydration. Acid base status will be checked in suspected severe disease, initial metabolic alkalosis (hypocholeraemic) will be followed by acidosis in more severe and protracted cases. Biochemical hyperthyroidism is common in severe cases. (60% cases) although it is self limiting. TFT provide a useful index of severity of hyperemesis, which correlate with degree of biochemical hyperthyroidism.
c) Persistent vomiting resulting in malnutrition may cause serious maternal morbidity. If not adequately treated, the maternal risks associated are Wernicke\'s encephalopathy, VTE, Mallory Weiss tears, and central pontine myelinolysis. Fetus is at increased risk of IUGR and low birth weight. W-encephalopathy is associated with 40% fetal loss. She needs inpatient management. Aim of treatment is correction of hypovalaemia, electrolyte imbalance, and acid base status and to prevent potential complications. I.V fluids replacement is done by N.saline with addition of Kcl to correct hyponatraemia and hypokalaemia. Dextrose solutions are contraindicated as these might precipitate Wernicke\'s encephalopathy. Daily monitoring of fluid balance and electrolyte disturbance is done to adjust the need. Monitoring will also include daily weight assessment, urine analysis for ketonuria, U & E and LFTs. Thiamine supplements will be given to prevent W. encephalopathy as IV infusion once a week. Antiemetic cyclizine, metoclopramide or prochlorperazine are given as 1st line drugs. In severe cases if no response, Ondansteron can be given but the experience is limited. If these agents fail corticosteroids are given and are found to be effective. As she is prone to develop VTE due to dehydration and immobility, she will be given LMWH and TED stockings. She will be given emotional support and reassurance as it plays a very vital role in the management. In protracted cases, entral feeding or total parental nutrition is considered to reverse catabolic state. The drawbacks are the need for central venous access & cost. In such a condition, termination of pregnancy may be considered as life saving. She will be discharged from the hospital once she starts to tolerate fluids and foods, no longer ketotic on urine analysis with normal biochemistry. Dietary advice will be given to avoid spicy food and eat frequent small meals.



Posted by R M.
a) Hyperemesis Gravidarum (HG) is severe or protracted vomiting in pregnancy with onset in the first trimester causing severe dehydration, fluid and electrolyte imbalance and weight loss (>10%) .

It is a diagnosis of exclusion. In case of this healthy young female, I’ll have to exclude the possibility of a current urinary tract infection (UTI) or acute gastroenteritis; other surgical causes like acute appendicitis, hepatitis or pancreatitis; obstetric causes like multiple pregnancy or molar pregnancy.

I’ll look for pointers in the history such as a similar episode in the previous pregnancy ,if any, favours diagnosis of HG (~50% recurrence risk). Associated symptom like dysuria is suggestive of possible UTI. Diarrhoea or associated abdominal pain points towards a gastrointestinal or surgical cause.

I’ll assess the level of dehydration by seeing the texture of skin, pulse and BP. Abdominal palpation will be done to see any suprapubic or renal angle tenderness suggestive of UTI; rebound tenderness or guarding suggestive of surgical cause.

Investigations will guide me to identify or exclude underlying causes and help me in confirming the diagnosis of Hyperemesis Gravidarum. I’ll do an FBC which will show raised haematocrit and leukocyte count in case of HG due to volume depletion. Blood urea, electrolytes and blood gas analysis will be done as it may be associated with hyponatremia, hypokalemia or metabolic alkalosis. Liver function tests will be done as it is abnormal in ~50% cases of severe HG (moderate rise of transaminaeses and bilirubin).
Thyroid function test may be deranged (elevated T4 and suppressed TSH due to TSH simulating effects of hCG). Urinalysis will be done to test for ketonuria and MSU to exclude UTI. Pelvic USG- to confirm a viable single intrauterine pregnancy as both multiple pregnancy and molar pregnancy are associated with hyperemesis.

b) Severity can be assessed by checking the level of dehydration and extend of weight loss(>3kg); by assessing the degree of ketonuria. Deranged LFTs (moderate rise of transaminaeses and bilirubin) and abnormal thyroid function tests (elevated T4 and suppressed TSH) are also seen in ~30 – 50% cases of severe HG. Electrolyte abnormalities such as hyponatremia, hypokalemia and metabolic alkalosis also indicate severe disease.

c) I’ll admit the patient immediately for inpatient management – delay in treatment or inappropriate treatment may result in serious morbidity and mortality. Early and aggressive treatment of the patient is essential.

