Vomiting in Pregnancy
Nausea and vomiting are often most pronounced in the first trimester , but by no means confined to it , and are also erroneously referred to as morning sickness .I . This may be very mild form starts after 6 8 wks of gestation but sometimes starts before that at 4th wks of gestation and gradually increases in severity and maximal intensity at 10 12 wks of gestation .
- The patient complains of irritability and excessive salivation( ptyalism ) , change in taste sensitivity and gustatory aversion .
- On examination : no evidence of dehydration , normal pulse rate , blood pressure and urinary output .
- About 90% of them have no symptoms by 16 wks of gestations .
Treatment :
They are treated as outpatient and they respond to reassurance , and simple measures ( advice them to eat frequent light meals , with protein and fluid intake ) .- Re-design the home enviroment to avoid sensory stimuli that provoke symptoms .
- sometimes may need simple antiemetic drugs .
II . Hyperemesis gravidarum : ( H. G. )
Is intractable nausea and vomiting that occurs in about 1% of gravid women .Acliology of pregnancy induced vomiting :
This is still unknownIt may be due to :
Psychological causes : The epidemiological observations show hyperemesis gravidarum ( H. G ) is most likely to occur in women of certain personality type or with a given psychopathological diathesis .
neuroendocrine alteration : It is related to hCG levels which is reach the peak at 10-12 wks of gestation , It is worse in a molar or multiple gestation and is probably related to high circulating human chronic gonadotrophin ( HCG ) levels . In addition , the association between biochemical hyperthyroidism with severity of H.G is strong , estrogen with its derivatives , progesterone and its effects on GIT , and serotonin affects both CNS & GIT .
Cytokines : Recent study investigated the role of cytokines in H.G. , they find concentration of interferon alfa ( INF alfa ) which involved in regulation of hCG production and IL 4 secreting cells incidence of H.G .
Genetic : evidences of support of a genetic predisposition to nausea and vomiting .
frequency of nausea & vomiting of pregnancy in monozygotic twin.
The fact that siblings of mothers of patient affected with nausea and vomiting of pregnancy are more likely to be affected than sibling at affected individuals .
More common inc younger age group , history of oral contraceptive pills sickness , history of motion sickness , history f migraine , down's syndrome , and more in white people .
The vestibular system dysfunction : ( due to B6 or zinc deficiency).
Infection (latent holicobacter pylori residing in the stomach) .
Clinical features :
Intractable nausea and vomiting .
Rapid weight loss .
signs of dehydration ( sunken eyes , dry, Coated tongue ) .
Hypotension , tachycardia , oligouria .
Haematemesis .
At the beginning the patient has metabolic alkalosis due to loss of HCL and K+ from stomach , but due to deficiency of caleries , the body is shift to fat metabolism to get more energy , inturn this leads to accumulation of keton bodies in blood metabolic acidosis .
Complications :
1. If this condition is neglected ,it leads to acute fat necrosis of liver & become enlarged & tender liver liver failure .
also lead to renal failure ( Acute tubular necrosis ) .
Neurological complications ( Wernicke's encephalopathy ) is serious complication of H.G leads to central nervous system dysfunction due to thiamin vitamin deficiency ( B1 ) . most of them presented with confusion and apathic , gait ataxia , Nystagmus ) .
Pneumothorax .
Mallory Weiss tears of the oesophagus .
splenic avulsion .
even death if its neglected .
Diagnosis :
- Clinical diagnosis is based on history and physical findings .- Laboratory workup : includes urine tests for ketonuria and blood tests for electrolytes and acetone .
- Electrolytes disturbances may include hypokalemia , hyponatremia and hypochloremic alkalosis Random blood sugar ,blood urea, serum creatinine ,&liver function tests.
- Medical and surgical diseases should be excluded in any intractable vomiting like :
a. gastrointestinal tract causes :
- gastro enteritis , pancreatitis , hepatitis , biliary tract disease , peptic ulcer , appendicitis ,achalasia.
b. Genito-urinary tract causes :
- Pyelonephritis , uremia , ovarian torsion , renal stone , degeneration of uterine fibroid .
c. Metabolic causes :
- Diabetic ketoacidosis , Addison disease , Hyper-thyroidism , hyper- parathyrodism .
d. neurological disorder :
- Migrin headach , psendo tumor cerebri , tumor of CNS .
e. Pregnancy related conditions :
- pre-eclampsia , acute fatty liver of pregnancy .
f. Miscellaneous causes :
- Drug toxicity or allergy .
-Psychological causes.
Treatment :
Is symptomatic , but if outpatient management fails , patients must be admitted for intravenous administration of fluids , electrolytes , vitamins ( B1 , B6 ) and antiemetics such as : cyclizine , Domperidone , metoclopromide or prochlorperazine are given in regular basis .
- Also antihistamine may be added .
- In sever cases we can use : Andasterone ( zoferan ) ( 5 HT3 receptor antagist ) . and short course corticosteroid .
- In the severest cases , total parenteral nutrition is given .
- In very worst cases , termination of pregnancy may be considered .
Note : The herbal medication ( Ginger ) may have a role in treatment of H.G.
Objective
The student should be known :How differentiate between the mild and sever cases of vomiting of pregnancy .
Should be known the different causes of nausea and vomiting and should be differentiated from the hyperemsis gravidarum .
The complications of the hyperemsis gravidarum .
Neglection of sever cases metabolic , neurological , hepatic and renal complications and even death .
Good management good outcome .