Vomiting in pregnancy

Question 1

What is early Gestosis?

Answer 1

• 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

Question 2

What are some examples of early gestosis?

Answer 2

• 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)

Question 3

What is vomitus matutinus gravidarum?

Answer 3

• 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

Question 4

What is ptyalismus gravidarum?

Answer 4

• 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

Question 5

What is singultus?

Answer 5

Hiccups (medically referred to as singultus3) occur when the diaphragm contracts, forcing air out through the vocal cords.

Question 6

What is pyrosis?

Answer 6

• 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.

Question 7

What is hyperemesis gravidarum?

Answer 7

• 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.

Question 8

What is vomiting of pregnancy?

Answer 8

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.

Question 9

How are the causes of vomiting in pregnancy classified?

Answer 9

The causes of vomiting in pregnancy can be
classified as follows:

A. Early Pregnancy
B. Late pregnancy

Medical, Surgical, Gynecological

Question 10

What are the causes of vomiting in pregnancy? Early vs Late

Answer 10

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

Question 11

What are the causes of vomiting in pregnancy? Medical, surgical, and gynecological?

Answer 11

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

Question 12

How is vomiting in pregnancy classified?

Answer 12

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

Question 13

What is “simple vomiting” in pregnancy?

Answer 13

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.

Question 14

How is simple vomiting managed?

Answer 14

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.

Question 15

What is Hyperemesis Gravidarum?

Answer 15

• 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.

Question 16

What is the incidence of hyperemesis gravidarum?

Answer 16

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.

Question 17

What is the etiology of hyperemesis gravidarum?

Answer 17

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).

Question 18

What are the theories of etiology of Hyperemesis gravidarum?

Answer 18

(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.

Question 19

What changes are seen in organs in a patient with hyperemesis gravidarum?

Answer 19

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

Question 20

What are the metabolic changes in a patient with hyperemesis gravidarum?

Answer 20

• 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.

Question 21

What are the biochemical changes in a patient with hyperemesis gravidarum?

Answer 21

• 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.

Question 22

What are the circulatory changes in a patient with hyperemesis gravidarum?

Answer 22

• 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.

Question 23

How is the clinical course of vomiting in pregnancy classified?

Answer 23

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.

Question 24

What are the signs and symptoms found in the late clinical course of vomiting in pregnancy?

Answer 24

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.

Question 25

What investigations can be done on a patient with vomiting in pregnancy?

Answer 25

Investigations:

 Urinalysis:
(1) Quantity—small,
(2) Dark color,
(3) High specific gravity with acid reaction,
(4) Presence of acetone, occasional presence of protein and rarely bile pigments and
(5) Diminished
or even absence of chloride.

 Biochemical and circulatory changes:
Routine and periodic estimation of the serum electrolytes (sodium, potassium and chloride) is helpful in the management of the case.

 Serum TSH, T3 and Free T4:
Women may suffer from a transient phase of thyroid dysfunction
(clinical or subclinical).

 Ophthalmoscopic examination is required if the patient is seriously ill. Retinal hemorrhage and
detachment of the retina are the most unfavorable signs.

 ECG when there is an abnormal serum potassium level.

Question 26

How is vomiting in pregnancy diagnosed?

Answer 26

DIAGNOSIS:

The pregnancy is to be confirmed first. Thereafter, all the associated causes of vomiting (enumerated before) are to be excluded.

Ultrasonography is useful not only to confirm the pregnancy but also to exclude other, obstetric (hydatidiform mole, multiple pregnancies), gynecological, surgical or medical causes of vomiting.

Question 27

What is the differential diagnosis?

Answer 27

• Differential diagnosis:

When vomiting is persistent in spite of usual treatment other causes of severe
vomiting (medical or surgical) should be considered and investigated.

Question 28

What are some maternal complications of vomiting in pregnancy?

Answer 28

Maternal:

The majority of the clinical manifestations are due to the effects of dehydration and starvation with resultant ketoacidosis.

Leaving aside those symptomatology, the
following complications may occur which are fortunately rare nowadays.

(1) Neurologic complications—
(a) Wernicke’s encephalopathy, beriberi due to thiamine deficiency;
(b) Pontine myelinolysis;
(c) Peripheral neuritis;
(d) Korsakoff’s psychosis.

