HYPEREMESIS GRAVIDARUM(PERNICIOUS VOMITING)
INTRODUCTION
The wait to bring a new life surfacing out of our body is that all of us
must aspire to experience at least once in our life time. This period is called
pregnancy. Responsibilities & growing concern for the new life now plays a
significant role as we set foot on the path that transmutes one from a woman
into a mother. Among these is our duty to the life i.e. yet to be & how we can
give of ourselves, in body & spirit, to form & nurture the new life that we seek
to bring into existence. Giving life is powerful. It is vital therefore, that we
prepare our body to become a suitable environment for the baby to grow in
while staying happy & healthy emotionally & mentally as well. Pregnancy an
incredible journey.
A women body has a great deal to do during pregnancy. Sometimes the
changes takes place will cause irritation & discomfort & on occasions they
may seem quite alarming. Pregnant women may have many health complaints
of varying degrees throughout their pregnancies. One such common complaint
that pregnant women are plagued with is morning sickness, (that is mild form
of nausea & vomiting), which is particularly observed during the first
trimester of pregnancy.
The cause is usually unknown. Most researchers believe it’s a
combination of the many physical changes taking place in the body such as the
higher levels of hormones during early pregnancy. Normal nausea & vomiting
may be an evolutionary protective mechanism. It may protect the pregnant
women & her embryo from harmful substances in food, such as pathogenic
micro organisms in meat products & toxins in plants, with the effect being
maximal during embryogenesis (the most vulnerable period of pregnancy).
This is supported by studies showing that women who had nausea &
vomiting were less likely to have miscarriage & still births. Some researchers
have found that women who are more likely to have nausea from birth control
pills, migraines or hormone replacement therapy. A continuous spectrum of
the severity of nausea & vomiting ranges leads to severe disorders of
hyperemesis Gravidarum.
Pernicious vomiting of pregnancy: Medically known as Hyperemesis
gravidarum, this is excessive vomiting in early pregnancy. Hyperemesis
Gravidarum 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.
MEANING
Hyperemesis gravidarum is the Latin for excessive vomiting in
pregnancy. Hyper means "over"; emesis means "vomiting"; and gravidarum
means "pregnant state." Nausea & vomiting of pregnancy commonly termed
‘morning sickness’ is a common phenomenon in pregnancy, occurring in about
70% of pregnancies.
DEFINITION
Excessive nausea & vomiting that start between 4 & 16 weeks gestation &
requiring intervention are known as Hyperemesis gravidarum.
Ammula Radha Ramana Sree
Hyperemesis gravidarum is a severe type of vomiting of pregnancy which has
got deleterious effect on the health of the mother, &/or incapabilities her in
day to day activities
D.C.Dutta
Hyperemesis Gravidarum (HG) is defined as a severe form of nausea and
vomiting in pregnancy
Hyperemesis Education and Research Foundation (HER)
Hyperemesis gravidarum (hyperemesis) is defined as excessive nausea and
vomiting in pregnancy starting before the 22nd week of gestation, which
might lead to nutritional deficiencies and weight loss.
BMJOURNALS
INCIDENCE
Nausea & vomiting affect over 50% of pregnancies
Affecting 0.3-3% of all pregnant women. It is associated with
dehydration
Most cases are mild & resolves with time, approximately 1 in every
1000 pregnant women requires hospitalization
Maternal age less than 2 years
Approximately 60,000 cases of HG are reported annually in the United
States; however, this statistic only reflects those women treated in
hospitals (HER, 2006).
ETIOLOGY
The etiology & pathogenesis of nausea & vomiting of pregnancy is still not
clear & various postulates have been put forth
1. Endocrine-hCG has been postulated to be the cause. This is probably
why Hyperemesis is more common in pregnancies with high hCG levels
like hydatidiform mole & multiple pregnancy. Estrogen has also been
implicated & it is observed that women who have vomiting while using
the combined oral contraceptive pill are likely to have Hyperemesis
2. Infection-Helicobacter Pylori is a gram negative bacillus that has been
associated with the development of peptic ulcer where similar
symptoms are seen.
3. Upper gastrointestinal dysmotility- during pregnancy esophageal,
gastric, & small bowel motility are impaired as a result of the smooth
muscle relaxation induced by the high levels of progesterone. This
dysmotility could be a factor contributing to the nausea & vomiting of
pregnancy
4. Psychological-this is one of the oldest theories postulated in the
pathogenesis of Hyperemesis.
5. Other postulates
Liver dysfunction
Altered lipid metabolism
Immunological
Whatever may be the cause of initiation of vomiting, it is probably aggravated
by the neurogenic element. Unless it is not quickly rectified,
MORNING SICKNESS vs. 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 down
Vomiting that does not allow you
to keep any food down
PATHOLOGY
There is no specific morbid anatomical findings. The changes in the various
organs as described by Sheehan are the generalized manifestations of
starvation & severe malnutrition.
