Vomiting in pregnancy

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VOMITING IN PREGNANCY

• MDIII
• HKMU
• By Dr. M. Chiduo
• 2023

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Causes of Vomiting In Pregnancy

• I-EARLY PREGNANCY
• Morning Sickness
• Emesis Gravidarum
• Hyperemesis Gravidarum
• II- LATE PREGNANCY
• Acute fulminating Preeclampsia

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Causes..

• Associated with Pregnancy (not related to
  pregnancy)
• Medical causes
• Worm infestation
• Urinary tract infection
• Hepatitis
• Diabetic keto-acidosis
• Uraemia
• Psycho-social

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Prevalence

• Studies shows that nausea occur in 66-89 of
  pregnancies and vomiting in 38-57.
• The nausea and vomiting associated with
  pregnancy
• - begins by 9-10 weeks of gestation
• - peaks at 11-13 weeks
• -resolves (in 50 of cases) by 14 weeks.
• In 1-10 of pregnancies, symptoms may continue
  beyond 20-22 weeks.

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Causes ..

• Surgical causes
• Appendicitis
• Peptic ulcers
• Intestinal Obstruction
• Cholecystitis
• Hiatus hernia
• Gynaecological Causes
• Twisted Ovarian cyst
• Red degeneration of fibroid

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Emesis Gravidarum

• Affects over 70-85 of pregnacies
• 0.3-2 of them may develop Hyperemesis
• Cause not well defined
• Associated with Hormonal changes (HCG,
  Progesterones, Thyroxine)
• Social-Psychological adjustments
• Neurological factors

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Emesis

• Occurs once or twice in a day and doesnt
  interfere the food intake.
• Usually limited to the first trimester and
  improves after 14/40.
• Management
• Assurance
• Dry foods (Crackers, biscuits)
• Fractional meals
• A drink before rising in the morning.

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HYPEREMESIS GRAVIDARUM

• Definition
• Vomiting in pregnancy which affects/ inhibits the
  food intake, leading to metabolic
  disarrangements. (Dehydration Electrolyte
  imbalance, and Starvation)
• Affects 4/1000 pregnancies

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Hyperemesis Cont.

• Clinical features
• - Excessive vomiting
• - Oliguria (decreased amount of urine)
• - Concentrated urine

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Hyperemesis- Differential diagnosis

• Exclude other causes of vomiting
• Molar pregnancy
• Twin pregnancy
• Intestinal obstruction
• Appendicitis
• Pancreatitis

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D. Diagnosis.

• Cholecystitis
• Gastritis, Ulcers
• Malaria
• Diabetes
• Migraine

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Some Causes of Nausea and Vomiting During Early
Pregnancy
Cause Suggestive Findings Diagnostic Approach
I. Obstetric Causes I. Obstetric Causes I. Obstetric Causes
Emesis gravidarum (uncomplicated nausea and vomiting) Mild, intermittent symptoms at varying times throughout the day, primarily during the 1st trimester Normal vital signs and physical examination Diagnosis by exclusion
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Hyperemesis gravidarum Nausea and vomiting, frequent, persistent - Inability to maintain adequate oral intake of fluids, food, or both Signs of dehydration (eg, tachycardia, dry mouth, thirst), - weight loss(10) - Urine ketones Serum electrolytes, Blood Urea, Creatinine - Liver function tests, - Pelvic USG
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Hydatidiform Mole Larger-than-expected uterine size Absent fetal heart sounds and movement BP sometimes elevated Vaginal bleeding with grapelike tissue - BP - Quantitative hCG - Pelvic USG - Endometrial Biopsy
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II. Non obstetric Causes II. Non obstetric Causes II. Non obstetric Causes
Gastroenteritis Acute, not chronic usually accompanied by diarrhea Normal abdomen (soft, non tender, not distended) Clinical evaluation
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Bowel obstruction Acute. Usually in patients who have h/o abdominal surgery. Colicky pain, with constipation and distended, tympanic abdomen. May be caused by or occur in patients with appendicitis Abdominal x-rays, supine and upright. Ultrasonogra-phy CT (if x-ray and ultrasound results are not conclusive)
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UTI or Pyelone-phritis Urinary frequency, urgency or hesitancy, with or without lumbar pain and fever Urinalysis Culture and sensitivity
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Investigations

• Full blood picture
• Serum Electrolytes
• Low urinary chlorides
• Ketonuria
• Proteinuria
• Bile salts

• Blood Glucose
• Blood Urea
• Liver function test
• hCG levels
• TSH , Thyroxine levels

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The principles of management

• Control vomiting
• Correct the fluids and electrolytes imbalance
• Correct metabolic disturbances (acidosis or
  alkalosis)
• Prevent serious complications
• Psychological support Sympathetic but firm
  handling of the patient is essential. Social and
  psychological support should be extended

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Management

• General measures
• Counselling and Reassurance
• Emotional support
• Rest and Lifestyle adjustment
• Ensure adequate hydration and
• Frequent, small, carbohydrate meals
• Avoid spicy foods

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Management..

• Severe cases
• Restrict oral intake 24-48 hrs
• Naso-gastric tube feeding
• Monitor electrolytes/24 hrs urine
• Parenteral nutrition
• IV fluids to combat Dehydration and alkalosis
• Gradual introduction of oral foods

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Management..

• IV fluids Ringer lactate, 5 dextrose, Normal
  Saline
• Vitamin B1 100mg IV 24 hourly mix in intravenous
  rehydration solution
• Pyridoxine Doxylamine tabs10mg 8 hourly till
  vomiting stops

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Management..

• Metoclopramide inj. IM 510 mg 8 hourly till
  vomiting stops.
• OR
• Promethazine inj. 25 -50mg IM 8 hourly
• OR
• Ondansetron ZOFRAN 4 mg IV or 8 mg IM, 12
  hourly till symptoms improve
• Termination of pregnancy

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Complications

• Dehydration
• Ketosis or Keto-acidosis
• Polyneuritis
• Wernickes Encephalopathy
• Hepatitis
• Emaciation

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Thank you

• For your Attention!!!!