Vomiting in pregnancy Flashcards
What is early Gestosis?
- Early gestosis is a term that is used only in the lexicon of doctors in the CIS countries, in Western medicine they are called “unpleasant symptoms during pregnancy” or “small complications of pregnancy.”
- violated adaptation of a pregnant woman to pregnancy
- can complicate the duration of pregnancy
What are some examples of early gestosis?
- Gestosis refers to pregnancy disorders whose symptoms often include high blood pressure and cloudy urine. These are presumably caused by pregnancy-related changes combined with various risk factors, such as obesity, smoking or high blood pressure.
- vomiting, nausea, hyperemesis gravidarum, singultus, pyrosis, ptyalismus gravidarum (sialorrhea)
What is vomitus matutinus gravidarum?
- Morning sickness
- Common signs and symptoms of morning sickness include nausea and vomiting, often triggered by certain odors, spicy foods, heat, excess salivation or — often times — no triggers at all. Morning sickness is most common during the first trimester and usually begins by nine weeks after conception.
- vomiting even when the stomach is empty
- appetite is not lost
- usually subsides after 3rd lunar month
What is ptyalismus gravidarum?
- It’s normal to have excess saliva during pregnancy. Excessive salivation is called ptyalism, or sialorrhea – in pregnant women, it’s called ptyalism gravidarum – and the condition won’t affect your baby.
- It’s thought to be caused by pregnancy hormones changing how your salivary glands work. The nerves that control salivation are more stimulated than usual. Salivating too much often goes hand in hand with nausea (pregnancy sickness) and severe sickness (hyperemesis gravidarum).
- may leave the woman distressed and uncomfortable if too much saliva is present
What is singultus?
Hiccups (medically referred to as singultus3) occur when the diaphragm contracts, forcing air out through the vocal cords.
What is pyrosis?
- painful burning sensation in chest
- complication of GERD
- Heartburn is common during pregnancy. Pregnancy hormones can make the valve at the entrance to the stomach relax so that it doesn’t close as it should. This lets acidic stomach contents move up into the esophagus, a condition known as gastroesophageal reflux (GER), or acid reflux.
What is hyperemesis gravidarum?
- Some pregnant women experience very bad nausea and vomiting. They might be sick many times a day and be unable to keep food or drink down, which can impact on their daily life. This excessive nausea and vomiting is known as hyperemesis gravidarum (HG), and often needs hospital treatment.
- leads to weight loss and volume depletion = diagnosis: loss of 5% of patient’s pre-pregnancy weight.
- The condition might be caused by rapidly rising serum levels of hormones such as HCG (human chorionic gonadotropin) and estrogen.
What is vomiting of pregnancy?
Vomiting is a symptom which may be related to pregnancy or may be a manifestation of some medicalsurgical-gynecological complications, which can occur at any time during pregnancy. The former is by far the
most common one and is called vomiting of pregnancy.
How are the causes of vomiting in pregnancy classified?
The causes of vomiting in pregnancy can be
classified as follows:
A. Early Pregnancy
B. Late pregnancy
Medical, Surgical, Gynecological
What are the causes of vomiting in pregnancy? Early vs Late
A. Early Pregnancy:
- Related to pregnancy (vomiting of pregnancy)
Simple vomiting (morning sickness, emesis
gravidarum)
Hyperemesis gravidarum (pernicious vomiting) - Associated with pregnancy
B. late Pregnancy:
- Related to pregnancy
Continuation or reappearance of simple vomiting of
pregnancy
Acute fulminating preeclampsia - Associated with pregnancy (see table below)
Medical-surgical-gynecological causes in early pregnancy
Hiatus hernia
What are the causes of vomiting in pregnancy? Medical, surgical, and gynecological?
Medical: Intestinal infestation Urinary tract infection Hepatitis Ketoacidosis of diabetes Pyelonephritis, uremia
Surgical:
- Appendicitis
- Peptic ulcer
- Intestinal obstruction
- Cholecystitis
- Pancreatitis
Gynecological:
- Twisted ovarian tumour
- Red degeneration of fibroid
How is vomiting in pregnancy classified?