Liver: there is centrilobular fatty infiltration without necrosis
Kidneys: usually normal with occasional findings of fatty change in the
cells of first convoluted tubule which may be related to acidosis
Heart-a small heart is a constant finding. There may be subendocardial
hemorrhage
Brain: a small hemorrhages in the hypothalamic region giving the
manifestation of Wernicke’s encephalopathy. The lesion may be related
to vitamin B1 deficiency
Metabolic, biochemical & circulatory changes: the changes are due to the
combined effect of dehydration & starvation consequent upon vomiting
1. Metabolic changes- starvation causes depletion of glycogen stores &
mobilization of fat stores. This leads to increased production of ketone
bodies, which are excreted through the kidneys & the breath. At the
same time, there is increased tissue protein metabolism, which leads to
increased blood urea nitrogen. If prolonged, hypoglycemia,
hypoproteinaemia & hypovitaminosis can supervene.
2. Biochemical-vomiting & dehydration can lead to hyponatraemia,
hypokalemia & hypochloraemia
3. Hematological- haemoconcentration can also occur as a result of
dehydration
PATHOPHYSIOLOGY
Etiology:Unknown
Predisposing Factor:-woman
Precipitating Factor:-pregnancy
Adverse reaction to the hormonal changes
of pregnancy
Increased level of beta HCG
Increased level of estrogen & progesterone
Decreased gastric motility
Immune response to fragments of chorionic villi that enter the maternal bloodstream; immune response
to the “foreign” fetus.
Loss of 5% or more of pre-pregnancy body
weight.
Dehydration
Metabolic imbalances
Difficulty with daily activities
Food leaving the stomach more slowly
Effect of Severe Vomiting
CLINICAL FEATURES
Nausea & vomiting of pregnancy tends to begin at 4-6 weeks, peaks at 8-
12 weeks & usually resolves by 20 weeks.
Abdominal pain
Nausea & vomiting
Hypersalivation
Difficulty in breathing
Low birth infants
Disorientation
Delusions
Nystagmus
Jaundice
Anaemia
Rapid pulse
Low blood pressure
Dry tongue
Hypovilaemia
GI disturbances
Sunken eyes
Loss of skin elasticity & dry
Lips cracked
Morning sickness
Coffee coloured vomitus
Anxious appearance
Ketotic odour of breath
Tachycardia
Hypotension
Upto 5% weight loss
In sever cases icterus
INVESTIGATIONS
1. Urinalysis
Oliguria
Dark colour
Increased specific gravity
Ketone bodies
Acidic pH
2. Hematological & biochemical
Raised haemocrit
Raised blood urea
Electrolytes may be abnormal
Abnormal liver function tests
3. Ultrasound
Confirms viable intrauterine pregnancy
Rules out molar pregnancy & multiple pregnancy
Differential diagnosis
Liver dysfunction
Peptic ulceration
Sever gastro-esophageal reflux
Psychological problems
COMPLICATIONS
Electrolyte imbalance
Liver dysfunction & jaundice
Renal abnormalities’
Stress ulcers in the stomach
Mallory-Weiss tears in the esophagus & esophageal rupture
Pneumothorax & pneumomediastinum
Complications due to vitamin deficiency
- Wernicke’s encephalopathy due to thiamine deficiency
- Korsakoff’s psychosis
- Peripheral neuritis
- Vitamin K deficiency & bleeding disorders
IUGR for the fetus
MANAGEMENT
The principles in the management are:
To control vomiting
To correct the fluids, electrolytes & other metabolic disturbances
promptly & effectively
To prevent or to detect at the earliest, the ominous complications
that may arise.
Morning sickness can be treated by reassurance & simple dietetic
regulation
Fatty acid rich rood is better avoided
Food should be composed of CHO, fruits & vegetable.
Toasts, biscuits, jelly are recommended
Sticks of barley sugar provide a palatable medium of easily assimilable
glucose. Bowel movement should be regular
I. MEDICAL INTERVENTIONS
1. Control of dehydration through IV fluids – often 1 to 3 liters of dextrose
solution with electrolytes and vitamins, as needed. Bicarbonate may be
given for acidosis.
2. Vomiting that persists after initial fluid and electrolyte replacement is
treated with an antiemetic taken as needed; antiemetics include:
a. Vitamin B6
o Drug classification: Vitamins & Minerals (Pre & Post Natal) /
Antianemics
o Indications: Treatment & prevention of metabolic disorders;
multivitamin & mineral deficiency states; treatment & prophylaxis
of Fe-deficiency anemias.
o Dosage: 10 to 25 mg every 8 hours
o Special precautions: Should be taken on an empty stomach (Best
taken between meals. May be taken w/ meals to reduce GI
discomfort.).
b. Doxylamine (Aldex, Unisom)
o Drug classification: Antihistamines
o Mechanism of action: Doxylamine competes with histamine for H1-
receptor sites on effector cells; blocks chemoreceptor trigger zone,
diminishes vestibular stimulation, and depresses labyrinthine
function through its central anticholinergic activity.
