Symptoms of Severe NauseaThe patient cannot retain anything in her stomach, vomitingoccurs through the day and night even without eatingThirst, constipation and infrequent urinationIn severe cases, vomitus is bile and/ or blood stainedFinally, there are manifestations of Werniche's encephalopathyas drowsiness, nystagmus and loss of vision then coma
Symptoms of Severe Nausea The patient cannot retain anything in her stomach, vomiting occurs through the day and night even without eating. Thirst, constipation and infrequent urination. In severe cases, vomitus is bile and/ or blood stained. Finally, there are manifestations of Werniche’s encephalopathy as drowsiness, nystagmus and loss of vision then coma
SignsManifestations of starvation and dehydration include:: Loss of weight - loss of 5 or more pounds over a 1-2 week periodSunken eyesDry tongue dry mucous membranes, and inelastic skinGums covered with soresBreath acetone smellLate, slight jaundice (yellow coloring to skin or whites of eyes) Pulse: rapid and weakBlood pressure: lowTemperature: slight rise
Signs Manifestations of starvation and dehydration include: • Loss of weight - loss of 5 or more pounds over a 1-2 week period. • Sunken eyes • Dry tongue dry mucous membranes, and inelastic skin • Gums covered with sores • Breath acetone smell • Late, slight jaundice (yellow coloring to skin or whites of eyes). • Pulse: rapid and weak • Blood pressure: low • Temperature: slight rise
Laboratory StudiesInitial lab studiesforhyperemesisgravidarumshouldincludethefollowing:Urinalysisforketonesand specificgravity:Asignofstarvation,ketonesmaybeharmful tofetal development. High specific gravity occurs with volume depletion.Serumelectrolytesandketones:Assesselectrolvtestatustoevaluateforlowpotassiumorsodium,identifyhyperchloremicmetabolicalkalosisoracidosis,andevaluaterenal functionandvolumestatusLiver enzymes and bilirubin:Elevatedtransaminaselevelsmayoccurinas manyas5o%of patients withhyperemesis gravidarum.Mildtransaminaseelevationoftenresolvesoncethenauseahasresolved.Significantlyelevatedliverenzymeshowever,maybeasignofanotherunderlyinglivercondition,suchashepatitis(viralischemic,autoimmune),orsomeotheretiologyofliverinjuryAmylase/lipase:Amylaselevel is elevated inapproximately10%ofpatientswithhyperemesisgravidarum.Lipase,whencombinedwithamylase,canincreasethespecificity in diagnosing pancreatitis as an etiology.TSH,freethyroxin:Hyperemesis gravidarumis often associated witha transienthyperthyroidism and suppressed TsH levels in 50-60% of cases. However, anelevated free thyroxin may suggest that overt hyperthyroidism is present, thusnecessitatingfurtherworkupandtreatmentUrine culture:This may be indicatedbecause urinarytract infectionis common inpregnancy and can beassociated with nausea and vomiting.Calciumlevel:ConsidermeasuringCa++levels.Somerarecaseshavebeenreportedof hypercalcemiabeingassociatedwithhyperemesisgravidarum,resultingfromhyperparathyroidism.Hematocrit:Thismaybe elevated because of volumecontractionHepatitis panel: If clinically indicated, hepatitis A, B, or C may be confused withhvperemesisaravidarum
Laboratory Studies • Initial lab studies for hyperemesis gravidarum should include the following: • Urinalysis for ketones and specific gravity: A sign of starvation, ketones may be harmful to fetal development. High specific gravity occurs with volume depletion. • Serum electrolytes and ketones: Assess electrolyte status to evaluate for low potassium or sodium, identify hyperchloremic metabolic alkalosis or acidosis, and evaluate renal function and volume status. • Liver enzymes and bilirubin: Elevated transaminase levels may occur in as many as 50% of patients with hyperemesis gravidarum. Mild transaminase elevation often resolves once the nausea has resolved. Significantly elevated liver enzymes, however, may be a sign of another underlying liver condition, such as hepatitis (viral, ischemic, autoimmune), or some other etiology of liver injury • Amylase/lipase: Amylase level is elevated in approximately 10% of patients with hyperemesis gravidarum. Lipase, when combined with amylase, can increase the specificity in diagnosing pancreatitis as an etiology. • TSH, free thyroxin: Hyperemesis gravidarum is often associated with a transient hyperthyroidism and suppressed TSH levels in 50-60% of cases. However, an elevated free thyroxin may suggest that overt hyperthyroidism is present, thus necessitating further workup and treatment. • Urine culture: This may be indicated because urinary tract infection is common in pregnancy and can be associated with nausea and vomiting. • Calcium level: Consider measuring Ca++ levels. Some rare cases have been reported of hypercalcemia being associated with hyperemesis gravidarum, resulting from hyperparathyroidism. • Hematocrit: This may be elevated because of volume contraction. • Hepatitis panel: If clinically indicated, hepatitis A, B, or C may be confused with hyperemesis gravidarum
Imaging Studies. Obstetric Ultrasonography is usually warranted in patientswith HEG to evaluate for multiple gestations ortrophoblastic disease. Additional imaging studies generally are not needed unlessthe clinical presentation is atypical (e.g., nausea and/orvomiting beginning after 9 -io weeks of gestation, nauseaand/or vomiting persisting after 20-22 weeks, acute severeexacerbation) or other disorder based on history or physicalexamination findings.If indicated clinically, performing upper abdominalultrasonography to evaluate the pancreas and/or biliary treeappears to be a low-risk study.In rare cases, abdominal CT scan or MRI may be indicatedif appendicitis is under consideration as a cause of nauseaand vomiting
Imaging Studies • Obstetric Ultrasonography is usually warranted in patients with HEG to evaluate for multiple gestations or trophoblastic disease. • Additional imaging studies generally are not needed unless the clinical presentation is atypical (e.g., nausea and/or vomiting beginning after 9 -10 weeks of gestation, nausea and/or vomiting persisting after 20-22 weeks, acute severe exacerbation) or other disorder based on history or physical examination findings. • If indicated clinically, performing upper abdominal ultrasonography to evaluate the pancreas and/or biliary tree appears to be a low-risk study. • In rare cases, abdominal CT scan or MRI may be indicated if appendicitis is under consideration as a cause of nausea and vomiting
Diagnostic ProcedureIn patients with abdominal pain or uppergastrointestinal bleeding, upper gastrointestinalendoscopy appears to be safe in pregnancy.Although careful monitoring is suggested
Diagnostic Procedure In patients with abdominal pain or upper gastrointestinal bleeding, upper gastrointestinal endoscopy appears to be safe in pregnancy. Although careful monitoring is suggested