Hyperemesis gravidarum: Nursing

Nausea and vomiting of pregnancy, or morning sickness, is a common sign of pregnancy. However if there’s more severe and persistent nausea and vomiting it is called hyperemesis gravidarum.

This disorder can be dangerous to the mother and fetus if left untreated. First, let’s quickly review some relevant physiology during pregnancy.

There are several hormonal changes, like increased estrogen and progesterone, as well as increased levels of human chorionic gonadotropin, or beta-hCG for short.

These changes ensure the normal progression of pregnancy, and also contribute to some maternal physiological changes, such as relaxation of smooth muscles in various parts of the body.

This leads to decreased motility in the gastrointestinal tract so there’s a delay in the movement of food through the stomach and intestines.

In addition, relaxation of the lower esophageal sphincter allows stomach acid to reflux up the esophagus. This can cause “heartburn” and sometimes nausea.

Due to these changes, many pregnant mothers experience “morning sickness” which is mild and episodic nausea that can appear, despite its name, at any time of the day.

It typically starts as early as 5-6 weeks of gestation and ends at 16 to 20 weeks. This is considered a physiological process during pregnancy and is harmless to the mother and fetus.Now, the cause of hyperemesis gravidarum is not fully understood, but it’s thought that some people produce increased levels of estrogen, progesterone and especially beta-hCG or they respond to the increased levels of these hormones more severely.

Some risk factors for hyperemesis gravidarum include conditions that cause an additional increase of beta-hCG levels, like multigestational pregnancy and gestational trophoblastic disease.

Other risk factors include being pregnant for the first time, called primigravida, white race, as well as a family history of hyperemesis gravidarum, which suggests a genetic component.

Those with a personal history of motion sickness or migraines also seem to be at greater risk of developing hyperemesis gravidarum.The pathology of hyperemesis gravidarum starts with a genetically susceptible client who is undergoing hormonal changes due to pregnancy.

This causes them to experience more severe and persistent nausea and vomiting compared to those experiencing regular morning sickness.

Persistent vomiting can impair digestion and lead to malnutrition and weight loss. When the body is energy-starved, it switches to using up all the fat stores for energy; and then moves on to breaking down proteins for fuel.

This produces ketones which can be detected in the urine and it’s called ketonuria. When ketones build up in the blood, it causes acidosis, however the loss of stomach acid with the vomiting could also cause alkalosis.

In addition fluid is also lost through the vomit so there’s often dehydration. Other complications include coagulation disorders and hypokalemia.

Alternatively, fetal complications include low-birth weight, preterm labor, and intrauterine growth restriction, or IUGR for short.

Clients with hyperemesis gravidarum typically present with nausea and vomiting several times a day, or persist throughout the day.

Signs and symptoms of dehydration include weight loss, decreased urinary output, dry skin or mucous membranes, decreased skin turgor, hypotension, tachycardia, and dizziness.

The diagnosis of hyperemesis gravidarum is often based on the client’s history and physical examination only. The diagnosis can be made if pregnancy related nausea and vomiting interferes with their normal daily intake of food or water; interferes with their activity of daily living; or if there’s a weight loss of over 5 percent of prepregnancy body weight.

Laboratory tests can show elevated levels of beta-hCG, and can demonstrate complications like electrolyte and acid-base imbalances, as well as the presence of ketones in the urine.

Treatment of hyperemesis gravidarum starts with dietary changes that decrease the frequency and severity of vomiting, like identifying trigger foods or smells and avoiding those if possible.

Additionally, antiemetics, like a combination of doxylamine and pyridoxine, can be given. Supportive treatment options include intravenous fluid replacement, vitamin and mineral supplementation, or total parenteral nutrition in severe cases.

Finally, recent studies have shown that hyperemesis gravidarum can be prevented by preconceptional supplementing with prenatal vitamins for at least one month before conception.Alright, let’s take a look at the nursing care you’ll be providing for a client with hyperemesis gravidarum.

Priority goals of care include initiating measures to reduce vomiting, maintaining fluid and electrolyte balance, and providing emotional support.

First, assess your client’s severity of nausea and vomiting. Ask them about frequency or nausea, how often they vomit, and the color and consistency of emesis.

Ask about things that make the vomiting worse or better, and if there are any treatments they have tried. Then, assess for signs and symptoms of dehydration, including weight loss, decreased urinary output, dry skin or mucous membranes, and decreased skin turgor.

Collect laboratory samples, including CBC, CMP, and urinalysis. Administer antiemetic medications as prescribed, and offer small, easily-digested meals, like crackers, or sips of cool water, juice, or carbonated beverages as tolerated.

Ensure your client is in an upright position after eating or drinking. Also be sure to institute fall precautions, and instruct them to make position changes slowly.

Report to the healthcare provider if they are unable to tolerate oral intake, if vomiting continues to be severe despite treatment, or if there’s blood in the vomit.

Establish intravenous access and administer fluid and electrolyte replacements as prescribed. Lastly, assess for feelings of anxiety about their condition and its effect on their baby.

Provide emotional support by using therapeutic communication techniques during client interactions. Help them to identify coping mechanisms that have helped them in the past, determine what support systems are available to your client, and provide a referral to counseling services, if needed.Okay, let’s move on to client and family teaching.

Begin by explaining to your client that hyperemesis gravidarum is severe vomiting that accompanies pregnancy, and is more severe than “morning sickness.” Reassure them that it typically improves after the first trimester.

Then, teach them how to manage their condition after they are stabilized and discharged. Teach them about dietary changes that can decrease the risk of nausea and vomiting, including eating frequent, small meals consisting of foods that are high in protein and carbohydrates, such as crackers, bread, and low-fat yogurt.

Instruct them to consume plenty of potassium and magnesium-rich foods, such as fruit, vegetables, nuts, and seeds, and drink liquids between meals rather than with meals, to avoid gastric distension.

Remind them to remain upright during and after meals to decrease the risk of gastric reflux. Also instruct them to avoid strong smells when possible, spicy foods, and foods that are high in fat.

Finally, instruct them to contact their healthcare provider right away if they are unable to tolerate foods or liquids, if they continue to have persistent vomiting, or if they notice blood in their vomit.

Stress the importance of seeking medical attention immediately if the are urinating less than usual, if they notice their urine is dark, or if they feel dizzy, especially when standing up.Alright, as a quick recap… hyperemesis gravidarum is severe nausea and vomiting that occurs during pregnancy.

Although the cause is unknown, it most likely occurs in susceptible individuals because of hormonal changes that occur during the gestational period.

Risk factors for hyperemesis gravidarum include conditions that raise levels of beta-hCG, such as multigestational pregnancies and gestational trophoblastic disease; as well as other situations, like first pregnancies, previous gastrointestinal side effects to estrogen-containing medications, and a history of motion sickness or migraines.

Signs and symptoms include weight loss, nausea, persistent vomiting several times a day, as well as signs of dehydration, orw fluid and electrolyte imbalances.

Diagnosis involves a history and physical examination, along with laboratory and urine testing. Depending on the severity, treatment of the condition may involve dietary changes that decrease the frequency and severity of vomiting or antiemetics.

Supportive treatment, including intravenous fluid replacement, vitamin and mineral supplementation, or total parenteral nutrition might be necessary.

Priority goals of nursing care include initiating measures to reduce vomiting, maintaining fluid and electrolyte balance, and providing emotional support.

Client and family teaching focuses on dietary modifications to reduce risk of nausea and vomiting, and signs and symptoms to watch out for and report to a healthcare provider.

nausea, and vomiting and signs, and symptoms to watch out for and report to