Prof. Dr.

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Nausea and Vomiting in Pregnancy

• BY
• Prof. Dr.
• Mohammad Emam
• Prof. of Obstetrics and Gynecology
• Mansoura Faculty of Medicine
• Mansoura Integrated Fertility Center (MIFC)
  EGYPT

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Nausea

• Unpleasant sensation at back of throat
• Awareness of urge to vomit
• Often accompanied by
• cold sweat
• pallor
• salivation
• disinterest in surroundings
• loss of gastric tone
• duodenal contractions
• reflux of intestinal contents into stomach

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Retching

• Spasmodic, rhythmic contractions of respiratory
  muscles
• Diaphragm
• Chest wall
• Abdominal wall muscles
• Without expulsion of gastric contents
• Normally generates pressure gradient leading to
  vomiting

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Vomiting (emesis)

• Forceful expulsion of gastric contents from the
  mouth
• Caused by
• powerful sustained contraction of abdominal
  muscles
• descent of diaphragm
• opening of gastric cardia

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Epidemiology

• Up to 90 of pregnant women have nausea
• Up to 55 have vomiting
• Occurs between 4-16 weeks
• Usually mild, self-limited
• 5 are nauseated until delivery.
• Nausea and vomiting are worse in morning.
• May continue throughout the day.
• Not disturb the patient's health or her
  pregnancy.

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Epidemiology

• Primigravida
• Young women
• Obesity
• History of motion sickness
• Nausea/vomiting with oral contraceptives
• Psychiatric issues

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Pathophysiology

• Not fully understood
• Correlated with increasing hCG .
• Correlation with smooth muscle relaxation?
• Correlation with thyroid, progesterone, estrogen,
  adrenal hormones?

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Causes

• I. During early pregnancy
• A. Obstetric causes
• Vesicular mole.
• Multiple pregnancy.
• Hydramnios.
• Retroverted gravid uterus.
• B. Non obstetric causes
• 1. Gastrointestinal causes
• Appendicitis.
• Cholecystitis.
• Peptic ulcers.
• Gastroenteritis.
• Intestinal obstruction.
• Hiatus hernia.

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CausesI. During early pregnancyB. Non obstetric
causes ( continue)

• 2. Liver
• Viral hepatitis.
• 3. Pyelitis with pregnancy
• 4.Cerebral tumors.
• 5. Infectious fevers.
• 6. Red degeneration in a fibroid with pregnancy .
  
• 7. Torsion of ovarian cyst during pregnancy

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Causes

• II. Persistent vomiting late in pregnancy
• Pregnancy induced hypertension severe
  preeclampsia, eminent eclampsia.
• Abruptio placenta.
• Other non obstetric causes of vomiting.

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Treatment-Mild

• Support and Reassurance
• Avoidance of triggering foods and odors.
• Frequent small meals
• Eating dry toast or crackers before rising.
• Drugs

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Prognosis

• Generally excellent
• Incidence of fetal demise is lower
• Birth weight, congenital FD unchanged.
• Untreated hyperemesis have high morbidity and
  mortality
• HG is associated with decreased gestational age.

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Hyperemesis Gravidarum
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Definition

• Protracted and severe vomiting before the 20th
  week of gestation that affects the general
  condition of patient and requires admission to
  hospital .

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Epidemiology

• Is the most severe manifestation of the spectrum
  of nausea and vomiting of pregnancy.
• It complicates 0.3 to 2 of all pregnancies.
• Typically occurs in first trimester.
• Vomiting with weight loss gt5 of pre-pregnant
  weight.

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Epidemiology

• Dehydration, electrolyte imbalance and acid base
  disturbances .
• may lead to renal and hepatic injury .
• At risk for growth restriction and fetal
  anomalies .

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Risk Factors for HG

• Pgda
• Multiple pregnancy.
• Under the age of 24.
• PH of HG.
• Obesity.
• Female fetus.

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Causes of HG

• Theories
• High levels of hCG (stim CRTZ, as in multiple
  molar).
• Increased estrogen levels allergy.
• Psychological factors.
• High-fat diet.
• Thyroid gland activation in early pregnancy.
• Vitamin B6 deficiency.
• PG.
• Helicobacter pylori(HP) ???

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What is HP?

• Is a spiral-shaped gram negative rods found on
  gastric mucosa particularly the antrum .

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Prevalence of HP

• Very common all over the world 55 .
• 90 In peptic ulcer.
• 60 - 80 in gastritis without ulcer.
• Developing gt developed.
• In Egypt very common at young age .

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Transmission HP

• Oral Oral.
• Faecal Oral.
• Vectorial.
• Iatrogenic.

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Biochemical changes

• Electrolytes disturbances (decreased Na,
  decreased Cl-).
• Hypovolemia.
• Hemoconcentration (increased viscosity).
• Oliguria. Starvation.
• Ketoacidosis.
• ketone bodies accumulation (Ketonuria).
• Vitamin deficiency (B6, B1).

