HYPEREMESIS

GRAVIDARUM

JANISS
KRISTINE
KRISTINE
TAN
MEI
LEE
TAN MEI LEE
HEINNA
HEINNA
EU
EUJOHNNY
JOHNNY
JACKIE
JACKIEKANG
KANG
VITHYA
VITHYA
LAKSHMI
LAKSHMI
MAISARAH
MAISARAH
FARAH
FARAH
ISMAIL
ISMAIL
FATIN
FATIN
ZAFIRAH
ZAFIRAH
BIBI
BIBI
YASIMAH

Anatomy &
Pysiology

CAUSES HYPEREMESIS GRAVIDARUM

Almost all women experience some degree of morning sickness

during their pregnancy.

Morning sickness is nausea and vomiting during pregnancy.

Despite the name, morning sickness isnt confined to the
morning and can occur at any time.

Morning sickness and HG seem to have a connection to human

chorionic gonadotropin (hCG).

A hormone created during pregnancy by the placenta. Your body

produces a large amount of this hormone at a rapid rate early in
pregnancy.

The American Pregnancy Association states that hCG levels

typically double every 48 to 72 hours. These levels can continue
to rise throughout your pregnancy.

factors that could increase your risk of getting

HG are:
having a history of HG
being pregnant with more than one baby
being overweight
being a first-time mother
Trophoblastic disease can also cause HG.

PATHOPHYSIOLOG
Y

Although
Althoughthe
thepathophysiology
pathophysiologyof
ofHG
HGisispoorly
poorlyunderstood,
understood,the
themost
most
commonly
commonlyaccepted
acceptedtheory
theorysuggests
suggeststhat
thatlevels
levelsofhCGare
ofhCGareassociated
associated
with
withit.Leptinmay
it.Leptinmayalso
alsoplay
playaarole.
role.
Possible
Possiblepathophysiological
pathophysiologicalprocesses
processesinvolved
involvedare
aresummarized
summarizedin
inthe
the
following
followingtable:
table:
Source

Etiology

Pathophysiology

hCG

Distention
ofgastrointestinal tract
Crossover withTSH,
causing
gestationalthyrotoxicosis

Placenta

Estrogen
Progesterone

Decreased gut mobility

Elevated liver enzymes
Decreasedlower
esophageal
sphincterpressure
Increased levels of sex
steroids in hepatic portal
system.

Gastrointestinal tract

Helicobacter pylori

Increased steroid levels in

circulation

Placenta
Corpus luteum

PHARMACOLOGIC THERAPY
Pyridoxine (Vitamin B6) and
Doxylamine

Pyridoxine can be used as a single

agent or in conjunction with
doxylamine.
One small study demonstrated that
vitamin B6 in a dosage of 25 mg
taken orally every eight hours (75
mg per day) was more effective than
placebo for controlling nausea and
vomiting in pregnant women.
[Evidence level A, RCT] In
pharmacologic doses, vitamin B6 has
not been found to be teratogenic.
A single 25-mg doxylamine (Unisom)
tablet taken at night can be used
alone or in combination with
pyridoxine (25 mg three times daily).
Diclectin (10 mg of pyridoxine and
10 mg of doxylamine in a delayedrelease tablet). Diclectin typically is
prescribed in a dosage of two tablets
at night for mild symptoms and in a
dosage of up to four tablets per day
for more severe symptoms.

Antiemetics

The prochlorperazine
(Compazine)(C) and
chlorpromazine (Thorazine)
(C) have been shown to
reduce nausea and vomiting
of pregnancy compared with
placebo.
for treatment with
prochlorperazine or
promethazine is
unsuccessful, some
physicians try other
antiemetics, such as
trimethobenzamide (Tigan)
(C) or ondansetron (Zofran)
(B)
Women with severe nausea
and vomiting of pregnancy
or hyperemesis gravidarum
may benefit from droperidol
(Inapsine)(C).

