Hyperemesis gravidarum: Complications and Management

What is hyperemesis gravidarum?

Hyperemesis gravidarum refers to the extreme and stubborn vomiting during pregnancy. This post focuses on the key features, causes, risk factors, diagnosis, complications and management of hyperemesis gravidarum.

Nausea and vomiting during pregnancy is a common problem during the first trimester of pregnancy. Nausea and emesis during pregnancy usually subside after 12 weeks of gestation (morning sickness)  and rarely extend to the second trimester. Around 2-3% of pregnant women are diagnosed with hyperemesis gravidarum.

nausea and vomiting during pregnancy, hyperemesis gravidarum

What are the key features of hyperemesis gravidarum?

Hyperemesis gravidarum is characterised by the features mentioned below:

  • Continuous vomiting (>3 times a day)
  • Weight loss (>5% of pre-pregnancy  weight)
  • Dehydration 
  • Electrolyte imbalance
  • Not being able to keep liquid or foods down
  • Fatigue
  • Dizziness and fainting
  • Headache
  • Increased ketone levels- ketonuria and/or ketonemia

Other features include

  • Increased heart rate
  • Dry skin
  • Low blood pressure
  • Confusion 
  • Jaundice
  • Dark urine as a result of dehydration
  • Serious complications like Wernicke-Korsakoff syndrome which is caused because of thiamine deficiency (caused by dehydration)

Causes of hyperemesis gravidarum

The cause of hyperemesis gravidarum is unclear. An increase in hormone levels (human chorionic gonadotropin  and estrogen) during pregnancy could be a reason. Lower esophageal sphincter relaxes because of an increase in estrogen and progesterone during pregnancy

Risk factors

  • Hyperemesis gravidarum in previous pregnancy
  • Multiple pregnancies (twins, triplets or more)
  • 1st pregnancy
  • Family history of hyperemesis gravidarum or morning sickness
  • History of migraine or motion sickness
  • Gestational trophoblastic disease (GTD)

Diagnosis  of hyperemesis gravidarum

Diagnosis of hyperemesis gravidarum is generally based on the following 

  • Signs and symptoms
  • Medical history
  • Physical examination
  • Checking body weight
  • Urine and blood analysis
  • Ultrasound of abdomen and gastrointestinal tract to rule out other diseases.

Complications of hyperemesis gravidarum

A pregnancy associated with hyperemesis gravidarum is usually termed as high risk pregnancy. The following are some of the maternal and foetal complications associated with hyperemesis gravidarum

  • Preterm birth
  • Low birth weight
  • Pneumothorax 
  • Esophageal rupture as a result of recurrent vomiting
  • Permanent disability of mother
  • Depression and anxiety

Management of hyperemesis gravidarum

The key features, risk factors, diagnostic criteria, causes, complications and management of hyperemesis gravidarum differentiates it from morning sickness.

Lifestyle modifications

  • Avoid triggers- certain foods and smell.
  • Eat small, frequent meals.
  • Avoid spicy and oily foods as it could trigger vomiting.
  • Include a protein rich diet (prefer bland, plain and dry food).
  • Hydrate well

Treatment of hyperemesis gravidarum

The treatment of hyperemesis gravidarum consists of the following 

  1. Fluid and electrolyte replacement with appropriate IV fluids and electrolytes. Check fluid and electrolyte levels frequently.
  2. Vitamin replacement
  • To prevent Wernicke’s encephalopathy, thiamine replacement (oral or IV)  is done. Give IV thiamine in case of intolerability to oral thiamine.
  • Pyridoxine / vitamin B6 
  1. Antiemetic therapy 
  • H1 receptor antagonists- Cyclizine & Promethazine.
  • Phenothiazines- Prochlorperazine & Chlorpromazine.
  • Dopamine antagonists- Metoclopramide & Domperidone.
  • 5-HT3 receptor antagonist- Ondansetron.
  1. Other drugs used in hyperemesis gravidarum
  • Corticosteroids (last option)- usually hydrocortisone or prednisolone is used. Tapering is done accordingly.
  1. Ginger- some studies show that ginger is effective in reducing pregnancy related nausea and vomiting.
  1. Other measures
  • Tube feeding
  • TPN- Total parenteral nutrition

 Although certain drugs are considered safe during pregnancy, care should be taken while taking drugs during pregnancy. Hence, consulting a doctor is recommended instead of taking OTC medications during pregnancy.

Written by Auxi Arobana. R

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