The vomiting is related to the pregnant state and depending upon the severity, it is classified as:
(i) Simple
vomiting of pregnancy or milder type
(ii) Hyperemesis gravidarum or severe type
What is “simple vomiting” in pregnancy?
SIMPLE VOMITING (Syn: morning sickness, emesis gravidarum):
The patient complains of nausea and
occasional sickness on rising in the morning.
Slight vomiting is so common in early pregnancy (about
50%) that it is considered as a symptom of pregnancy
- can occur at any time of the day
The vomitus is small and clear or bile stained. It does not produce any impairment of health or restricts
the normal activities of the women.
The feature disappears with or without treatment by 12–14th week of pregnancy.
High level of serum human chorionic gonadotropin, estrogen and altered immunological
states are considered responsible for initiation of the manifestation, which is probably aggravated by
the neurogenic factor.
How is simple vomiting managed?
Management:
Assurance is important. Taking of dry toast or biscuit and avoidance of fatty and spicy foods are enough to relieve the symptoms in majority. Ginger tea/ supplements.
Supplementation with vitamin B1 100 mg daily
is helpful.
If the simple measures fail, antiemetic drugs
- trifluoperazine (Espazine) 1 mg twice daily is
quite effective.
Promethazine and ondansetron can be used.
Patient is advised to take plenty of fluids
(2.5 L in 24 hours) and fruit juice.
What is Hyperemesis Gravidarum?
- DEFINITION: It is a severe type of vomiting of pregnancy that has a deleterious effect on the health of the mother and/or incapacitates her in day-to-day activities.
- The adverse effects of severe vomiting are—dehydration, metabolic acidosis (from starvation) or alkalosis (from loss of hydrochloric acid), electrolyte imbalance (hypokalemia) and weight loss.
What is the incidence of hyperemesis gravidarum?
There has been a marked fall in the incidence during the last 30 years. It is now a rarity in hospital practice (less than 1 in 1,000 pregnancies).
The reasons are —
(a) better application of family planning knowledge which reduces the number of unplanned pregnancies,
(b) an early visit to the antenatal
clinic and
(c) potent antihistaminic and antiemetic drugs.
What is the etiology of hyperemesis gravidarum?
The etiology is obscure but the following are the known facts:
(1) It is mostly limited to
the first trimester;
(2) It is more common in the first pregnancy, with a tendency to recur again in subsequent pregnancies (15%);
(3) Younger age;
(4) Low body mass
(5) History of motion sickness or migraine;
(6) It has got a familial history — mother and sisters also suffer from the same manifestation;
(7) It is more prevalent in hydatidiform mole and multiple pregnancy and
(8) It is more common in unplanned pregnancies but much less amongst illegitimate ones.
Women with hyperemesis gravidarum, often suffer from transient form of hyperthyroidism (clinical
or subclinical).
What are the theories of etiology of Hyperemesis gravidarum?
(1) Hormonal
(2) Psychogenic
(3) Dietetic deficiency
(4) Allergic or immunological basis
(1) Hormonal: (a) Excess of chorionic gonadotropin or higher biological activity of hCG is associated.
This is proved by the frequency of vomiting at the peak level of hCG and also the increased association with hydatidiform mole or multiple pregnancy when the hCG titer is very much raised; (b) High serum level of estrogen and
(c) Progesterone excess leading to relaxation of the cardiac sphincter and simultaneous retention of gastric fluids due
to impaired gastric motility. Other hormones involved are: thyroxine, prolactin, leptin and adrenocortical hormones.
(2) Psychogenic: It probably aggravates the nausea once it begins. But neurogenic element sometimes plays a
role, as evidenced by its subsidence after shifting the patient from the home surroundings. Conversion disorder, somatization, excess perception of sensations by the mother are the other theories.
(3) Dietetic deficiency: Probably due to low carbohydrate reserve, as it happens after a night without food.