Chlorpromazine (Thorazine)
10 to 25 mg orally two to four
times daily
Prochlorperazine (Compazine)
5 to 10 mg orally three or four
times daily
Promethazine (Phenergan)
12.5 to 25 mg orally every four
to six hours
Trimethobenzamide (Tigan)
250 mg orally three or four
times daily
Ondansetron (Zofran)
8 mg orally two or three times
daily
Droperidol (Inapsine)
0.5 to 2 mg IV or IM every
three or four hours

Antihistamines and
Anticholinergics

Meclizine (Antivert),
dimenhydrinate
(Dramamine), and
diphenhydramine have
been used to control
nausea and vomiting
during pregnancy.
All have been shown to
be more effective than
placebo.
Although meclizine was
previously thought to be
teratogenic, studies have
demonstrated its safety
during pregnancy.

Diphenhydramine (Benadryl) B
25 to 50 mg orally every four to
eight hours
Meclizine (Antivert) B
25 mg orally every four to six
hours
Dimenhydrinate (Dramamine) B
50 to 100 mg orally every four to
six hours

Motility Drugs and

Corticosteroids

Metoclopramide (Reglan)
acts by increasing pressure
at the lower esophageal
sphincter, as well as
speeding transit through the
stomach.
This drug has been shown
to be more effective than
placebo in the treatment of
hyperemesis gravidarum.
the study suggested that
methylprednisolone
(Medrol), in a dosage of 16
mg three times daily (48 mg
per day) followed by
tapering over two weeks, is
a worthwhile treatment for
women with refractory
hyperemesis gravidarum.

Motility drug
Metoclopramide (Reglan)
(B)
5 to 10 mg orally three
times daily
Corticosteroid
Methylprednisolone (Medrol)
(C)
16 mg orally three times
daily; then taper

TERAPI FITOTERAPI /
HERBA

JAHE (Zingiber
officinale Roscoe)

Zat-zat yang terkandung dalam jahe antara lain

gingerol, shogaol, zingerone, zingiberol dan
paradol.
Galanolakton (unsur lain) yang terkandung
pada jahe, adalah suatu antagonis kompetitif
pada ileus 5- HT reseptor - menimbulkan efek
anti-emetik
Dosis bagi kehamilan trimester pertama adalah
sebanyak 250 mg jahe diminum 4 kali sehari,
dapat diminum dalam bentuk sirup maupun
kapsul- mengurangi mual dan muntah.
Bubuk jahe 1 gram per hari mengurangi mual
disebabkan faktor lain.
Dosis maksimum tidak lebih 4 gram per hari
(Regina dkk, 2011)

Peppermint
Efek yang menenangkan pada perut,
mengurangi mual dan muntah semasa
kehamilan sediaan yg aman dan lembut
Diambil sebagai teh (sering dikombinasikan
dengan jahe sebagai bahan sedap rasa) yang
diteguk
kecil
dalam
bentuk
perasa
peppermint atau sebagai minyak peppermint
yang dihidu dalam bentuk aromaterapi.
Namun ramuan peppermint kaya dengan
minyak volatile (dpt melewati plasenta)
perawatan hanya bila perlu sahaja dan dalam
jumlah kecil sebagai teh dan bukan sebagai
tingtur atau minyak essensial untuk menelan.

Black Horehound

Ahli herba British menggunakan Black

Horehound dalam pengobatan motion
sickness, mual dan muntah ketika
kehamilan.
Biasanya diambil dalam dos yang kecil (
1-2 ml tingtur 3 kali sehari ) dalam
kombinasi dengan jahe atau chamomile
memberikan efek yang besar.
Bisa
ditambahkan
ke
dalam
air
berkarbonisasi.
Baik Botanical Safety Handbook dan
German Commission E menentang
penggunaan peppermint dan black
horehound selama kehamilan.

Acupuncture
Acupuncture

In addition to standard treatment, acupuncture to PC6,

could quicken the resolution of hyperemesis
8-hour treatment effect had been shown
Women in the active acupuncture group vs the placebo
group
Women in the active acupuncture group decreased in
the amount of nausea they experienced, but had
significantly fewer patients vomiting
There are a few possible mechanisms of action
inhibit nociceptive transmission
autonomic reflexes
decrease pain through endorphinergic mechanisms
effect on the GI tract
somatovisceral reflexes
(Carlsson CP,2000)

Hypnosi
Hypnosi
ss

1.

2.