o Indications: For hypersensitivity reactions and insomnia;
Doxylamine has been approved for used in pregnancy-associated
nausea and vomiting
o Dosage: Oral: Adults: One tablet 30 minutes before bedtime; once
daily or as instructed by healthcare professional (can be taken in
addition to vitamin B6)
o Contraindications: Hypersensitivity to doxylamine or any
component of the formulation
o Side effect: Sedation
o Adverse reactions: Cardiovascular: Palpitation, tachycardia ;
Central nervous system: Dizziness, disorientation, drowsiness,
headache, paradoxical CNS stimulation, vertigo; Gastrointestinal:
Anorexia, dry mucous membranes, diarrhea, constipation,
epigastric pain, xerostomia; Genitourinary: Dysuria, urinary
retention; Ocular: Blurred vision, diplopia
o Special precautions: May impair ability to drive and operate
machinery. Angle-closure glaucoma, urinary retention, prostatic
hypertrophy or pyloroduodenal obstruction; epilepsy; hepatic
impairment. Elderly. Lactation.
o Pregnancy Considerations: Doxylamine has been approved for used
in pregnancy-associated nausea and vomiting.
c. Promethazine (Metagon, Phenerzin)
o Drug classification: Antihistamines
o Mechanism of action: Blocks postsynaptic mesolimbic
dopaminergic receptors in the brain; exhibits a strong alpha-
adrenergic blocking effect and depresses the release of
hypothalamic and hypophyseal hormones; competes with
histamine for the H1-receptor; muscarinic-blocking effect may be
responsible for antiemetic activity; reduces stimuli to the brainstem
reticular system.
o Indications: Symptomatic relief of allergy e.g. hay fever, urticaria,
premed; emergency treatment of anaphylactic reactions; sedation;
motion sickness.
o Dosage: Deep IM injection/slow IV injection/infusion Nausea &
vomiting 12.5-25 mg 4 hourly. Max: 100 mg/day. Other indications
25-50 mg. Max: 100 mg. Rate of infusion: Not >25 mg/min.
o Contraindications: Hypersensitivity to promethazine or any
component of the formulation (cross-reactivity between
phenothiazines may occur); coma; treatment of lower respiratory
tract symptoms, including asthma.
o Side Effects: Extra pyramidal symptoms, sedation
o Special precautions: Avoid extravasation or inadvertent intra-
arterial inj. Induction of & recovery from anesthesia. Patients w/
acute porphyria. Allergy to Na metabisulfite.
Appropriate administration: Not for Subcutaneous or intra-arterial
administration. I.M. is the preferred route of parenteral
administration. I.V. use has been associated with severe tissue
damage; unintentional intra-arterial administration/infiltration has
been associated with severe tissue necrosis and loss of digits/limb.
In some institutions, I.V administration may be avoided or specific
administration techniques may be used to minimize risk.
Discontinue immediately if burning or pain occurs with I.V.
administration.
o Pregnancy Considerations: Teratogenic effects were not observed
in animal studies. Crosses the placenta. May be used alone or as an
adjunct to narcotic analgesics during labor.
d. Metoclopramide (Biclomet, Clomitene, Reglomar)
o Drug classification: Antiemetics
o Mechanism of action: Blocks dopamine receptors and (when given
in higher doses) also blocks serotonin receptors in chemoreceptor
trigger zone of the CNS; enhances the response to acetylcholine of
tissue in upper GI tract causing enhanced motility and accelerated
gastric emptying without stimulating gastric, biliary, or pancreatic
secretions; increases lower esophageal sphincter tone.
o Indications: Relief of nausea & vomiting associated w/ radiation
therapy, malignant disease, labor, infectious diseases & uremia.
Control of post-op vomiting & assist in intestinal intubation.
o Dosage: Adult 10 mg TID, 15-20 yr 5-10 mg TID. Max: 0.5 mg/kg
body wt.
o Contraindications: Hypersensitivity to metoclopramide or any
component of the formulation; GI obstruction, perforation or
hemorrhage; pheochromocytoma; history of seizures or
concomitant use of other agents likely to increase extra pyramidal
reactions.
o Side Effects: Tardive dyskinesia (black-box warning)
o Special precautions: May cause drowsiness so avoid activities
which require high levels of concentration. May mask symptoms of
a serious disease. Discontinuation of therapy: Abrupt
discontinuation may (rarely) result in withdrawal symptoms
(dizziness, headache, nervousness).
o Pregnancy Considerations: Teratogenic effects were not observed
in animal studies; however, there are no adequate and well-
controlled studies in pregnant women. Crosses the placenta;
available evidence suggests safe use during pregnancy.
e. Ondansetron (Emodan, Zofran)
o Drug classification: Antiemetics
o Mechanism of action: Hypersensitivity to ondansetron, other
selective 5-HT3 antagonists, or any component of the formulation.