(2) Stress ulcer in stomach;
(3) Esophageal tear (MalloryWeiss syndrome);
(4) Jaundice, hepatic failure;
(5) Convulsions and coma;

(6) Hypoprothrombinemia
due to vitamin K deficiency and

(7) Renal failure.

Question 29

What are some effects on the fetus?

Answer 29

Effects on the fetus:

Fetus usually remains unaffected once the problem is resolved.

Fetal risks may
be due to low birth weight.

Question 30

What are the principles of management?

Answer 30

The principles in the management are:
 Maintenance of hydration
 To control vomiting
 To correct the fluids and electrolytes imbalance
 To correct metabolic disturbances (acidosis or alkalosis)
 To prevent the serious complications of severe vomiting
 Care of pregnancy

Question 31

What are some methods of management?

Answer 31

• Hospitalization
• Fluids
• Drugs
• Nursing care

(a) Hospitalization: Whenever a patient is diagnosed as a case of hyperemesis gravidarum, she is admitted. Surprisingly, with the same diet and drugs used at home, the patient improves rapidly. The relatives may be too sympathetic or too indifferent.
(b) Fluids: Oral feeding is withheld for at least 24 hours after the cessation of vomiting. During this
period, fluid is given through the intravenous drip method. The amount of fluid to be infused in 24 hours
is calculated as follows: The total amount of fluid approximates 3 liters, of which half is 5% dextrose
and half is Ringer’s solution. Extra amount of crystalloids equal to the amount of vomitus and urine in
24 hours, is to be added. With this regime—dehydration, ketoacidosis, water and electrolyte imbalance
are likely to be rectified. Serum electrolyte should be estimated and corrected if there is any abnormality.
Enteral nutrition through nasogastric tube may also be given.

(c) Drugs:
(i) Antiemetic drugs promethazine (Phenergan) 25 mg or prochlorperazine (Stemetil) 5 mg or triflupromazine (Siquil) 10 mg may be administered twice or thrice daily intramuscularly.
Trifluoperazine (Espazine) 1 mg twice daily intramuscularly is a potent antiemetic therapy. Vitamin B6
and doxylamine are also safe and effective. Metoclopramide stimulates gastric and intestinal motility
without stimulating the secretions. It is found useful.

(ii) Hydrocortisone 100 mg IV in the drip is given in a case with hypotension or in intractable vomiting.
Oral method prednisolone is also used in severe cases.

(iii) Nutritional supplementation— with vitamin B1 (100 mg daily), vitamin B6
, vitamin C and vitamin
B12 are given.

(d) Nursing care: Sympathetic but firm handling of the patient is essential. Social and psychological
support should be extended. Hyperemesis progress chart is helpful to assess the progress of patient while in hospital. Daily record
of pulse, temperature, blood pressure at least twice daily, intake-output, urine for acetone, protein, bile,
blood biochemistry and ECG (when serum potassium is abnormal) are important.

(e) Diet: Before the intravenous fluid is omitted, the foods are given orally. At first, dry carbohydrate
foods like biscuits, bread and toast are given. Small but frequent feeds are recommended. Gradually
full diet is restored.

Question 32

Which drugs are administered?

Answer 32

Drugs:

(a) Antiemetic drugs promethazine (Phenergan) 25 mg or prochlorperazine (Stemetil)
5 mg or triflupromazine (Siquil) 10 mg may be administered twice or thrice daily intramuscularly.
Trifluoperazine (Espazine) 1 mg twice daily intramuscularly is a potent antiemetic therapy. Vitamin B6
and doxylamine are also safe and effective. Metoclopramide stimulates gastric and intestinal motility
without stimulating the secretions. It is found useful.

(b) Hydrocortisone 100 mg IV in the drip is given in a case with hypotension or in intractable vomiting.
Oral method prednisolone is also used in severe cases.

(c) Nutritional supplementation— with vitamin B1 (100 mg daily), vitamin B6
, vitamin C and vitamin
B12 are given.

Question 33

What are some clinical features that are evidence of improvement?

Answer 33

Clinical features of improvement are evidenced by —

(a) subsidence of vomiting (b) feeling of hunger
(c) better look
(d) normalization of blood biochemistry (electrolytes) (e) disappearance of acetone from
the breath and urine
(f) normal pulse and blood pressure and
(g) normal urine output.

Question 34

What is the PUQE score?

Answer 34

• The Pregnancy-Unique Quantification of Emesis (PUQE) is a scoring system to quantify the severity of nausea and vomiting of pregnancy (NVP).

(pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy