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 its 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 pregnancies. in pregnancy, occurring in about 70% of

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. 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 Psychological-this is one of the oldest theories postulated in the pathogenesis of Hyperemesis.

3.

4.

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 Nausea sometimes accompanied by vomiting Hyperemesis Gravidarum Nausea accompanied by severe vomiting

Nausea that subsides at 12 Nausea that does not subside weeks or soon after Vomiting that does not cause Vomiting that causes severe severe dehydration dehydration Vomiting that allows you to Vomiting that does not allow keep some food down 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 Wernickes encephalopathy. The lesion may be related to vitamin B1 deficiency Metabolic, biochemical & circulatory changes: the changes are due to the combined consequent upon vomiting
1.

effect of dehydration starvation causes

& starvation depletion of

Metabolic

changes-

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 Predisposin g Factor: -woman Precipitati ng 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. Dehydratio n Metabolic imbalances Difficulty with daily activities

Food leaving the stomach more slowly Hypersalivatio Nausea & vomiting Abdominal pain Difficulty in

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. 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 - Wernickes encephalopathy due to thiamine deficiency - Korsakoffs 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: Vitamin B6

a. o

Drug classification: Vitamins & Minerals (Pre & Post Natal) / Antianemics 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.). Doxylamine (Aldex, Unisom) of action: Doxylamine competes with

b.

o Drug classification: Antihistamines

o

Mechanism

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 pregnancyassociated nausea and vomiting 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) Contraindications: Hypersensitivity to doxylamine or any component of the formulation

o Side effect: Sedation

o

Adverse tachycardia stimulation, pain,

reactions: ; Central

Cardiovascular: nervous system:

Palpitation, Dizziness, dry

disorientation, drowsiness, headache, paradoxical CNS vertigo; Gastrointestinal: Genitourinary: Anorexia, mucous membranes, diarrhea, constipation, epigastric xerostomia; Dysuria, urinary retention; Ocular: Blurred vision, diplopia
o

Special precautions: May impair ability to drive and operate machinery. Angle-closure glaucoma, urinary retention, obstruction; Lactation. prostatic hypertrophy hepatic or pyloroduodenal Elderly. epilepsy; impairment.

o Pregnancy vomiting.

Considerations:

Doxylamine

has

been

approved for used in pregnancy-associated nausea and

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; muscarinicblocking effect may system. be responsible for antiemetic activity; reduces stimuli to the brainstem reticular Indications: Symptomatic relief of allergy e.g. hay fever, urticaria, premed; emergency treatment of anaphylactic reactions; sedation; motion sickness. 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. 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

Special precautions: Avoid extravasation or inadvertent intra-arterial 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 institutions, I.V has been may associated with or severe tissue necrosis and loss of digits/limb. In some administration be avoided specific administration techniques may be used to minimize risk. Discontinue immediately if burning or pain occurs with I.V. administration. inj. Induction of & recovery from anesthesia. Patients w/ acute porphyria. Allergy to Na

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
o

Drug classification: Antiemetics 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. Contraindications: obstruction, Hypersensitivity or to

Max: 0.5 mg/kg body wt.

o

metoclopramide or any component of the formulation; GI perforation hemorrhage; pheochromocytoma; history of seizures or concomitant use of other agents likely to increase extra pyramidal reactions. o o avoid disease. Side Effects: Tardive dyskinesia (black-box warning) Special precautions: May cause drowsiness so activities which mask require of high of in therapy: result levels a of May may symptoms serious Abrupt

concentration. discontinuation o Pregnancy

Discontinuation (rarely)

withdrawal effects

symptoms (dizziness, headache, nervousness). Considerations: Teratogenic 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. o

o

Ondansetron (Emodan, Zofran) Drug classification: Antiemetics Mechanism of action: Hypersensitivity to

ondansetron, other selective 5-HT3 antagonists, or any component of the formulation. o Indications: Prevention of nausea and vomiting with moderatelyto highly-emetogenic prevention of chemotherapy; radiotherapy; associated cancer

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

Special precautions: May cause drowsiness so activities which require of high therapy: result in levels of of a serious Abrupt withdrawal effects

avoid disease.

concentration. May mask symptoms Discontinuation may (rarely) discontinuation o Pregnancy

symptoms (dizziness, headache, nervousness). considerations: Teratogenic 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 effect the and chemoreceptor depresses the trigger zone; of exhibits a strong alpha-adrenergic and anticholinergic blocking release 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 anxiety
o

disorders,

including

schizophrenia

and

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 pregnancy. Prompt hospitalization is mandatory to prevent complications
1.

low

doses

suggests

safe

use

during

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 Wernickes encephalopathy in severe cases 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

2.

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 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 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 Alternative therapies like psychotherapy, acupressure & medical hypnosis can be tried 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.

4.

5.

6.

7.