o Indications: Prevention of nausea and vomiting associated with
moderately- to highly-emetogenic cancer chemotherapy;
radiotherapy; prevention of postoperative nausea and vomiting
(PONV); treatment of PONV if no prophylactic dose of
ondansetron received. Unlabeled/Investigational use:
Hyperemesis gravidarum; breakthrough treatment of nausea and
vomiting associated with chemotherapy
o Dosage: Treatment of hyperemesis gravidarum (unlabeled use): 8
mg administered over 15 minutes every 12 hours or 1 mg/hour
infused continuously for up to 24 hours; 8 mg oral every 12 hours
o Contraindications: Hypersensitivity to ondansetron, other
selective 5-HT3 antagonists, or any component of the formulation
o Side effects: Constipation, diarrhea, headache, fatigue
o Special precautions: May cause drowsiness so avoid activities
which require high levels of concentration. May mask symptoms
of a serious disease. Discontinuation of therapy: Abrupt
discontinuation may (rarely) result in withdrawal symptoms
(dizziness, headache, nervousness).
o Pregnancy considerations: Teratogenic effects were not observed
in animal studies; however, there are no adequate and well-
controlled studies in pregnant women. Use of ondansetron for the
treatment of nausea and vomiting of pregnancy (NVP) has been
evaluated. Additional studies are needed to determine safety to
the fetus, particularly during the first trimester. Based on
preliminary data, use is generally reserved for severe NVP
(hyperemesis gravidarum) or when conventional treatments are
not effective.
f. Prochlorperazine (Compazine)
o Drug classification: Antipsychotics, Antivertigo
o Mechanism of action: Prochlorperazine is a piperazine
phenothiazine antipsychotic which blocks postsynaptic
mesolimbic dopaminergic D1 and D2 receptors in the brain,
including the chemoreceptor trigger zone; exhibits a strong alpha-
adrenergic and anticholinergic blocking effect and depresses the
release of hypothalamic and hypophyseal hormones; believed to
depress the reticular activating system, thus affecting basal
metabolism, body temperature, wakefulness, vasomotor tone and
emesis.
o Indications: Management of nausea and vomiting; psychotic
disorders, including schizophrenia and anxiety
o Dosage: Adult: PO Prevention of nausea and vomiting As maleate
or mesilate: 5-10 mg 2-3 times/day. Nausea and vomiting as
maleate or mesilate: 20 mg, may repeat if needed. Vertigo As
maleate or mesilate: 15-30 mg/day in divided doses. May reduce
gradually to 5-10 mg/day. IM Nausea and vomiting as mesilate:
12.5 mg, may repeat via PO if needed.
o Contraindications: Hypersensitivity to prochlorperazine or any
component of the formulation (cross-reactivity between
phenothiazines may occur); severe CNS depression; coma
o Side effects: Extra pyramidal symptoms, sedation
o Special precautions: Extra pyramidal syndrome, hypotension,
epilepsy, impaired hepatic, renal, CV, cerebrovascular or
respiratory function, glaucoma. May impair ability to drive or
perform tasks requiring mental alertness or physical
coordination. Parenteral use in children is not recommended.
History of jaundice, parkinsonism, diabetes mellitus,
hypothyroidism, myasthenia gravis, paralytic ileus, prostatic
hyperplasia or urinary retention. Regular eye examinations are
recommended in patients on long-term treatment.
o Pregnancy Considerations: Crosses the placenta. Isolated reports
of congenital anomalies, however, some included exposures to
other drugs. Jaundice, extra pyramidal signs, hyper-/hyporeflexes
have been noted in newborns. Available evidence with use of
occasional low doses suggests safe use during pregnancy.
Prompt hospitalization is mandatory to prevent complications
1. Supportive treatment with IV crystalloids & correction of dehydration
ketosis, electrolyte deficit & acid base imbalance is vital. Oral feeding is
stopped to provide rest to the gastrointestinal tract. Most patients
respond & slowly an oral diet can be reintroduced, beginning with fluids
& then low fat solids. If Hyperemesis is prolonged, parenteral vitamins
should be given, especially B vitamins due to the possibility of
Wernicke’s encephalopathy in severe cases
2. Antiemetics like doxylamine 10mg orally or twice a day, alone or in
combination with vitamin B6 (10-30mg) is considered as first line
pharmaco therapy. Metachlopramide 10mg orally upto 4times a day can
also be given. Both these drugs are FDA category B drugs
3. Pyridoxine or B6 has been shown to be effective in the management of
nausea in early pregnancy but may not be very effective in intractable
vomiting
4. Methylpredisolone has been found to be effective in severe
Hyperemesis probably by a direct effect on the vomiting centres of the
brain. The dosage is 20mg orally twice daily. It should only be used
when all other causes are excluded & the risks are clearly explained to
the patient. There is a marginal increase of congenital malformations
with first trimester use of steroids in experimental animals & so if used,
should be after 8weeks in refractory cases
5. Life style & diet changes. General advice is to avoid offensive foods &
odours; eating of small frequent meals; a high protein, low fat, low
carbohydrate diet; & avoiding iron supplements. She should be asked to
take whichever foods appeal to her. Reassurance & explanation will go a
long way
6. Alternative therapies like psychotherapy, acupressure & medical
hypnosis can be tried
7. Termination of pregnancy is very rarely needed as a last resort, to be
considered only in severe cases when there is a danger to life.
