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Hyperemesis gravidarum: a short case study

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VOL: 97, ISSUE: 32, PAGE NO: 55

JOY FIELD, RN, is clinical nurse specialist, clinical nutrition unit, Queen's Medical Centre, Nottingham

Hyperemesis gravidarum is a miserable condition for patients and a frustrating one for the staff caring for them. While nausea and vomiting are common and expected in early pregnancy, the syndrome of hyperemesis gravidarum, which can be defined as persistent vomiting starting in the first trimester, is relatively uncommon. A study in 1992 found that among 9,088 pregnancies 35 had hyperemesis of sufficient severity to require intravenous rehydration (Spiller, 1992).

Hyperemesis gravidarum is a miserable condition for patients and a frustrating one for the staff caring for them. While nausea and vomiting are common and expected in early pregnancy, the syndrome of hyperemesis gravidarum, which can be defined as persistent vomiting starting in the first trimester, is relatively uncommon. A study in 1992 found that among 9,088 pregnancies 35 had hyperemesis of sufficient severity to require intravenous rehydration (Spiller, 1992).

Helen Bond, a 36-year-old single women pregnant with her first child, was transferred to the nutrition unit at 20 weeks of pregnancy with persistent vomiting and weight loss. On transfer she was mildly dehydrated and had ketonuria.

Ketonuria reflects the accelerated development of the starving state in the mother, which helps preserve glucose for the foetus. Despite the use of antiemetics and intravenous rehydration her symptoms did not settle: she vomited on the hour, every hour, day or night, and became tired, withdrawn and miserable. At a time when she should have enjoyed her pregnancy and 'blossoming' - this was a planned and wanted baby - she was wretched.

In view of Ms Bond's weight loss and the evidence from the foetal growth chart it was decided that parenteral nutrition should be started. A central venous catheter was inserted under image intensifier, a lead apron being used to cover the abdomen and protect the foetus from radiation. This gave protein, calories, vitamins and fluid and took the pressure off Ms Bond to try to eat and drink. Unfortunately it did nothing to stop her retching and vomiting.

Parenteral nutrition as a mode of nutritional support has increasingly been used for patients with hyperemesis gravidarum in recent years. A number of antiemetic agents were tried, including metoclopramide, domperidone and cyclizine - all safe during pregnancy - but without success. Although Ms Bond was not now vomiting such large amounts she had persistent retching with unrelenting nausea.

Ms Bond was managed with parenteral nutrition until her 34th week of pregnancy, when her vomiting stopped and she was discharged home. Vomiting started again at 36 weeks' gestation and an elective Caesarean section was performed at 37 weeks. She delivered a healthy boy weighing 3.1kg.

Intractable vomiting in hyperemesis gravidarum, despite minimal oral intake and antiemetic use, is unusual. Most patients respond to a short period of intravenous nutrition and antiemetic drugs. An elective Caesarean was performed because of concern for the mother's health and mental well-being. The immediate relief of symptoms on delivery confirmed the diagnosis of hyperemesis gravidarum, the causes of which are not known, although it is said to be more common in multiple pregnancy or in the presence of a hydratidiform mole. While drugs can be successful in suppressing vomiting, the sensation of severe nausea persists.

Our role in caring for Ms Bond was to monitor her physical signs, ensure accurate fluid balance recordings, perform weight and urine tests, prevent metabolic complications and care for her parenteral nutrition and central venous catheter correctly to prevent any infective complications occurring.

On the psychological side, we encouraged Ms Bond to be enthusiastic and interested in the baby, talking about it and looking forward to the birth, something not easy to achieve when she spent most of the day or night with her head in a bowl either vomiting or retching.

All normal antenatal care had to be abandoned. Ms Bond could not attend antenatal clinic or parentcraft sessions. This isolated her from the contact she would have had with other expectant mothers, important with a first baby and single mother. It made her pregnancy a period of illness and not normality. Although scans were placed in a diary as a record of the pregnancy, there was nothing normal about this pregnancy for Ms Bond.

It has to be difficult to be enthusiastic about anything in this situation, especially something that is making you feel so awful for so long. Caring for Ms Bond was both challenging and rewarding for the whole team in the nutrition unit and highlighted one of the rare and miserable complications of pregnancy.

After delivery, Ms Bond and her son bonded well. She successfully breast-fed him and was discharged home soon after delivery, vowing this would be her one and only pregnancy.

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