Case Based Discussion

“Hiperemesis Gravidarum”
31 October 2019

DEPARTEMEN OBSTETRI DAN GINEKOLOGI

RSI JEMURSARI SURABAYA
UNIVERSITAS NAHDLATUL ULAMA SURABAYA
 Pembimbing :
dr Amir Fahad, Sp.OG

Dokter Muda :
Dinda Mutiara Sukma Prastika
Anang Maulana Yusuf
Aisyah Imas Setiawati
Himami Firdausiyah
Fithrotun Nisak

2
Definition
Hyperemesis gravidarum is the most severe form of nausea and vomitting during
pregnancy and is characterized by intractable nausea and vomitting that leads to
dehydration, electrolyte and metabolic disturbances, and nutritional deficiency that
may require hospitalization.

Onset of vomitting typically starts between 6 and 8 weeks’ gestation and peaks by 12
weeks. Hyperemesis gravidarum are usually limited to first trimester but 20% of
women continue throughout pregnancy.
Epidemiology
The incidence of Nausea and vomiting in pregnancy (NVP) reaches 91% which equals approximately
4 million and 350,000 women who are affected every year in the United States and Canada respectively.
Although HG is a rare disease compared to NVP, it occurs in 0.3% to 2% of all pregnancies. It varies with
ethnicity and ranges between 3 and 20 per 1000 pregnancies. This varies may be due to different
diagnostic criteria in addition to ethnic variation in populations

A study from Canada of 367 women found that Asians and blacks were less likely to report symptoms of
NVP than Caucasians. Socio-demographic factors did not explain the racial/ethnic variation in disease
prevalence, suggesting that genetic and/or cultural factors may contribute
Etiology
•Hormonal
1. higher HCG level
2. higher oestrogen level
3. progesterone excess -relaxation of cardiac sphincter & impaired gastric motility
•Dietary deficiency-low carbohydrate intake, vit B6,B1 deficiency
•Psychogenic
•Genetic
•Allergic or immunological basis
•Liver dysfunction
•Vestibular system dysfunction
Risk Factors
Risk factors for hyperemesis gravidarum include:

•High levels of the ß-hCG hormone.

•Increased estrogen levels.
•Gastrointestinal changes.
•Psychological factors.
•High-fat diet.
•Helicobacter pylori.
a. High levels of the ß-hCG hormone
This hormone rises rapidly on the first quarter of pregnancy and can trigger parts of the brain
that are control nausea and vomiting.
b. Increased estrogen levels
Affects the part of the brain that is control nausea and vomiting.
c. Gastrointestinal changes
During pregnancy, the gastrointestinal tract is pressed because it gives room for fetal
development. This can result in acid reflux (the release of acid from the stomach to the throat)
and the stomach works more slowly to absorb food, causing nausea and vomiting.
d. Psychological factors
Stress and anxiety can trigger it morning sickness.
e. High-fat diet
The risk of hyperemesis gravidarum increases 5 times for each addition of 15 g of saturated fat
every day
f. Helicobacter pylori
Research reports that 90% of cases pregnancy with hyperemesis gravidarum is also infected
with this bacterium, which can cause sores on the stomach.
Pathophysiology
The exact cause of hyperemesis gravidarum remains unclear. However, there are
several theories for what may contribute to the development of this disease process.

Hormone Changes
Levels of human chorionic gonadotropin (hCG) have been implicated.
Estrogen is also thought to contribute to nausea and vomiting in pregnancy.
Changes in the Gastrointestinal System
It is well-known that the lower esophageal sphincter relaxes during pregnancy due
to the elevations in estrogen and progesterone.
Genetics
Two genes, GDF15 and IGFBP7, have been potentially linked to the development
of hyperemesis gravidarum
 Pathophysiology
The exact cause of hyperemesis gravidarum remains unclear. However, there are several theories for what may
contribute to the development of this disease process.

