Emilio Aguinaldo College

School of Nursing and Midwifery

A Case Analysis on

Hyperemesis Gravidarum

Submitted by: Garong, Roseflorenz Czarina R. 08-1-63688 Section 2 / Group D

Submitted to: Maam Amparo Lim, RN

I.

INTRODUCTION Overview of the Case

Hyperemesis gravidarum is a rare condition of severe nausea and vomiting which starts in the first 20 weeks of gestation. The vomiting results in weight loss, dehydration, acidosis from starvation, alkalosis from loss of hydrochloric acid, and electrolyte imbalances. The fetus is at risk for IUGR, abnormal development, and death if the condition is not treated. Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids." Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0%.

CAUSES OF HYPEREMESIS GRAVIDARUM

The cause of HG is unknown. The leading theories speculate that it is an adverse reaction to the hormonal changes of pregnancy. In particular Hyperemesis may be due to raised levels of beta HCG (human chorionic gonadotrophin) as it is more common in multiple pregnancies and in gestational trophoblastic disease. This theory would also explain why hyperemesis gravidarum is most frequently encountered in first trimester (often around 8 12 weeks of gestation), as HCG levels are highest at that time and decline afterwards. Additional theories point to high levels of estrogen and progesterone, which may also be to blame for hypersalivation; decreased gastric motility (slowed emptying of the stomach and intestines); immune response to fragments of chorionic villi that enter the maternal bloodstream; or immune response to the "foreign" fetus. There is also evidence that leptin may play a role in HG. Historically, HG was blamed upon a psychological condition of the pregnant women. Medical professionals believed it was a reaction to an unwanted pregnancy or some other emotional or psychological problem. This theory has been disproved, but unfortunately some medical professionals espouse this view and fail to give patients the care they need. A recent study gives "preliminary evidence" that there may be a genetic component.

RISK FACTORS A risk factor is something that increases a persons chance of getting a disease or condition. Risk factors do not necessarily mean that a person will develop a condition. In the case of hyperemesis gravidarum, the following are risk factors:

Hyperemesis gravidarum during a previous pregnancy

Being overweight Having a multiple pregnancy Being a first-time mother The presence of trophoblastic disease, which involves the abnormal growth of cells inside a woman's uterus

SIGNS AND SYMPTOMS OF HYPEREMESIS GRAVIDARUM Signs of Severe HG: Debilitating, chronic nausea Frequent vomiting of bile or blood Chronic ketosis and dehydration Muscle weakness and extreme fatigue Medication does not stop vomiting/nausea Inability to care for self (shower, prepare food) Loss of over 5-10% of your pre-pregnancy weight Weight loss (or little gain) after the first trimester Inability to eat/drink sufficiently by about 14 weeks

Symptoms of Severe HG: When HG is severe and/or inadequately treated, it may result in: Loss of 5% or more of pre-pregnancy body weight Dehydration, causing ketosis and constipation Nutritional deficiencies Metabolic imbalances Altered sense of taste Sensitivity of the brain to motion Food leaving the stomach more slowly Rapidly changing hormone levels during pregnancy Stomach contents moving back up from the stomach Physical and emotional stress of pregnancy on the body Subconjunctival hemorrhage (broken blood vessels in the eyes) Difficulty with daily activities Hallucinations

Some women with HG lose as much as 20% of their body weight. Many sufferers of HG are extremely sensitive to odors in their environment; certain smells may exacerbate symptoms. This is known as hyperolfaction. Ptyalism, or hypersalivation, is another symptom experienced by some women suffering from HG.