ALTERNBATIVE & COMPLIMENTARY THERAPIES IN HYPEREMESIS
GRAVIDARUM
The aim of the treatment is to restore proper balance & stop nausea &
vomiting
Traditional Chinese medicine
Stimulation of the acupuncture point p6 (neiguan), this point is
located on the inner arm, just above the wrist. Has been shown in
multiple trials to be effective in reducing nausea & vomiting.
The intensity & duration of the sickness has a direct relationship to
the state of the woman’s digestive system(spleen & stomach
meridians) before conception.
The effects of the acupuncture calm the digestive system, decrease
fatigue, decrease nausea & vomiting.
Homeopathic approaches
It can be an excellent choice for treatment of Hyperemesis because
small tasteless pills are dissolved under the tongue with little chance
of inducing nausea & vomiting
Sepia is the remedy most helpful for ordinary nausea & vomiting of
pregnancy. It is indicated when nausea is intensified by the smell or
thought of foods &/or when the woman is regarded as irritable,
emotional & selfish because of her need to be alone & quite.
Phosphorus is very effective for ailments of pregnancy & is
recommended when there are complaints related to an overactive
imagination with exaggerated fears, burning pains & thirst for cold
drinks.
Hypnotherapy
When emotional factors are implicated in the cause of Hyperemesis,
the use of hypnosis with positive suggestions can be helpful.
It involves the removal of fears of hypnosis, along with an
explanation of the role of the vomiting center in the brain & how it
works, coupled with a general discussion about the value of good
nutrition in pregnancy
Herbal therapy
The cutaneous application of wild yam cream has been anecdotally
reported to reduce nausea & vomiting
Dandelion root tea calms & strengthens the stomach, improves the
appetite, & supports the liver.
An infusion of ginger (in small amounts), chamomile, peppermint,
catnip, fennel, red raspberry, or lemon balm can also help.
Cranial Sacral & polarity therapy
Cranial sacral & polarity therapies can be used together energetically
to normalize the adaptational processes of the body.
If anxiety or any other emotional issues are at the root of the
sickness, these therapies allow the body, mind & spirit to integrate &
relax in a nurturing environment
DIETARY MANAGEMENT
Eat frequent small meals every two to three hours
Speak to a dietitian about ensuring the nutritional adequacy of your diet
during pregnancy and nutrition strategies to improve nausea and
vomiting symptoms
Eat dry crackers 15 minutes before getting out of bed in the morning
Do not skip meals needlessly
Drink fluids half an hour before a meal or half an hour after a meal.
Avoid drinking with your meal to prevent becoming overfull
Drink about eight glasses of liquid during the day to avoid dehydration
Try eating cold food rather than hot food (cold foods have less odour)
Avoid spicy foods
Avoid foods high in fat
Protein-containing snacks are helpful (e.g. yoghurt and fruit; wholegrain
crackers with sliced cheese)
Sugar free mineral waters or soda waters can assist in settling nausea
Herbal teas containing peppermint or ginger or other ginger-containing
beverages may ease nausea
If odours bother you while cooking, try to improve ventilation in your
kitchen area
NURSING DIAGNOSIS
Fluid volume deficit related to
Altered nutrition less than body requirements related to
Acute pain related to nausea & vomiting
Activity intolerance related to weakness due to inadequate nutrition
Risk for sleep pattern disturbance related to nausea & persistent
vomiting
Risk for maternal / fetal injury related to severe complications of
Hyperemesis
Risk for ineffective individual or family coping result emotional status &
hospitalization
NURSING CARE PLAN
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective:hypersalivationnausea & vomitingObjective:-Irritated-(+) nausea and vomiting-(+) hypersalivation-(+) dry skin-Vital signs taken as follows:BP: 90/70CR: 80bpmRR: 22cpmT: 37°C
Deficient fluid volume related to hyperemesis gravidarum as manifested by hypersalivation, vomiting and dry skin.
After the shift of nursing interventions, the patient will decreased the possibility in vomiting, hypersalivation decreased and skin becomes moisturized. And irritability will diminish.
-Established rapport to the patient and to the S.O.-Monitored vital signs and recorded.-Monitored IVF drip and its patency.-Maintained quiet environment.-Provided comfort measures.-Administered and documented medications (METOCLOPRAMIDE) given as ordered by the physician.-Encouraged patient to increase oral fluid intake.-Encouraged patient to eat dry toast foods.
-To gather information.-For Baseline data.-To prevent overload of the fluid. And IVF can help for the hydration of the patient.-For relaxation of the patient.-To prevent irritation/ discomfort of the patient.-To provide wellness to the patient. And to prevent patient from vomiting.-For hydration of the patient.-Dry toast foods inhibit the urge of vomiting and at the same time the patient will be refilled to prevent gastric ulcer.
Goal met: After the shift of nursing interventions the patient was able to perform changes in her status.
Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:The patient verbalizes irritability pain
Objective:-9/10 pain scale-Irritable-Grimacing-Guarding behavior-Vital signs taken as follows:BP: 90/70CR: 80bpmRR: 22cpmT: 37°C
Acute pain related to hyperemesis gravidarum as manifested by verbal report and guarding behavior.
After 4 hours of nursing intervention, the patient will relieve from pain.The patient can perform activities (sitting, standing, walking and etc.) comfortably.Pain scale will decelerate to 5/10.
-Established rapport to the patient and to the S.O.-Monitored vital signs and recorded.-Monitored IVF drip and its patency.
-Maintained quiet environment.
-Provided comfort measures.-Positioned the patient to her comfortable state.-Massage patient.
-Instructed S.O. not to leave the patient.
-To gather information.
-For Baseline data.-To prevent overload of the fluid.
-For relaxation of the patient.
-To lessen the pain felt by the patient.
-To decreased pain.
- To alleviate suffering from perceived pain. -To prevent from fall.
Goal met: After 4 hours of nursing intervention the patient was relieved from pain, can do things comfortably and report pain scale to 5/10.
Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:The patient verbalizes that orthopneaObjective:-Irritated-Orthopnea-Alterations in depth of breathing-Nasal flaring-Vital signs taken as follows:BP: 90/70CR: 80bpmRR: 22cpmT: °C
Ineffective breathing pattern related to pain as evidenced by orthopnea, alterations in depth of breathing and nasal flaring.
After 3 hours of nursing intervention the patient will be able to breathe properly.
-Established rapport to the patient and to the S.O.-Monitored vital signs and recorded.-Monitored IVF drip and its patency.
-Maintained quiet environment.-Provided comfort measures.-Positioned patient to orthopneic position.
-Provided air to patient.-Instructed S.O. to massage chest and back of the patient.
-To gather information.
-For Baseline data.
-To prevent overload of the fluid.
-For relaxation of the patient.-To prevent irritation/ discomfort of the patient.-Helps in the breathing pattern of the patient. It helps the patient to breathe properly.-For proper ventilation.
-It helps the patient’s breathing pattern.
Goal met: After 3 hours of nursing intervention the patient can perform proper breathing pattern and can breathe properly.
Assessment Diagnosis Planning Intervention Rationale EvaluationSubjective:Objective:-Irritability-Facial tension-Trembling-Restlessness-Vital signs taken as follows:BP: 100/80CR: 89bpmRR: 22cpmT: 37°C
Anxiety related to perceived proximity of death as manifested by the verbal report, irritability, facial tension, trembling, and restlessness.
After 3 hours of nursing intervention the will no longer feel the proximity of death.
-Established rapport to the mother.-Monitored vital signs and recorded.-Monitored IVF drip and its patency.
-Maintained quiet environment.-Provided comfort measures.
-Provided calm and peaceful setting.
-Encouraged patient to pray to God.
-Taught patient and S.O. about the condition of the patient.
-To gather information.
-For Baseline data.-To prevent overload of the fluid.
-For relaxation of the patient.
-To prevent irritation/ discomfort of the client.-Promotes relaxation and ability to deal with situations.-For the patient be filled with faith and hope.
-For them to be clarified about the situation of the patient.
Goal met: After 3 hours of nursing intervention, the patient was filled with hope.
II. NURSING INTERVENTIONS
1. Maintaining fluid volume
a. Establish an IV line, and administer IV fluids as prescribed.
b. Monitor serum electrolytes, and report abnormalities.
c. Medicate with antiemetics as prescribed. Administer
intramuscularly (IM) or by rectal suppository to avoid loss of dose
through vomiting.
d. Maintain NPO status except for ice chips until vomiting has
stopped.
e. Assess intake and output, urine specific gravity and ketones, vital
signs, skin turgor, and fetal heart tones as indicated by condition.
2. Encouraging adequate nutrition
a. Advice the woman that oral intake can be restarted when emesis
has stopped and appetite returns.
b. Begin small feedings. Suggest or provide bland solid foods; serve
hot foods hot and cold foods cold; do not serve lukewarm.
oAvoid greasy, gassy, and spicy foods.
oProvide liquids at times other than meal times.
c. Suggest or provide an environment conducive to eating.
oKeep room cool and quiet before and after meals.
oKeep emesis pan handy, yet out of sight.
3. Strengthening coping mechanisms
a. Allow patient to verbalize feelings regarding this pregnancy.
b. Encourage patient to discuss any personal stress that may have a
negative effect on this pregnancy.
4. Allaying fears
a. Explain the effects of all medications and procedures on maternal
as well as fetal health.
b. Accentuate the positive signs of fetal well-being.
c. Praise mother for attempts at following nutritious diet and
healthy lifestyle.
