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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 4
th
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 .
Fourth Stage – Obstetrics – Dr.Enas – Lecture 4
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Acliology of pregnancy induced vomiting :
This is still unknown
It may be due to :
1. 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 .
2. 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 .
3. 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 .
4. Genetic : evidences of support of a genetic predisposition to nausea
and vomiting .
a. frequency of nausea & vomiting of pregnancy in monozygotic twin.
b. 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 .
5. 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 .
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6. The vestibular system dysfunction : ( due to B6 or zinc deficiency).
7. Infection (latent holicobacter pylori residing in the stomach) .
Clinical features :
1. Intractable nausea and vomiting .
2. Rapid weight loss .
3. signs of dehydration ( sunken eyes , dry, Coated tongue ) .
4. Hypotension , tachycardia , oligouria .
5. 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. 1. If this condition is neglected ,it leads to acute fat necrosis of liver
& become enlarged & tender liver liver failure .
2. also lead to renal failure ( Acute tubular necrosis ) .
3. 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 ) .
4. Pneumothorax .
5. Mallory – Weiss tears of the oesophagus .
6. splenic avulsion .
7. even death if its neglected .
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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.
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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.
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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 .