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Obstetrics

Hyperemesis Gravidarum

Severe and persistent nausea and vomiting during pregnancy leading to dehydration, electrolyte imbalance, ketosis, and significant weight loss (>5% of pre-pregnancy weight).

Also known as: Severe Morning Sickness

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Referral and warning signs

When to refer

Refer ALL suspected Hyperemesis Gravidarum cases to hospital for assessment, IV fluids, antiemetics, investigation.

Red flags

  • Signs of severe dehydration
  • Significant weight loss (>5-10%)
  • Persistent ketonuria
  • Electrolyte abnormalities
  • Neurological symptoms (Wernicke's)
  • Abdominal pain/fever suggesting alternative diagnosis

Signs and symptoms

  • Severe, persistent nausea and vomiting.
  • Inability to tolerate oral intake.
  • Signs of dehydration (dry mucous membranes, poor turgor, tachycardia, hypotension).
  • Weight loss (>5% pre-pregnancy weight).
  • Ketonuria.
  • Electrolyte abnormalities (hypokalaemia, hyponatremia).
  • Haematemesis (Mallory-Weiss tears possible).

Risk factors

  • Multiple gestation.
  • Molar pregnancy.
  • History of hyperemesis.
  • Female fetus.
  • History of motion sickness/migraines.

Diagnosis

Clinical assessment

Severe N/V + weight loss + dehydration + ketonuria, after excluding other causes (gastroenteritis, UTI/pyelo, PUD, hepatitis, pancreatitis, DKA, hyperthyroid, molar pregnancy).

Investigations

  • Urinalysis: Check ketones, SG, rule out UTI.
  • Serum Electrolytes, Urea, Creatinine.
  • FBC (haemoconcentration).
  • LFTs.
  • Thyroid Function Tests (TSH, FT4).
  • Ultrasound Scan: Confirm viable IUP, exclude multiple/molar pregnancy.

Diagnostic criteria

Persistent vomiting + Ketosis + Weight loss (>5%), unrelated to other causes.

Management

Non-pharmacological management

  • Hospital admission.
  • Dietary modification (small, frequent, bland meals/snacks).
  • Rest.

Pharmacological treatment

  • Fluid/Electrolyte Replacement: IV Fluids (NS/RL initially, then D5% once rehydrated, add KCl as needed). Monitor intake/output/electrolytes.
  • Antiemetics (Stepwise): Vitamin B6 (Pyridoxine) +/- Doxylamine -> Promethazine PO/IM/PR -> Metoclopramide PO/IM/IV -> Ondansetron PO/IV (specialist discussion) -> Chlorpromazine IM/PO.
  • Thiamine (Vitamin B1): Give IV/IM BEFORE glucose if prolonged vomiting/malnutrition (prevent Wernicke's).

Monitoring

Monitor vitals, intake/output, weight, ketones, electrolytes. Assess N/V severity. Monitor fetal well-being.

Complications

  • Dehydration, electrolyte imbalance.
  • Malnutrition, weight loss.
  • Wernicke's encephalopathy.
  • Mallory-Weiss tears.
  • Renal failure.
  • Liver dysfunction.
  • DVT.
  • Psychological distress.

Prevention

  • Early management of N/V.
  • Pre-emptive Rx if previous history.

Patient education

  • Explanation of condition.
  • Reassurance usually resolves.
  • Importance of hydration/electrolytes.
  • Dietary advice.
  • Antiemetic use.
  • When to seek further help.

Uganda-specific notes

Differentiate from malaria/other infections. IV fluids, Promethazine/Metoclopramide available HC3/4. Ultrasound crucial (rule out molar). Risk of Thiamine deficiency.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 16, Section 16.3.1

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