Initial management includes intravenous therapy using Normal Saline or Hartmann’s with potassium chloride as needed to correct dehydration and electrolyte abnormalities. Dextrose solutions should be avoided as it may precipitate Wernicke’s encephalopathy. Double strength saline should be avoided as rapid correction of hyponatremia may result in Central Pontine Myelinolysis. Treatment should be titrated based on fluid balance charts, weight charts and daily urea and electrolytes. Urinary ketones should be monitored fourth hourly to see improvement.

Thiamine should be supplemented as deficiency can cause Wernicke’s encephalopathy (characterized by diplopia, abnormal ocular movements, ataxia and confusion). Thiamine can be given orally if tolerated or parenterally along with vitamin B12 and B6 (deficiencies of which may cause anemia and peripheral neuropathy).

Symptom control should be achieved with antiemetics as persistent and prolonged vomiting may lead to haemetemesis due to esophageal Mallory-Weiss tears. There is substantial evidence to support the safety of conventional antiemetics in pregnancy including their use in first trimester- antihistamines like cyclizine or promethazine can be used. Dopamine antagonists like metoclopramide or domperidone are also effective. Phenothiazines are also safe. H2 blockers like ranitidine may be used for dyspeptic symptoms.

Patient should be advised to stop oral iron intake as it can aggravate gastric irritation and vomiting. Psychological and emotional support will be provided. I’ll reassure the patient that there is no increased incidence of congenital abnormalities for the baby and the condition will usually resolve as pregnancy by 20-24weeks.There is a small risk of IUGR for the baby if the condition doesn’t improve.

Thromboprophylaxis using LMWT Heparin should be considered as dehydration and bed rest are risk factors for thromboembolism.

In refractory cases steroids such as prednisolone or hydrocortisone may provide rapid resolution of symptoms(evidence from RCTs to support beneficial effect of steroids in HG)

Life threatening cases may require total parenteral nutrition (advice from dietitian will be sought) or enteral feeding. Last resort will be termination of pregnancy if all measures fail or if the patient requests. Patient will be explained about her condition and written information will be given. I’ll tell her regarding ~50% recurrence risk. I’ll give addresses of support groups like Blooming Awful (www.hyperemesis.org.uk).
Posted by SHAGUFTA T.
A) Hyperemesis gravidarum is vomiting in early pregnancy (8-12Wks) severe enough to require hospital admission due to dehydration, electrolyte imbalance & weight loss. It affects 3-10 women/1000 pregnancies. As Hyperemesis gravidarum is diagnosis of exclusion, detailed history, examination & investigation is needed to confirm the diagnosis. I will take history of duration & severity of her symptoms. History of any accompanying symptoms like dysuria, frequency, burning urine or hematuria to exclude Urinary tract infection. I will ask her about any gastrointestinal symptoms like diarrhea, heart burn, epigastric or abdominal pain to exclude diseases like gastroenteritis, peptic ulcer, pancreatitis, appendicitis, hepatitis or Mallory Weis tears. I will history of any past or present Psychological/ Psychiatric disorder. H/O hyperemesis in previous pregnancy if she is multip, or family Hx of hyperemesis.
On examination, I will look for signs of dehydration, vitals, Postural hypotension, check weight (compare if previous weight known). I will do per abdomen examination to look for epigastric/ RIFossa/ hypochondrial tenderness, any hepatosplenomegaly.
Investigations: FBC, MSU, U&E, to check hematocrit, to exclude UTI, electrolyte imbalance respectively. LFT, Thyroid function, S. amylase will be done to exclude liver disorders including hepatitis, thyroid dysfunction & pancreatitis respectively. I will also do USS for dating of pregnancy and to exclude multiple or molar pregnancy.
B) Severity of her symptoms will be assessed by history, examination &investigation results. In history I will ask whether she is able to eat / drink and retain it. She is passing urine or not (amount & colour of urine). If she feels confused, irritable or dizzy, double vision to rule out Wernicke’s encephalopathy. On examination, I will look for signs & severity of dehydration by loss of skin turgor, dry & coated tongue, sunken eyes. I will check Vital signs, postural hypotension. Presence of ketotic breath to be checked. On investigation—acidic urine, ketonuria, S. potassium to check hypokalemia.
C) Severe hyperemesis if left untreated is associated with considerable maternal & fetal morbidity. Mainstay of Treatment is in patient admission for rehydration and correction of electrolyte imbalance if there, till patient is stabilized. I will start IV fluids—0.9% normal saline or Hartmans solution to correct dehydration, if hypokalemia is there, KCL may be needed to avoid complications like arrhythmia. Dextrose containing fluids should be avoided in view of worsening of hyponatremia & precipitation of Wernicke’s encephalopathy. Pt should be kept NPO for first 24 hrs to avoid more vomiting.
Antiemetics like cyclizine, promethazine, metoclopramide, prochloperazine or domperidone are given I/V, I/M or rectal if unable to tolerate orally. They are safe 7 no terratogenecity demonstrated. Ondansetron might be given but limited experience. In severe non responding cases, corticosteroids I/V hydrocortisone followed by oral prednisolone is beneficial but if used for long duration can lead to increased risk of GDM, IUGR, infections. Thiamine therapy may be given to prevent thiamine deficiency & Wernicke’s encephalopathy. After stabilization, before discharge Dietary advice is given to avoid spicy food & to take small frequent meals. Avoid drugs like ferrous sulphate to avoid gastric irritation.
Thromboprophyllaxis in form of TED stockings & LMWH should be considered as pregnancy, admission & dehydration predisposes her to increased risk of VTE. Psychological & emotional support should be provided, with explanation that there is minimal risk to her fetus. TOP is considered as last resort in severe & intractable cases with maternal wishes in consideration. Leaflet provided on diet, medications & informed about risk of recurrence (50%) in future pregnancies
Posted by SK K.
a) Vomiting in early pregnancy is commonly due to hyperemsiss. As many as 50 % of pregnant females have nausea & vomiting . but this gets settled by 14-16 weeks. All the same it is imperative to confirm hyperemesis and rule out other sinister condition that present as vomiting.
History of onset of hyperemesis should be enquired . Nature of vomiting should be noted as projectile & billous could indicate ominous condition .Any associated symptoms of urinary tract infection, gastrointestinal symptoms, pain abdomen, diarrhea should be asked as all could present with vomiting. Intake of any emesisis causing drugs to be asked. Also awareness of the attitude of the women towards the pregnancy as unwanted pregnancies are more likely to be associated with hyperemeisis. Clinical examination revealing dehydration, nutritional and vitamin deficiency, absence of any positive specific clinical sign and pelvic examination confirming pregnancy will add to confirming the diagnosis. A USS confirming the pregnancy, multiple pregnancy or molar pregnancy will make the diagnosis of hyperemisis more likely as vomiting is caused by the high circulating goandotropin levels