As compared to morning sickness, HG tends to begin somewhat earlier in the pregnancy and last significantly longer. While most women will experience near-complete relief of morning sickness symptoms near the beginning of their second trimester, some sufferers of HG will experience severe symptoms until they give birth to their baby, and sometimes even after giving birth. An overview of the significant differences between morning sickness and HG can be found at Hyperemesis or Morning Sickness: Overview EXAMS AND TESTS The doctor will perform a physical exam. Blood pressure may be low. Pulse may be high. The following laboratory tests will be done to check for signs of dehydration:

Hematocrit Urine ketones

Your doctor may need to run tests to rule out liver and gastrointestinal problems. A pregnancy ultrasound will be done to see if you are carrying twins or more, and to check for a hydatidiform mole.

DIAGNOSIS Women who are experiencing hyperemesis gravidarum often are dehydrated and losing weight despite efforts to eat. The nausea and vomiting begins in the first or second month of pregnancy. It is extreme and is not helped by normal measures. Fever, abdominal pain, or late onset of nausea and vomiting usually indicate another condition, such as appendicitis, disorders, gastritis, hepatitis, or infection.

COMPLICATIONS

For the pregnant woman: If inadequately treated, HG can cause renal failure, central pontine myelinolysis, coagulopathy, atrophy, Mallory-Weiss syndrome, hypoglycemia, jaundice, malnutrition, Wernickes encephalopathy, pneumomediastinum, rhabdomyolysis, deconditioning, splenic avulsion, and vasospasms of cerebral arteries. Depression is a common secondary complication of HG. On rare occasions a woman can die from hyperemesis; Charlotte Bront is a presumed victim of the disease.

For the fetus: Infants of women with severe hyperemesis who gain less than 7 kg (15.4 lb) during pregnancy tend to be of lower birth weight, small for gestational age, and born before 37 weeks gestation, in contrast, infants of women with hyperemesis who have a pregnancy weight gain of more than 7 kg appear similar as infants from uncomplicated pregnancies. No long-term followup studies have been conducted on children of hyperemetic women.

TREATMENT

Because of the potential for severe dehydration and other complications, HG is generally treated as a medical emergency. Treatment of HG may include antiemetic medications and intravenous rehydration. If medication and IV hydration are insufficient, nutritional support may be required. Management of HG can be complicated because not all women respond to treatment. Coping strategies for uncomplicated morning sickness, which may include eating a bland diet and eating before rising in the morning, may be of some assistance but are unlikely to resolve the disorder on their own. There is evidence that ginger may be effective in treating pregnancyrelated nausea; however, this is generally ineffective in cases of HG. IV hydration IV hydration often includes supplementation of electrolytes as persistent vomiting frequently leads to a deficiency. Likewise supplementation for lost thiamine (Vitamin B1) must be considered to reduce the risk of Wernicke's encephalopathy. A and B vitamins are depleted within two weeks, so extended malnutrition indicates a need for evaluation and supplementation. Additionally, mineral levels should be monitored and supplemented; of particular concern are sodium and potassium. After IV rehydration is completed, patients generally progress to frequent small liquid or bland meals. After rehydration, treatment focuses on managing symptoms to allow normal intake of food. However, cycles of hydration and dehydration can occur, making continuing care necessary. Home care is available in the form of a PICC line for hydration and nutrition (called total parenteral nutrition). Home treatment is often less expensive than long-term and/or repeated hospital stays. Medications While no medication is considered completely risk-free for use during pregnancy, there are several which are commonly used to treat HG and are believed to be safe. The standard treatment in most of the world is Benedictin (also sold under the trademark name Diclectin), a combination of doxylaminesuccinate and vitamin B6. However, due to a series of birth-defect lawsuits in the United States against its maker, Merrill Dow, Benedictin is not