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 womans 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 gingercontaining 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 Risk for maternal / fetal injury related to severe result complications of Hyperemesis for ineffective individual or family coping emotional status & hospitalization

NURSING CARE PLAN

Assessmen t Subjective: hyper salivation nausea & vomiting Objective: -Irritated -(+) nausea and vomiting -(+) hypersaliv ation -(+) dry skin -Vital signs taken as follows: BP: 90/70 CR: 80bpm RR: 22cpm T: 37C Diagnosis Deficient fluid volume related to hypereme sis gravidaru m as manifeste d by hypersaliv ation, vomiting and dry skin. Planning After the shift of nursing interventio ns, the patient will decreased the possibility in vomiting, hypersaliv ation decreased and skin becomes moisturize d. And irritability will diminish. Intervention -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 (METOCLOPRAMI DE) given as ordered by the physician. -Encouraged patient to Rationale -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 Evaluation Goal met: After the shift of nursing interventi ons the patient was able to perform changes in her status.

increase oral fluid intake. -Encouraged patient to eat dry toast foods. Assessme nt Subjective : The patient verbalizes irritability pain Objective: -9/10 pain scale -Irritable -Grimacing -Guarding behavior -Vital signs taken as follows: BP: 90/70 Diagnosis Acute pain related to hypereme sis gravidaru m as manifeste d by verbal report and guarding behavior. Planning 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. Intervention -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

vomiting and at the same time the patient will be refilled to prevent gastric ulcer. Rationale -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. Evaluation 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.

the her

- To alleviate

CR: 80bpm RR: 22cpm T: 37C

comfortable state. -Massage patient. -Instructed S.O. not to leave the patient.

suffering from perceived pain. -To prevent from fall.

Assessme nt Subjective: The patient verbalizes that orthopnea Objective: -Irritated Orthopnea Alterations in depth of breathing -Nasal

Diagnosis Ineffective breathing pattern related to pain as evidenced by orthopnea, alterations in depth of breathing and nasal flaring.

Planning After 3 hours of nursing intervention the patient will be able to breathe properly.

Intervention -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

Rationale -To gather information. -For data. Baseline

Evaluation Goal met: After 3 hours of nursing intervention the patient can perform proper breathing pattern and can breathe properly.

-To prevent overload of the fluid. -For relaxation of the patient. -To prevent irritation/ discomfort of

flaring -Vital signs taken as follows: BP: 90/70 CR: 80bpm RR: 22cpm T: C

comfort measures. -Positioned patient orthopneic position.

to

-Provided air to patient. -Instructed S.O. to massage chest and back of the patient.

the patient. -Helps in the breathing pattern of the patient. It helps the patient to breathe properly. -For proper ventilation. -It helps patients breathing pattern. Rationale -To gather information. -For Baseline data. -To prevent overload of the fluid. -For relaxation of the

Assessmen t Subjective: Objective: -Irritability -Facial tension -Trembling Restlessne ss -Vital signs

Diagnosis Anxiety related to perceived proximity of death as manifested by the verbal report, irritability,

Planning After 3 hours of nursing intervent ion the will no longer feel the proximit y of

Intervention -Established rapport to the mother. -Monitored vital signs and recorded. -Monitored IVF drip and its patency.

Evaluation Goal met: After 3 hours of nursing interventio n, the patient was filled with hope.

taken as follows: BP: 100/80 CR: 89bpm RR: 22cpm T: 37C

facial tension, trembling, and restlessness .

death.

-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.

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.

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 semiprone position. oDrink spearmint or peppermint tea.
o Take

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). Dodds, Linda PhD; Fell, Deshayne B. MSc; Joseph, K S. MD, on Outcomes and of Pregnancies with an outcomes Complicated to women by with

2.

PhD; Allen, Victoria M. MD, MSc; Butler, Blair MD conducted a study Hyperemesis maternal Gravidarum neonatal objective among evaluate

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. Levine MG, Esser D conducted a study on Total parenteral for the treatment of severe effects by hyperemesis and fetal maternal nutritional

3.

nutrition

gravidarum: nutritional

outcome. The purpose of this study was to examine the state of pregnancy complicated 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 populationbased 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 1.811.1), psychiatric illness (RR 4.1, 95% CI 3.05.7), previous molar pregnancy (RR 3.3, 95% CI 1.66.8), preexisting diabetes (RR 2.6, 95% CI 1.54.7), gastrointestinal disorders (RR 2.5, 95% CI 1.83.6), and asthma (RR 1.5, 95% CI 1.21.9) 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. Jennifer L. Bailit, MD, MPH, conducted a study on

5.

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. Golberg, Deborah MD, CCFP; Szilagyi, Andrew MD, FRCPC; and Review. Helicobacter The objective pylori of the Infection: study is A to

6.

Graves, Lisa MD, CCFP conducted a study on Hyperemesis Gravidarum Systematic hyperemesis

systematically review studies examining the relationship between 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. a References of selected papers were examined for additional relevant studies. They evaluated studies investigating 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-today 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
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https://www.thiemeconnect.com/ejournals/abstract/ajp/doi/10.105 9424 5/s-2000-

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http://www.nursingcenter.com/prodev/ce_article.asp? tid=866194 http://www.nursingtimes.net/nursing-practice-clinicalresearch/hyperemesis-gravidarum-a-short-casestudy/200677.article http://www.obgyn.net/educational-tutorials/article/16247 http://www.netce.com/coursecontent.php?courseid=762

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