Educational Materials

1. Associate Clinical Prof. Dr. Aisha Elbareg, MD, PhD.
Senior Consultant in (Obs & Gyn/Reproductive Medicine)
Faculty of Medicine, Misurata University, LIBYA.

2. NVP
 NVP (emesis) Symptoms of nausea and/or
vomiting during early pregnancy where there
are no other causes.
 Hyperemesis gravidarum (HG) is severe,
protracted form of NVP with the triad of
 More than 5% weight loss
 Dehydration
 Electrolyte imbalance

3. NVP
 NVP affects up to 80% of pregnant women.
 Most common indications for hospitalization.
 Occurs between 4-14 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 baby.

4.  Common in
 Primigravida
 Young women
 Obesity!
 History of motion sickness
 Nausea/vomiting with oral contraceptives
 Psychiatric issues
NVP

5. NVP- pathophysiology
Theories
 Not fully understood.!!
 Fetoprotective, genetic, immunological, bioche-
mical, biosocial.
 Correlated with increasing hCG.
 Correlation with thyroid, progesterone, estrogen,
adrenal hormones?
 Correlation with GIT smooth muscle relaxation?

6.  Psychological factors.
 Thyroid gland activation in
early pregnancy.
 High-fat diet.
 Vitamin B6 deficiency?
 Helicobacter pylori(HP) ???
NVP- pathophysiology
Theories

7. 1. During early pregnancy
A. Obstetric causes
Molar pregnancy (Vesicular mole).
Multiple pregnancy.
Hydramnios.
NVP- Causes

8. 1. During early pregnancy
B. Non obstetric causes
1. Gastrointestinal causes
 Appendicitis, Cholecystitis.
 Pancreatitis, hepatitis.
 Peptic ulcers.
 Gastroenteritis.
 Intestinal obstruction.
 Chronic infection with Helicobacter pylori
NVP- Causes

9. I. During early pregnancy
B. Non obstetric causes
2. Endocrine: DKA, thyrotoxicosis
3. Pyelonephritis.
4.Cerebral tumors.
5. Infectious fevers.
6. Red degeneration in a fibroid with preg.
7. Torsion of ovarian cyst during pregnancy.
8. Drug induced N & V (Iron, opioid)
NVP- Causes

10. II. Persistent vomiting late in pregnancy
 Acute Fatty liver of pregnancy
 Pregnancy induced hypertension: severe
preeclampsia, eminent eclampsia.
 Abruptio placenta.
 Other non obstetric causes of vomiting.
NVP- Causes

11. NVP- Treatment
 Support and Reassurance.
 Avoidance of triggering foods and odors.
 Frequent small meals.
 Eating dry toast or crackers before rising.
 Medications.
 Admission if not responding or not
tolerating oral medications or fluid.

13. HG is a debilitating and potentially life
threatening pregnancy problem marked
by rapid weight loss, malnutrition, and
dehydration due to protracting severe
vomiting with potential adverse
consequences for the newborn(s).
HG- Definition

14.  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 >5% of pre-
pregnant weight.
HG- incidence

15.  Debilitating fatigue – inability to work or take
care of their families
 Malnutrition and dehydration
 Frequent vomiting of blood or bile
 Oesophygeal rupture, gastritis, esophagitis
 Retinal hemorrhage.
 Wernicke’s encephalopathy.
 Depression, anxiety and
social isolation.
 DVT
HG- Maternal complications

16.  Miscarriage (25% for HG pregnancies)
 Pre-term labor
 Low birth weight
 Developmental delays
 Congenital heart disease
 Skeletal malformations
 Behavior/emotional problems
HG- Fetal complications

17.  Electrolytes disturbances:
 Hyponatremia, hypokalemia.
 Hypovolemia (raised hematocrit)
 Hemoconcentration (increased viscosity).
 Oliguria, starvation.
 Ketonuria with metabolic hypochloraemic
alkalosis.
 If sever, a metabolic Ketoacidosis.
HG- Biochemical changes

18.  Vitamin deficiency (B6, B1).
 Abnormal thyroid function test (2/3 of cases).
 Biochemical thyrotoxicosis
 Raised free thyroxin with or without
suppressed TSH.
 Abnormal Liver function test.
HG- Biochemical changes

19. HG- Clinical picture
 It starts as morning sickness that become
aggravated gradually
1. Manifestations of dehydration as
 Sunken eyes.
 Dry tongue.
 Dry wrinkled skin.
 Oliguria.

20. 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
HG- Clinical picture

21. 4. Nervous manifestations in severe cases.
Thiamine B1deficiency
 Peripheral neuritis resulting in pain & tingling
sensation.
 Wernicke's encephalopathy (WE):triad of
 Occulomotor abnormalities
(nystagmus, diplopia, optic neuritis)
 Cerebellar dysfunction.
 Impaired mental state or mild memory impair.
HG- Clinical picture

22. Wernicke's encephalopathy:
 Death up to 20%.
 Korsakoff's syndrome (KS)
(confusion & loss of memory for recent events).
HG- Clinical picture

23. HG- Investigation
1. Ultrasonogram: to exclude multiple pregnancy
& exclude vesicular mole, organ USS.
2. Serum electrolytes (decreased of Na, K & Cl)
3. Renal function tests.
4. Liver function test, thyroid function test
5. S. Amylase
6. Urine analysis.
7. Complete blood count.
8. Ophthalmic & neurological examination

24. Treatment of severe cases
1. Hospitalization :
A. Intravenous fluids
B. Medications
C. Nutrition
D. Thiamine supp
E. Thromboprophylaxis

25. Intravenous fluids
 Normal saline with additional KCL.
 Daily monitoring of electrolytes
 Dextrose infusion is not recommended unless
serum sodium level is normal and thiamine
has been administered.
 Dextrose infusion precipitate WE in thiamine-
deficient status.

26. Medication
1st line anti-emetic therapy
 2 of these drugs used together may be more
effective than a single drug.
Phenothiazines – Prochlorperazine
Largactil 25 IM inj, Stematil suppositoreis.
Antihistamines - Cyclizine 50mg by IM or IV
injection x 3 daily .

27. Medication
2nd line Anti-emetic
In addition to a first line drug
 Metoclopramide – (plasil) 10mg 3 times daily
 Ondansetron – (Danset) 4mg IV 12 hourly.
3rd line Anti-emetic
 Hydrocortisone 100mg bd initially followed by
Prednisolone 20mg bd for 7 days reducing the
dose thereafter.

28. Nutrition
 Encourage oral fluids when they can be
tolerated.
 Record fluid balance.
 Encourage frequent snacks of “safe foods”
when able to eat .
 Assistance to eat when required.
 Avoid iron containing food.
 Consider referral to Dietician in severe cases.

29. Thiamine
Thiamine 50mg x 3x5 daily should be routinely
given to all women admitted to hospital until
eating normally. Oral Thiamine may need to be
continued after discharge.
Thromboprophylaxis
• Anti-embolic stockings
• LMWH
• given to all clinically dehydrated patients on
bed rest.

30. 2. 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.

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

32. Complementary & Alternative Therapies
 Herbal remedies:
Ginger, 1 gm. powder daily (ACOG)
Peppermint leaf
Chamomile
 Acupuncture &
acupressure, at wrist .
 Hypnosis