b) severity of condition can be assessed by an integrated approach of history, examination, investigation.
No. of episodes of vomiting, limitation of daily routine activities , no response to antiemetics, history of hematemsisis, retrosternal burning indicating esophageal tears .A note of disorientation or confabulation (as seen in korsakoff’s psychosis secondary to severe vitamin & nutritional deficiency) will point to severity of hyperemesis .
On clinical examination degree of dehydration, tachycardia, hypotension, sign of nutrition deficiency, clouded consciousness, will add to knowledge of severity .
Investigations will objectively confirm the severity of dehydration as a sequalae to hyperemesis ; urinary ketones, full blood count showing increased heamatocrit and increased leucocytes, electrolyte imbalance of decreased serum sodium, potassium and calcium, all suggestive of hypochloremic alkalosis. Altered liver function test & raised TFT are also seen in severe hyperemesis

c) As this is a case of severe hyperemeiss inpatient treatment is required.
Vitals and urinary ketones to be monitored frequently as will reflect response to treatment. Also frequent serum urea and electrolytes to be monitored as they are deranged .
Patient to be nil per oral so as to decrease complications of hyperemeisis eg: esophageal tears, aspiration.
Intravenous fluids to be started, dextrose containing fluids to be avoided as will cause precipitation of wernickes encephalopathy.
KCL to be added to intaravenous fluids & thiamine 100 mg / weekly to be given to correct vitamin deficiency.
Antiemetics, odansterone, pyridoxine, prochlorphenazine , ginger may be tried to subside nasea and vomittings .Thromboprophylaxisis to be considered if severly dehydrated.
If still unresponsive to provide total parental nutrition with steroid .
Also to arrange for GE endoscopy to rule out APD, esophageal tears.
Termination of pregnancy to be considered if loss weight exceeds > 10 % of original body wt .

As condition improves gradually to start orally liquids, than soft diet finally normal diet.
Advice to avoid spicy food ,and consume small frequent carbohydrate snacks.
Counseling and gaining her confidence, involving a dietician, sympathetic nurse to care for her.,
Attempt must be made to know of any social pressures on her, and if pregnancy is unwanted.Involving her patner and relatives in her care will boost her morale and may help in recovery .
She should be put in contact with support groups.
She should be advised to continue folic acid and provided with contact numbers in case of need .