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Clinical Picture

• It starts as morning sickness that become
  aggravated gradually
• 1. Manifestations of dehydration as
• Sunken eyes.
• Dry tongue.
• Dry wrinkled skin.
• Oliguria.

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Clinical Picture

• 2. Manifestations of starvation as
• Emaciation.
• Loss of weight.
• 3. General Examination
• Vital signs decreased blood pressure,
  tachycardia, and subnormal temperature.
• Jaundice in severe cases
• Urine Oliguria in late cases

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Clinical Picture

• 4. Nervous manifestations in severe cases.
• Peripheral neuritis resulting in pain tingling
  sensation.
• Wernicke's encephalopathy (nystagmus, optic
  neuritis diplopia).
• Korsakoff's syndrome (confusion loss of memory
  for recent events).

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Investigations

• 1. Sonar to exclude multiple pregnancy exclude
  vesicular mole.
• 2. Serum electrolytes (decreased of Na Cl)
• 3. Renal function tests.
• 4. Liver function test.
• 5. Urine analysis.
• 6. Complete blood count.
• 7. Ophthalmic examination .

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Treatment

• Hospitalization
• IV hydration with electrolytes and vitamins
• Brief gut rest, then high carb, low fat diet
• Pharmacotherapy
• Enteral feeding if all other methods fail

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I. Treatment of Mild Cases

• 1. Reassurance and isolation from stressful home
  environment by hospitalization
• 2. Diet small, frequent, semisolid, rich in
  carbohydrate, poor in fat and proteins.
• 3. Treatment of dehydration by ample fluids
  intake .
• 4. Drugs
• Antiemetics cortigen B6, metclopramide
  (primperan and plasil).
• Antihistaminic
• Corticosteroids in resistant cases.
• Vitamin B1 and B6

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II. Treatment of Severe cases

• Hospitalization isolation of the patient in a
  single room, no visitors are allowed.
• 2. IV fluids (glucose 5, normal saline
• 3. Drugs
• Antiemetics (metclopramide, antihistaminic).
• Antacids.
• Vitamin B6 B1.
• Sedatives.
• Hydrocortisone.

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II. Treatment of Severe cases

• 4. Follow up of maternal fetal conditions
• Maternal
• Vital signs twice /day for hypotension and
  tachycardia.
• Urine analysis for acetone and chloride.
• Frequency, amount characters of vomiting.
• Daily fluid chart for fluid input output. Serum
  electrolytes daily (Na, Cl-, K).
• Examination of the fundus oculi/week.
• Liver function tests weekly .
• Renal function tests weekly.
• Fetal observation by serial sonography.

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II. Treatment of Severe cases

• 5. Termination of pregnancy
• 1. Severe persistent vomiting unresponsive to all
  measures.
• 2. Jaundice.
• 3. High blood urea, oliguria or anuria.
• 4. Wernicke's encephalopathy.
• 5. Retinal hemorrhages.

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Complementary Alternative Therapies

• Acupuncture/acupressure, at wrist .
• Nerve stimulation at wrist.
• Herbal remedies
• Ginger, 1 gm powder daily (ACOG)
• Peppermint leaf
• Chamomile
• Vitamin supplements- B6.
• Hypnosis

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A The location of pericardium P6 point (Neiguan)
Is three fingers breadth (patients fingers)
about 5 cm proximal to the proximal flexor palmar
crease, about 1 cm deep between the tendons of
flexor carpi radialis and palmaris longus . B
Active acupressure An elastic wristband with a
pressure stud, a small button the size of a pea
(7mm) Seaband (SeaBand, UK Ltd., Leicestershire,
England) was placed bilateral before anaesthesia
over the P6 point. C The location of a
non-acupoint. A point on the dorsal side of the
forearms, four fingers breadth (patients
fingers) proximal to the flexor palmar crease was
used for stimulation. D Pressure on a
non-acupoint Seabands was placed bilateral
before anaesthesia over the non- acupoints
described under C.
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ACUPUNCTURE AND ACUPRESSURE

• Stimulation of the P6 (Neiguan) point, located
  three-fingers breadth proximal to the wrist, has
  been used for thousands of years by
  acupuncturists to treat nausea and vomiting from
  a variety of causes.

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ACOG Recommendations

• Level A
• Multivitamin use at conception reduces N/V
• B6 with or without doxylamine is 1st line therapy
• Level B
• Ginger appears to be beneficial
• Antihistamines, Phenothiazines, Benz amides
• Methylprednisolone may be a last resort

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Thank you
Prof. DR. MOHAMMAD EMAM
OB GYN, Mansoura Faculty of Medcine Mansoura
Integrated Fertility Center (MIFC) EGYPT Telfax
0020502319922 0020123475579 Email.
mae335_at_hotmail.com