Hormone Changes
Levels of human chorionic gonadotropin (hCG) have been implicated. hCG levels peak during the first trimester,
corresponding to the typical onset of hyperemesis symptoms.
Estrogen is also thought to contribute to nausea and vomiting in pregnancy. Estradiol levels increase early in pregnancy
and decrease later, mirroring the typical course of nausea and vomiting in pregnancy.
Changes in the Gastrointestinal System
It is well-known that the lower esophageal sphincter relaxes during pregnancy due to the elevations in estrogen and
progesterone. This leads to an increased incidence of gastroesophageal reflux disease (GERD) symptoms in pregnancy,
and one symptom of GERD is nausea
Genetics
An increased risk of hyperemesis gravidarum has been demonstrated among women with family members who also
experienced hyperemesis gravidarum. Two genes, GDF15 and IGFBP7, have been potentially linked to the development
of hyperemesis gravidarum
Signs and Symptoms
Hyperemesis gravidarum according to severity of symptoms can be divided into 3 grades,
namely:
Grade I
1) Mother feels weak
2) Continuous vomiting that affects the general state
3) There is no appetite
4) Decreased body weight
5) Increased body temperature
6) The pulse increases by about 100 per minute and systolic blood pressure decreases
7) Reduced skin turgor
8) The tongue dries
9) Sunken eyes
10) Feeling pain in the epigastrium
Grade II
1) Mother looks weaker and apathetic
2) Weight loss
3) Blood pressure drops, pulse is small and fast
4) The temperature sometimes rises
5) Eyes slightly jaundice and sunken
6) More reduced skin turgor
7) The tongue dries and looks dirty
8) Hemoconcentration, oliguria, constipation
9) Acetone smells in breathing, because it has a distinctive aroma and can also be found in
urine
Level III
1) The general situation is more severe
2) Vomiting stopped
3) Awareness decreases from somnolence to coma
4) Small and fast pulse
5) Temperature is rising
6) Tension decreases
7) Mouth is dry and dirty, breathing smells of acetone
8) Concave eyes and the onset of jaundice indicate a lack of effort
Diagnosis for hyperemesis gravidarum
1. History taking accurate dating of pregnancy, onset of symptoms, past medical history of HG
2. Nausea and vomitting when onset is in the first trimester of pregnancy
3. Using PUQE score to assess severity
4. Hypersalivation may occur in 60% of cases
5. Inability to keep food and fluids
6. Onset is between the fourth and seventh weeks of gestation, peaks around the ninth week and
recovery occurs by the 20th week in 90% of patients
7. Rare case : symptoms persist into the second trimester of pregnancy
8. HG is characterised by severe, protracted nausea and vomiting associated with weight loss of
more than 5% of pre pregnancy weight, dehydration and electrolyte imbalances
 Examination
•Vital sign
•Physical examination
•Dehydration sign : Dry lips and tongue, decreased skin turgor and reduced urine output
•Laboratory
 Complete blood count ; hematocrit value may be raised due to hemoconcentration
Pre-albumin levels may be low which indicate poor food intake especially protein and possible
poor fetal weight gain
 Random blood glucose to exclude hypoglycemia as a complication of HG electrolytes panel
should be measured to exclude hypokalemia, hyponatremia, metabolic alkalosis and other
electrolyte imbalance
Liver function test
B-HCG
Creatinine
Blood urea nitrogen
Urinalysisis : increase ketones, spesific gravity
•In refractory cases RCOG recommend checking thyroid function tests : TSH levels may be low in HG
Prevention
The principle of prevention is to treat emesis to prevent hyperemesis gravidarum by:

1. Provide application of pregnancy and childbirth as a physiological process.

2. Giving confidence that nausea and sometimes vomiting are physiological symptoms in
young pregnancy and will disappear after 4 months of pregnancy.
3. Recommend changing daily meals with small portion but frequent meals.
4. Advise when you wake up in the morning do not immediately get out of bed, for example
eat dry bread or biscuits with hot tea.
5. Foods that are oily and have a fat smell should be avoided.
6. Food should be served hot or very cold.
7. Avoiding cardohydrate deficiency is an important factor, it is recommended that foods
contain lots of sugar (Wiknjosastro, 2005).
Management
1. Medical: Drugs that can be given include multivitamin supplements, antihistamines,
dopamine antagonists, serotonin antagonists, and corticosteroids.

2. Nutrition

3. Psychological therapy: Need to be assured to patients that the disease can be cured.
Eliminate fear due to pregnancy and childbirth because it is a physiological process

4. Parenteral fluid: Fluid resuscitation is a top priority. Give enough parenteral fluid
electrolytes, carbohydrates, and protein with 5% glucose in physiological saline as much
as 2-3 liters a day.
CASE
Patient’s Identity

Name : Mrs. i
Gender : Woman
Age : 30th years old
Adress : Surabaya
Occupation :
Marital Status : Married
Religion : Muslim
Date of examination : 18 th October 2019
Time of examination : 23.30 WIB
Place of examination : PONEK Jemursari Surabaya Hospital
Anamnesis
Main complaint
Vomitting
Current complaint
Patients came to the ER Jemursari Hospital Surabaya with complaints of vomiting since 4
weeks of SMRS. Complaints have become worse in the last 2 days. The patient vomits in the form
of liquid mixed with mucus and the last leftover food eaten. In a day the patient can vomit > 10
times.
The contents of the vomit in the form of food and drinks consumed before, vomit
contained no blood. Complaints of nausea and vomiting get worse if after eating and
drinking, and decrease at rest. In addition, patients also complain that the body feels weak
so unable to perform daily activities as usual, the lips feel dry, appetite is felt to decrease
because the patient is afraid of vomiting. The patient also complained of heartburn and
decreased body weight. Weight before pregnancy 54 kg now 45 kg and felt his shirt was
very loose. Urinate concentrated yellow with a slight volume, last Defecate 12 hours SMRS.
Anamnesis