5. Patient education and health maintenance
a. Educate the woman about proper diet and nutrition in pregnancy.
b. Educate the woman about health weight gain in pregnancy.
c. Educate the woman on the need for child care during the periods
of severe nausea and vomiting.
d. Encourage the woman to move slowly, avoiding quick changes of
position. Quick changes in position can cause vertigo and then
nausea and vomiting.
e. Educate the woman on the need to take antiemetics during the
nausea phase before vomiting occurs.
f. Educate the woman on tips to assist with hyperemesis
gravidarum:
oEat dry toast or crackers before rising from bed or anytime
nausea begins.
oGet fresh, outside air daily; lie down in a semi-prone
position.
oDrink spearmint or peppermint tea.
oTake vitamin B6 50-100mg daily.
oAvoid food odors.
oEat smaller, frequent meals.
HEALTH EDUCATION
Drink lots of fluids to avoid dehydration.
Drink small amounts of fluid often.
Small frequent feeding rather than having heavy meals.
Increase oral fluids and food intake at the time of the day when you feel
least nauseated.
Avoid fatty, hot and spicy foods.
Avoid foods with smell that makes you feel nauseated.
Early morning nausea may be helped by eating dry crackers before
getting out of bed.
Avoid having empty stomach.
Lie down when nauseated.
Have enough rest and sleep.
JOURNAL ABSTRACT
1. Hyperemesis gravidarum is a miserable condition for patients and a
frustrating one for the staff caring for them. While nausea and vomiting are
common and expected in early pregnancy, the syndrome of hyperemesis
gravidarum, which can be defined as persistent vomiting starting in the first
trimester, is relatively uncommon. A study in 1992 found that among 9,088
pregnancies 35 had hyperemesis of sufficient severity to require intravenous
rehydration (Spiller, 1992).
2. Dodds, Linda PhD; Fell, Deshayne B. MSc; Joseph, K S. MD, PhD; Allen,
Victoria M. MD, MSc; Butler, Blair MD conducted a study on Outcomes of
Pregnancies Complicated by Hyperemesis Gravidarum with an objective
to evaluate maternal and neonatal outcomes among women with hyperemesis
during pregnancy. A population-based retrospective cohort study was
conducted among women with singleton deliveries between 1988 and 2002.
Hyperemetic pregnancies were defined as those requiring one or more
antepartum admissions for hyperemesis before 24 weeks of gestation.
Severity of hyperemesis was evaluated according to the number of antenatal
hospital admissions (1 or 2 versus 3 or more) and according to weight gain
during pregnancy (< 7 kg [15.4 lb] versus ≥ 7 kg). Maternal outcomes
evaluated included weight gain during pregnancy, gestational diabetes,
gestational hypertension, labor induction, and cesarean delivery. Neonatal
outcomes included 5-minute Apgar score of less than 7, low birth weight,
small for gestational age, preterm delivery, and perinatal death. Logistic
regression was used to generate adjusted odds ratios for all outcomes, and the
odds ratios were converted to relative risks. The results of this study suggest
that the adverse infant outcomes associated with hyperemesis are a
consequence of, and mostly limited to, women with poor maternal weight
gain.
3. Levine MG, Esser D conducted a study on Total parenteral nutrition
for the treatment of severe hyperemesis gravidarum: maternal
nutritional effects and fetal outcome. The purpose of this study was to
examine the nutritional state of pregnancy complicated by hyperemesis
gravidarum and the effects of total parenteral nutrition on maternal nutrition
and fetal outcome when given during the first trimester of pregnancy. Using a
standard method of indirect calorimetry, the basal metabolic expenditure and
adjusted metabolic expenditure were determined, and appropriate calories
were calculated for each patient. The patients were then started on total
parenteral nutrition. Follow-up indirect calorimetry studies showed improved
nutritional status, with return of anabolic parameters. The results of this
study support the conclusion that total parenteral nutrition given during the
first trimester is a safe and effective method of nutritional support.
4. Fell, Deshayne B. MSc; Dodds, Linda PhD Joseph, K S. MD, PhD; Allen,
Victoria M. MD, MSc; Butler, Blair MD conducted a study on Risk Factors for
Hyperemesis Gravidarum Requiring Hospital Admission During
Pregnancy with an objective to identify risk factors for hyperemesis
requiring hospital admission during pregnancy. Data from a population-based
cohort of all deliveries in Nova Scotia, Canada between 1988 and 2002 were
obtained from the Nova Scotia Atlee Perinatal Database. Women with 1 or
more antepartum admissions for hyperemesis were compared with women
with no admissions for hyperemesis. Relative risks (RRs) and 95% confidence
intervals (CIs) were estimated using logistic regression and used to determine
a set of independent risk factors for hyperemesis. The results shows that the
overall rate of admission for hyperemesis was 0.8% (n = 1,301) among
157,922 deliveries. In the adjusted analysis, hyperthyroid disorders (RR 4.5,
95% CI 1.8–11.1), psychiatric illness (RR 4.1, 95% CI 3.0–5.7), previous molar
pregnancy (RR 3.3, 95% CI 1.6–6.8), preexisting diabetes (RR 2.6, 95% CI 1.5–
4.7), gastrointestinal disorders (RR 2.5, 95% CI 1.8–3.6), and asthma (RR 1.5,
95% CI 1.2–1.9) were all statistically significant risk factors for hyperemesis,
whereas maternal smoking and maternal age older than 30 were associated
with decreased risk. Compared with singleton male pregnancies, singleton
female pregnancies, pregnancies with multiple male fetuses, and male and
female combinations were associated with statistically significant increased
risk of hyperemesis. Although hospitalization for hyperemesis occurs in less
than 1% of pregnant women, this translates to a large number of hospital
admissions. The factors associated with hyperemesis are primarily medical
and fetal factors that are not easily modifiable, but identification of these
factors may be useful in determining those women at high risk for developing
hyperemesis.