Hypnosis is used to control physiologic changes that are thought

to be involuntary
An example of this is the unnoticed hum of a computer motor
Hypnosis treating hyperemesis performed by Simon and Schwartz
The treatment was effective in two ways
A deep relaxation that acts to decrease sympathetic nervous
system arousal
the response to hypnotic suggestion of symptom removal
It is also used for women with morning sickness would prevent the
nausea and vomiting from worsening or progressing to
hyperemesis gravidarum.
(Simon EP,1999)

MONITORING HG

Monitor weight,electrolytes and urinary ketones at

each visit.

Monitor vital signs, including standing and lying blood

pressure and pulse

Monitor Volume status (eg, mucous membrane

condition, skin turgor, neck veins, mental status)

nausea and/or vomiting beginning after 9-10 wk of

gestation, nausea and/or vomiting persisting after 2022 wk->Obstetric ultrasonography,Upper
abdominal ultrasonography

Segala yang dimakan atau diminum

dimuntahkan, apalagi kalau
berlangsung lama

Berat badan turun lebih dari 1/10 dari

berat badan normal

Turgor kulit berkurang, lidah kering

Adanya aceton dalam urin

Masu
k ke
RS

EVALUATION OF
HYPEREMESIS
GRAVIDARUM

Evaluation of fluid, acidbase balance, and

electrolyte status, with particular attention to serum
sodium, potassium, and chloride concentrations.
Elevated blood urea nitrogen (BUN) and serum
creatinine (SCr) concentrations, suggest severity
dehydration.
Evaluation of renal function may become important,
particularly in patients with volume contraction and
progressive electrolyte disturbances.
Specific parameters include daily urine volume,
urine specific gravity, and urine electrolyte
concentrations.
Physical assessment of patients should include
evaluation of mucous membranes and skin turgor,
because dryness of these tissues may be indicative
of significant volume loss.
(DiPiro, 2009)

PREVENTION AND COUNSELLING

Prevention-Avoid

large meals
heavy exercise
take vitamins on an empty stomach
dont mix solid foods woth liquids
take iron supplements
swollow excess saliva as this may worsen
nausea
strong-smelling foods
spicy or oily foods
Cigarette smoke

Counselling

mental- stress (aromatherapy, yoga, music, rest, cooking,

meditation, gardening).
doubts (communication with the doctor and spouse).
acupressure The pressure point to reducenausea is located at
the middle of the inner wrist, three finger lengthsaway from the
crease of the wrist, and between the two tendons. Locateand
press firmly, one wrist at a time for three minutes. Sea bands
alsohelp with acupressure and can be found at your local drug
store. Acupunctureis also effective, however, try the
wristbands first as they are convenient and less expensive than
acupuncture.
herbs ginger or peppermint drinks or take 500 mg dried ginger
in capsules 2-3 times per day. Ginger has been shown in many
clinical trials to be highly effective for relieving nausea,
including hyperemesis gravidarum. Do not exceed 1,500 mg per
day.

hypnosis- relax
fluids intake
try to eat small protein-rich meals every two hours
to keep your strength up. Eating protein before you
go to bed is especially important. Some peanut
butter on a slice of whole grain bread or protein
shakes can be good choices. Take your prenatal
vitamin with dinner instead of in the morning.
(yogurt or almonds)
take 25 mg ofvitamin B6three times per day. It has
proved highly effective for relieving morning
sickness for many women. Do not take more than
100mg per day.

REFERENCE

Regina Satya Wiraharja , Heidy, Selvi Rustam & Marissa

Iskandar. Kegunaan Jahe Untuk Mengatasi Gejala Mual
Dalam Kehamilan. Damianus Journal of Medicine; Vol.10
No.3 Oktober 2011: hlm. 161170.
Botanical Treatment of Nausea and Vomiting of
Pregnancy and
Hyperemesis Gravidarum. Available at :
http://medicinalplants.us/botanical-treatment-of-nauseaandvomiting-of-pregnancy-and-hyperemesis-gravidarum
Simon EP, Schwartz J. Medical hypnosis for hyperemesis
gravidarum. Birth. 1999;26:248254
F. Gary, et al. 2015. Williams Obstetrics TwentySecond Ed. Cunningham,Ch. 49. HER Foundation,
www.hyperemesis.org