Posted by Farkhanda A.
A---- Confirmation of diagnosis
Hyper emesis gravidarium is a diagnosis of exclusion. It is associated with pregnancy and so all other causes which can cause nausea and vomiting have to exclude to confirm its diagnosis. There are some investigations which are important to carry out. Urin dip stick at the bed side can give clue about the urinary tract infection ( UTI ) by showing blood, leucocytes, nitrates and proteins. UTI can be confirmed by sending mid stream urine (msu). Thyrotoxicosis can cause intractable vomiting which can be excluded by checking TSH, T3 and T4. IF in history, there is suspicion of gastroenteritis ask about diarrhoea and eating some thing different from the routine or appendicitis or intestinal obstruction. Check for pancreatitis, cholecystitis or hepatitis by sending blood for liver function test (LFT) or by ultra sound scan (USS).
USS can be arranged to exclude or confirm multiple, molar (complete) or ectopic pregnancy as first 2 forms can give troublesome vomiting.
B------assess the severity
It can be assessed by general examination and from history. Check her blood pressure which may be lower or orthostatic hypotension due to dehydration , pulse may be faster or tachycardia. In sever cases, she may be breathlessness. On urin dip stick, there may be lot of ketones in severe cases. She will give history that she cannot tolerate orally. Due to constant and severe vomiting, she may be very quite and depressed. In severe cases, it will be difficult to get the intra venous (IV) access as all veins will be collapsed.
C----management
Hyper emesis if intractable and not treated can be fatal for mother and foetus. Admit the patient , get IV access and obtain blood for full blood count to check haemoglobin level and white cells count , C reactive protein (CRP), LFT, urea + electrolytes level. IV fluid replacement by 0.9% normal saline alternating Hartman’s’. Ant emetics can be given by IV, intra muscular or per rectum. We can give cyclizine, prochlorthiazines, metchlorpropamide and promazines. In severe cases ondansterone can help to control. In resistant cases where all measures to control vomiting are unsuccessful, steroids can be used with good result. We can use Hydrocortisone 100mg twice a day and change it by prednisone 30-40 mg and tailoring it down to 10-15 mg per day.
First 24-48 hours patient should be nil by mouth as taking anything orally can aggravate vomiting.
There is a risk of venous thrombo-embolism, so her dehydration should be corrected as soon as possible. She should use deterrent stockings and Lower molecular weight Heparin in a prophylactic dose.
Due to severe vomiting, there may be mal absorption of vitamin B and due to its deficiency; there is a risk of wernick encephalopathy. It can be avoided by giving thiamine in IV fluids 50 mg per day. If at all there is no improvement, then last option may be termination of pregnancy.



Posted by Anna L.
Anna O\'Brien

a)
Hyperemesis gravidarum is a diagnosis of exclusion. I will take a history of current complaints and ask for presence, onset and severity of nausea and vomiting. I will asses her ability to keep oral fluids or any food. I will ask whether members of family are similarly affected to exlude possibility of food poisining. I will ask for urinary symptoms, bowel irregularitis and abdominal pain. I will take an obstetric history and ask for hyperemesis in previous pregnancies considering the high risk of recurrence. Since she is described healthy underlying medical causes can be excluded.
I will check whether an US was done to confirm viable IUP and exclude multiple pregnacy or molar.
I will examine the patient, checking HR, BP and palpate the abdomen, excluding a pregnancy large for dates (Molar/Twins). I will dipstick her urine and check for ketones as sign for dehydration typical with H.gravidarum and check for signs of UTI. I will send bloods to assses for hypokalaemia secondary to severe vomiting, LFTs and TFT which can be deranged in H.gravidarum. With no other causes found in a symptomatic, pregnant woman I will manage her empirically as for H. gravidarum and reassses for other causes if not improving.

(b) How would you assess the severity of the condition? [4 marks]

I will consider the patients general status, her ability to keep oral fluids and her degree of dehydration (dry mucosae, large ketones in urine, por urine output). Severe hyperemesis is reflected by worsening biochemistry, haemoconcentration ( high Hb), deranged electrolytes (Hypokalaemia, hypernatriaemia) and raised LFTs. Abnormal TFT can be observerd with severe H.gravidarum.

(c ) The woman has severe hyperemesis. Justify your management [9 marks].