5. Jennifer L. Bailit , MD, MPH, conducted a study on Hyperemesis
gravidarium: Epidemiologic findings from a large cohort . the Objective of
this study was undertaken to quantify the frequency, clinical course, charges,
and outcomes of hyperemesis gravidarum. California birth certificate data
linked with maternal and neonatal hospital discharge data in 1999 were used
(N = 520,739). Hyperemesis was defined by ICD-9 codes. The frequency,
estimated charges, and demographic characteristics associated with
hyperemesis patients were assessed. Maternal and neonatal perinatal
outcomes were compared by maternal hyperemesis status. Results shows that
Hyperemesis complicated 2,466 of 520,739 births. The average length of stay
was 2.6 days and the average charge was $5,932. Singleton hyperemesis
infants were smaller (3,255 vs 3,380 g; P < .0001 and more likely to be small
for gestational age (29.21% vs 20.8%; P < .0001). Hyperemesis occurs in 473
of 100,000 live births and is associated with significant charges. Infants of
mothers with hyperemesis have lower birth weights and the mothers are
more likely to have infants that are small for gestational age.
6. Golberg, Deborah MD, CCFP; Szilagyi, Andrew MD, FRCPC; Graves, Lisa
MD, CCFP conducted a study on Hyperemesis Gravidarum and
Helicobacter pylori Infection: A Systematic Review. The objective of the
study is to systematically review studies examining the relationship between
hyperemesis gravidarum and Helicobacter pylori (H pylori) infection. A 1966
to January 2007 search using MEDLINE/PubMed, EMBASE, and Web of
Science included MeSH terms: Helicobacter pylori, Helicobacter infections,
hyperemesis gravidarum, and the text words nausea, vomit, pregnancy, and
Helicobacter. References of selected papers were examined for additional
relevant studies. They evaluated studies investigating a relationship between
hyperemesis gravidarum and H pylori infection. Studies were included in
which the diagnosis of hyperemesis gravidarum was made at or before entry
into the study, and H pyloridiagnosis was made by serum antibody sample,
gastric biopsy, saliva test, or stool sample. The search produced 169 titles; 22
were reviewed in further detail. Fourteen case-control studies met established
criteria, involving 1,732 participants and controls tested for H pylori infection.
Studies were evaluated according to patient demographics and study
methodology (case definition, exclusion criteria, H pylori testing). An estimate
of the odds ratios with 95% confidence intervals was calculated by using a
random effects model for dichotomous variables with review article software.
Ten studies showed a significant association between hyperemesis
gravidarum and H pylori infection. Odds ratios varied from 0.55 to 109.33;
three results were less than 1.0. Tests for heterogeneity applied to several
subgroups were considerable with values above 75% for all groups. An
association between hyperemesis gravidarum and H pylori infection is
suggested by this systematic review. However, the considerable heterogeneity
among studies highlights study limitations.
SUMMARY
Excessive vomiting of pregnancy incapacitating the day-to-day activities
&/or deteriorating the health of the mother is called Hyperemesis
gravidarum. It is rare now a days (1 in 1000). It is common in first birth &
limited to early pregnancy. The exact cause is not known but once vomiting
starts, probably neurogenic elements aggravate the state. The morbid
pathological changes are due to starvation. The clinical manifestations are due
to the effect of dehydration, starvation & keto-acidosis. Management consists
of hospitalization, sympathetic but firm handling of the patient, antiemetic
drugs, replacement of fluids by infusion, correction of electrolyte imbalance &
supply of glucose to protect the liver & vitamin supplement. Intractable
Hyperemesis gravidarum in spite of therapy is rare these days. Termination of
pregnancy is rarely indicated
BIBLIOGRAPHY
TEXTBOOK REFERENCE
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3. Elizabeth Stepp Gilbert. Manual of High Risk Pregnancy & Delivery. 4th
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NET REFERENCE
1. https://www.thieme-connect.com/ejournals/abstract/ajp/doi/10.105
5/s-2000-9424
2. http://www.nursingcenter.com/prodev/ce_article.asp?tid=866194
3. http://www.nursingtimes.net/nursing-practice-clinical-research/
hyperemesis-gravidarum-a-short-case-study/200677.article
4. http://www.obgyn.net/educational-tutorials/article/16247
5. http://www.netce.com/coursecontent.php?courseid=762