Deficiency of vitamin B6
, vitamin B1
and proteins may be the effects rather than the cause.
(4) Allergic or immunological basis.
(5) Decreased gastric motility is found to cause nausea.
Whatever may be the cause of initiation of vomiting, it is probably aggravated by the neurogenic
element. Unless it is not quickly rectified, features of dehydration and carbohydrate starvation supervene
and a vicious cycle of vomiting appears — vomiting → carbohydrate starvation → ketoacidosis →
vomiting.
What changes are seen in organs in a patient with hyperemesis gravidarum?
There are no specific morbid anatomical findings. The changes in the various organs are the generalized manifestations of starvation and severe malnutrition.
Liver: Liver enzymes are elevated. There is centrilobular fatty infiltration without necrosis.
Kidneys: Usually normal with occasional findings of fatty change in the cells of the first convoluted tubule,
which may be related to acidosis.
Heart: A small heart is a constant finding. There may be subendocardial hemorrhage.
Brain: Small hemorrhages in the hypothalamic region giving the manifestation of Wernicke’s encephalopathy. The lesion may be related to vitamin B1 deficiency
What are the metabolic changes in a patient with hyperemesis gravidarum?
- The changes are due to the combined
effect of dehydration and starvation consequent upon vomiting. - Metabolic: Inadequate intake of food results in glycogen depletion.
- For the energy supply, the fat reserve is broken down.
- Due to low carbohydrate, there is incomplete oxidation of fat and accumulation of ketone bodies in the blood.
- The acetone is ultimately excreted through the kidneys and in the breath.
- There is also increase in endogenous tissue protein metabolism resulting in excessive excretion of
nonprotein nitrogen in the urine. - Water and electrolyte metabolism are seriously affected leading to
biochemical and circulatory changes.
What are the biochemical changes in a patient with hyperemesis gravidarum?
- The changes are due to the combined
effect of dehydration and starvation consequent upon vomiting. - Biochemical: Patients develop acidosis (due to starvation) and alkalosis from loss of hydrochloric
acid and hyokalemia. - Loss of water and salts in the vomitus results in fall in plasma sodium, potassium
and chlorides. - The urinary chloride may be well below the normal 5 g/L or may even be absent. -
- Hepatic dysfunction results in ketosis with rise in blood urea and uric acid. Patient suffers from hypoglycemia,
hypoproteinemia and hypovitaminosis.
What are the circulatory changes in a patient with hyperemesis gravidarum?
- The changes are due to the combined
effect of dehydration and starvation consequent upon vomiting. - Circulatory: There is hemoconcentration leading to rise in hemoglobin percentage, RBC count and hematocrit values.
- There is slight increase in the white cell count with increase in eosinophils. There is concomitant reduction of extracellular fluid.
How is the clinical course of vomiting in pregnancy classified?
From the management and prognostic point of view, the cases are grouped into:
Early
Late (moderate to severe)
The patient is usually a nullipara, in early pregnancy. The onset is insidious.
EARLY: Vomiting occurs throughout the day. Normal day-to-day activities are curtailed. There is no
evidence of dehydration or starvation
LATE: (Evidences of dehydration and starvation are present).
“Nulliparous” is a fancy medical word used to describe a woman who hasn’t given birth to a child. It doesn’t necessarily mean that she’s never been pregnant — someone who’s had a miscarriage, stillbirth, or elective abortion but has never given birth to a live baby is still referred to as nulliparous.
What are the signs and symptoms found in the late clinical course of vomiting in pregnancy?
Symptoms:
- Vomiting is increased in frequency with retching.
- Urine quantity is diminished even to the stage of oliguria. - Epigastric pain, constipation may occur.
- Complications may appear
if not treated.
Signs:
- Features of dehydration and ketoacidosis: Dry coated tongue, sunken eyes, acetone smell in
breath, tachycardia, hypotension, rise in temperature may be noted, jaundice is a late feature. Such late cases are rarely seen these days.
- Vaginal examination and/or ultrasonography is done to confirm the diagnosis of pregnancy.