Severe hyperemesis can not be managed safely in the community and therefore I will admit this patient. I will Insert an iv access and send bloods for FBC, U+Es, LFTs, TFT and Clotting to assess severity of disease and give iv fluids (N saline or Hartmann\'s solution) to rehydrate and correct hypokalaemia if needed. I will give thromboprophylaxis with heparin and Teds as severe hyperemesis and immobility is a risk factor for DVT. I will arrange for an US if not done to exclude molar and multiple pregnancy as a cause. I will prescribe Thiamin, 10mg OD to avoid Wernicke\'s Encephaly and regular antiemetics via routes tolerable for the patient( IV, IM, PR or orally). Suitable are Metoclopramide, Cyclizine and Chlorproperazine. To control accompanying heartburn i will give ranitidine. In treatment resistant cases hydrocortison has been benefitial. I will refer her to the obstetric medical team or medial team in the hospital for joint approach. With severe uncontrollable hyperemesis, after appropriate counselling a TOP may need to be considered in rare cases.
Posted by Srivas  P.
Sir
Please give your opinion on this extract from article on Hyperemesis Gravidarum in TOG 2003 Vol5 Num4 page204 :

Value of routine assessment of thyroid function in all women with HG is questionable however Thyroid function tests provide a useful index of severity of HG, which correlates with the degree of biochemical hyperthyroidism. Women with HG and abnormal thyroid function usually require longer hospitalisation to avoid readmission
Posted by Farkhanda A.
Dear paul
I always remind you to check my essay. All others who posted their reply after me, their essays have been checked. Is my essay is of low standard to answer on its turn.

It is important to check your facts before making public statements. I suggest you look through the sequence of answers carefully and you will find that essays have been marked strictly on a first-come-first-served basis. There is the odd occasion when an answer has been missed and we will normally post an apology. The essay that was posted before yours was downloaded last night for marking and has just been uploaded.

We recognise that we are a day behind with the marking but this is because we sometimes need to seek advice with regards to specific issues before marking can begin.
Posted by Srivas  P.
Your frustration at not having your answers corrected is understandable. But Dr Paul is our teacher and I feel requests should be more polite
Posted by Dr. Ruvana T.
healthy 23 year old woman is referred by her midwife because of possible hyperemesis gravidarum at 9 weeks gestation. (a) How would you confirm the diagnosis of hyperemesis gravidarum? [7 marks]

For confirmation of diagnosis I have to take history from patient, perform examination and do some investigations .For hyperemesis possible complaints may be increased frequency of vomiting and decreased urine volume. There may be sign of dehydration,ketosis. Dry tongue sunken eye, acetone breath, tachycardia. postural hypotention.rise of temperature and even jaundice. To exclude other cause of severe vomiting urine analysis should done (UTI) , an USG to exclude molar pregnanacy and multiple preg. S. electrolyte should done.
As it is diagnosed by exclusion so UTI, pepticulcer, hepatitis, acute appendisitis should exclude.
As it has deletirios effect on mother like dehydration, malnutrition,electrolyte imbalance , jaundice, Mallory- weiss tear , DVT, Wernicke\'s encephalopathy, so careful assesment is necessary to adverse effect on fetus.

(b) How would you assess the severity of the condition? [4 marks]
Severity can be asses by examination of patient. She may severely dehydrated, sunken eye , dry tongue, acetone breath, tachycardia, postural hypotention, rise of temperature, hepatitis may noticed.Urine output may reduced with high colour urine.
By doing some investigation Urine small in quantity,high specific gravity, ketonuria. On Serum electrolyte there may be Hyponatremia leading to pontine myelysis . feature of hypokalaemia. Patient may even unconcous in severe condition.
There may thiamine deficiency leading to Wernicks encephalopathy.
(c ) The woman has severe hyperemesis. Justify your management [9 marks].
Such patiant should manage after immediate admission. Patient should kept NPO after 24 hour of stoppage of vomiting. An intravenous fluid of 0.9% normal saline or Hartsol should start . With vitamin c and vitamin B complex in i/v fluid. Electrolyte balance according to Serum electrolyte report. Measure Urine output to assess urine volume . Intravenous antiemetic like cyclizine , metachlopramide,prochloperazine,promethazine,domperidone- all these are safe in 1st trimester.
corticosteroid can given in intractable case.
Some patient may neede TOP but it is very rare.
When patient general condition improve by stoppage of vomiting , increase urine output, rise of BP - she could start dry carbohydrate like toast and repeated small dry food. After complete cure patient can discharge.
She should give moral support and ensure her this condition will resolve spontaneously by 12 to 14 week.