Hyperemesis Gravidarum

Question 1

What are the risk factors of hyperemesis gravidarum?

Answer 1

• Nulliparity
• Multiple pregnancy
• Obesity
• Hyperthyroid
• Trophoblastic disease (more b-hCG)
• Previous HG
• Smoking is Protective

Question 2

What are the signs and symptoms of hyperemesis gravidarum?

Answer 2

• Diagnostic criteria to diagnose HG
  
  • ≥5% pre-pregnancy weight loss
  • Dehydration
  • Electrolyte imbalance
• Vomiting and inability to tolerate food and fluids
  
  • Starts between 4th and 7th gestational week and resolves by 20th week
• Examination
  
  • Basic obs - temperature, pulse, BP, O2 sats, RR, weight
  • Abdomen exam
  • Signs of dehydration
  • Signs of muscle wasting

Question 3

What investigations should be done for suspected hyperemesis gravidarum?

Answer 3

• Exclude other causes
• Body weight
• U&E
• Urine dipstick (check ketones)
• PUQE-24 to assess severity of HG
  
  • ≥13 = admission

Question 4

What is the management of hyperemesis gravidarum?

Answer 4

• Mild and moderate NVP/HG treated in the community
  
  • If fails, treat as a day case in ambulatory care
  • Remember VTE, KCl, Vitamin B1 (thiamine)
• 1st line = Antihistamines - IV promethazine, cyclizine, prochlorperazine, chlorpromazine
• 2nd line = Antiemetics - IV ondansetron, metoclopramide, domperidone
• 3rd line = Steroids - IV hydrocortisone
• 4th line = Alternative therapy - Ginger and P6 wrist acupressure
• Combinations can be used if a single medication is ineffective
• Pay attention to the psychological effect of hyperemesis gravidarum

Question 5

What is the prognosis of hyperemesis gravidarum?

Answer 5

• Maternal
  
  • Major
    
    • VTE
    • Wernicke’s
    • Mallory-Weiss tear
    • Hypokalaemia
    • Hyponatraemia
      
      • Central pontine myelinolysis - from rapid Na+ correction
    • Acute tubular necrosis - dehydration
  • Dehydration
• Foetal
  
  • IUGR
  • PTL
  • Termination

Question 6

What counselling should be given to women with hyperemesis gravidarum?

Answer 6

• Risk Factors education
  
  • Previous hyperemesis
  • Multiple pregnancy
  • First pregnancy
  • Obesity
• Explain that it a very severe form of morning sickness
• Medication should help reduce the nausea – antihistamine followed by an antiemetic
• Most patients find that the symptoms improve after about 12-14 weeks
• Stress the importance of adequate fluids and nutrition