Hisroty of Medical
hypertention -, diabetes melitus -, ashtma -, HEG 1 month ago

History of Medical family

hypertention -, diabetes melitus -, asma -

History of medical treatments

-

History of allergies
-
Physical Examination

Status generalis
General : weak
Awareness : CM (GCS 456)
Blood pressure : 105/75 mmHg
Pulse frequency : 102 x / minute (regular)
RR : 22x / minute
Temperature : 36 C
SpO2 :-
Current BB : 54kg
Current height :154 cm
BMI : 18
 Physical Examination
Head and Neck
A- / i- / c- / d-
Nasal lobe breathing (-)
KGB and thyroid enlargement (-)
↑ JVP (-)
Pharyngeal hyperemia (-)
Dry mouth mucosa (+)
Coward eyes (+)
Swallow pain (-)
Thoraks
Pulmo
I: Symmetrical shape, retraction (-), symmetrical
chest movement.
Pa: Symmetrical lung development, right
hemithorax fremitus is decreased.
Pe: Sonor in left lung hemithorax, dim in right
hemothorax
A: Vesicular decreased left hemithorax. Rhonki (- / -)
wheezing (- / -)
Heart Abdomen:

• I: Normochest, ictus cordis is not seen •I: Flat, no traces of surgery, no mass.

• Pa: Ictus cordis is not palpable • A: BU (+) increases

• Pe: Right border of the heart, in the • Pa: Supple, epigastric tenderness, There

parasternal line of ICS 4 and left lateral is no enlargement of the liver or spleen
in the lateral 2 cm mid clavicular line of • Pe: hipertimpani
- + -
ICS 5 sinistra - - -
• A: Nomal heart sound - - -
Extremities:
Wet, cold, pale on all four extremities,
Minimal pitting (- / -) edema of the limbs
CRT <2s
Obstetric status
last date of menstruation : 28 Juli 2019
EDC : 5 April 2019
- pregnancy history :
1. I : spontan/Boy/3000g/8years
2. II : Hamil ini

Uterus fundal height: 2 fingers above the

symphysis
heart rate: - x / minute,
Uterine Contractions: -
Leopold: ballotement
 Parameter Value Reference Inteval

Leukosit 12.00 3.60 - 11.0

Basofil 0.451 0-1
Neutrofil 57.01 39.3 - 73.7
Limfosit 5.493 25 - 40
Complate Blood Count Eosinofil 0.020 2-4
15/10/19 Monosit 2.857 2-8
Eritrosit 4.256 3.8 - 5.20
Hemaglobin 11.67 11.7 - 15.5

Hematokrit 40.2 35 - 47
MCV 78.0 80 - 100
MCH 25.0 26.0 - 34.0
MCHC 32.1 32 - 36
RDW-CV 12.5 11.5 - 14.5

Trombosit 195 150 - 450

MPV 8,2 7.2 - 11.1
Diagnosis :
G2P1A0 13/14 weeks S/L IU + HEG grade I + moderate
dehydration
• Planning of Diagnosis
serum electrolytes, urinalysis
• Planning of Therapy
Infus RL 2700  1350 First 8 hours, 1350
16 hours later
Inj. Ondansentron 3x8mg
Diets High-calories high-protein
• Planning of Monitoring
Vital Sign, patient complaints, urine
output
• Planning of Education
Bed Rest
Eat a little but often
consumption of sweet and savory foods.
References

1. Tamay AG, Kuscu NK (2011) Hyperemesis gravidarum: Curren aspect. J Obstet Gynaecol 31: 708-712.
2. Bottomlay C, Bourne T (2009) Management strategies for hyperemesis. Best Pract Res Clin Obstet Gynaecol
23: 549-564.
3. Jarvis S, Nelson-Piercy C (2011) Management of nausea and vomiting in pregnancy. BMJ, Vol. 342.
4. Sanu O, Lamont RF (2011) Hyperemesis gravidarum: pathogenesis and the use of antiemetic agents. Expert
Opin Pharmacother 12: 737-748.
5. Lee NM, Saha S (2011) Nausea and vomiting of pregnancy. Gastroenterol Clin North Am 40: 1-27
6. Castillo MJ, Phillippi JC (2015) Hyperemesis Gravidarum. J Neonatal Nurs 6: 21-28.
7. London V, Grube S, Sherer DM, Abulafia O (2017) Hyperemesis gravidarum: A review of recent literature.
Pharmacology 100: 161-171.
 THANK YOU
JAZAKUMULLAH