currently on the market in the U.S. (None of the lawsuits were successful, and numerous independent studies and the Food and Drug Administration (FDA) have concluded that Benedictin does not cause birth defects.) Its component ingredients are available over-thecounter (doxylamine succinate is the active ingredient in many sleep medications), and some doctors will recommend this treatment to their patients. Antiemetic drugs, especially ondansetron (Zofran), are effective in many women. The major drawback of ondansetron has been its cost. In severe cases of HG, the Zofran pump may be more effective than tablets. Zofran is also available in ODT (oral disintegrating tablet) which can be easier for women who have trouble swallowing due to the nausea. Promethazine (Phenergan) has been shown to be safe, at least in rats and may be used during pregnancy with minimal/no side effects. Metoclopramide is sometimes used in conjunction with antiemetic drugs; however, it has a somewhat higher incidence of side effects. Other medications less commonly used to treat HG include Marinol, corticosteroids and antihistamines. Anecdotal evidence suggests that the use of marijuana, or of the pharmaceutical extract Marinol can relieve the symptoms of HG, in a similar way to treating nausea in people with Cancer and AIDS. However, due to the criminalization of cannabis, there have been no clinical trials into its effectiveness or risks to the fetus. Nutritional support Women who do not respond to IV rehydration and medication may require nutritional support. Patients might receive parenteral nutrition (intravenous feeding via a PICC line) or enteral nutrition (via a nasogastric tube or a nasojejunum tube). Support It is important that women get early and aggressive care during pregnancy. This can help limit the complications of HG. Also, because depression can be a secondary condition of HG, emotional support, and sometimes even counseling, can be of benefit. It is important, however, that women not be stigmatized by the suggestion that the disease is being caused by psychological issues.

Distinguishing between morning sickness and hyperemesis gravidarum: Morning Sickness: Hyperemesis Gravidarum: Nausea sometimes accompanied by vomiting Nausea accompanied by severe vomiting Nausea that subsides at 12 weeks or soon after Nausea that does not subside Vomiting that does not cause severe dehydration Vomiting that causes severe dehydration Vomiting that allows you to keep some food Vomiting that does not allow you to keep down any food down

PATHOPHYSIOLOGY The etiology of nausea and vomiting of pregnancy is unknown. Many have postulated that nausea and vomiting are protective in pregnancy to reduce exposures to potentially teratogenic materials. Some theories hold that elevated human chorionic gonadotrophin (HCG) or estradiol levels could be causative, due to correlations in numerous studies between levels and symptoms, but this has not been demonstrated conclusively. Psychological theories of the etiology are falling out of favor, and the American College of Obstetrics and Gynecology warns that attributing vomiting to psychological disorders has likely impeded progress in understanding the true etiology of hyperemesis gravidarum. EPIDEMIOLOGY

Frequency United States Hyperemesis gravidarum occurs in 0.5-2% of pregnancies, with the variation in incidence arising from different diagnostic criteria and ethnic variations. Studies have found an admission rate of 0.8% for hyperemesis gravidarum and an average of 1.3 hospital admissions per hyperemesis patient, with an average hospital stay of 2.6-4 days.
Mortality/Morbidity

With mild-to-moderate vomiting, the patient and the fetus are unlikely to experience any increased morbidity or mortality. Before the advent of intravenous hydration, hyperemesis was a major cause of maternal death. Currently, mortality is exceedingly rare, but maternal morbidities may include Wernicke encephalopathy from vitamin B-1 deficiency, Mallory-Weiss tears, esophageal rupture, pneumothorax, and acute tubular necrosis. Hyperemesis is the second leading cause of hospitalization in pregnancy, second only to preterm labor. Additionally, many women experience significant psychosocial morbidity, occasionally interfering with assumption of the maternal role and rarely leading to termination of the pregnancy.
Race

Hyperemesis patients are more likely to be nonwhite.

Age

Patients younger than 30 years are more likely to experience hyperemesis.

NURSING IMPLICATION Nursing implications include the following: Record accurate intake and output to include emesis. Monitor intravenously (IV) solutions ordered by the physician. Record the patient's weight daily. Assess the patient for skin damage if dehydration is obvious. Implement prophylactic measures (lotions, massages, op-site) to prevent skin breakdown. Be alert to the psychological needs of the patient. She may be concerned about this crisis and of the results on herself and the fetus.