Question

1. A 30-year-old gravida 3 para 2 Caucasian female at 16 weeks' gestation

# Hyperemesis gravidarum

a. What is the pathophysiology of Hyperemesis gravidarum?

b. What is the therapeutic regimen for Hyperemesis gravidarum?

# Dehydration

a. What is the pathophysiology of Dehydration?

b. What is the therapeutic regimen for Dehydration?

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Answer 1

30 year old gravid aat 16 weeks of pregnancy has vomiting due to hormonal changes

     Pathophysiology of Hyperemesis gravidarum

Due to many factors such as hormonal changes, genetic, psychological factors are responsible for hyperemesis gravidarum

           Hormonal changes mainly due to the human chorionic gonadotropin and estrogen and progesterone which are factors increases vomiting during pregnancy

                   Relaxation low esophageal sphincter and delay gastric time results from hormonal changes as a result of increased level of progesterone that leads to lower esophageal sphincter relaxation results in back flow of foods and fluids.

                          Accumulation of fluids and food in gastrointestinal system results from increased progesterone that causes vomiting along with relaxation of lower esophageal sphincter

                                      Vomiting occurs continuously due to delay gastric emptying and relaxation of lower esophageal sphincter.  if not treated that leads to hyperemesis gravidarum. There is also increased level of thyroid stimulating hormone during pregnancy also reason for the increases causes of vomiting

                   

                   Inadequate food and fluids that leads to depletion of glycogen stores and that leads to stagnation of ketone results from incomplete breakdown of fat and breakdown of body protein in order to meet energy

                                          Loss of electrolyte as a result of vomiting

                         That leads to acidosis and ketosis and that causes the hypoglycemia, hypoproteinamia

                                  Signs and symptom of ketoaciodosis and severe dehydration

,

Therapeutic regimen of hyperemsis gravidarum

·

· Mother is restricted to consume fluids until the vomiting resolves

· Administration of intravenous fluids if mother is not tolerating oral fluids and signs and symptoms dehydration and there is a chance of fetal injury occurs

· Mother can be administered approximately 3 liters of fluid. First half of the fluid should be 5% dextrose and remaining half should be ringer lactate solution. Then the fluid can be administered according to the loss of fluid through the vomiting

· Mother is commenced on antiemetic medication s promethazien 25 mg, prochloraperazien or triflupromazine. She is prescribed metroclopramide in order to increase gastric and intestinal motility

· Antenatal mother is commenced on hydrocortisone if the mother has intractable vomiting

· Nutritional supplements such as vitamin B1, B6, C and vitamin B12 is given to mother in case hypovitaminosis occurs

· Monitor intake and output chart in order to fluids status and identify any dehydration

· Monitor vital signs in order any deviation in physiological changes

· Monitor laboratory values such as sodium and potassium in order to assess electrolyte

· Mother can be monitored for any changes in rhythm in case of hypokalemia.

· Mother is advised to consume dry foods in the morning such as biscuits, toast. Dry foods that reduces vomiting after settling of hyperemesis gravidarum

· Mother can be advised to consume small and frequent diet. Large amount of foods at a time that increase the vomiting

· Mother can be advised to consume ginger made tea to avoid nausea

· Advise mother to do deep breathing exercise and relaxation exercise to relieve stress. Because stress is the reason the hyperemesis gravidarum

· Advise mother to lie in semi fowler position and advise to lie after 2 hours of intake of food. Because progesterone relaxes the lower esophageal sphincter and delay gastric emptying

· Advise mother to sit in noxious free environment. becauses Noxious stimuli increases vomiting

· Educate mother to avoid consumption of fluids in between foods. Fluid consumption causes fullness abdomen increases the vomiting

· Advise to limit oil foods. Oil foods delay in emptying from the gastrointestinal system

· Therapeutic support can be given to the mother throughout therapy. because Stress also reason for vomiting

Dehydration

etiology factors: Etiological factors for dehydration vomiting, diarrhea, and hyperthermia. Other causes include diabetes, diuretic and climate such as increased temperature, hemorrhage

Types of dehydration

Isotonic dehydration: in which electrolytes and water are lost equally

Hypertonic dehydration: in which water is lost excessively than electrolytes

Hypotonic dehydration: in which electrolytes is lost than water

Severity of dehydration:

Mild dehydration: dehydration is less than 5%, patient may have no symptoms, has mild thirst and concentrated urine

Moderate dehydration: dehydration is 6 to 9%. Patient may exhibit signs and symptoms of sunken eyes, oliguria, dry mucous membrane, postural hypotension

Severe dehydration: dehydration is more than 10%. Patient may exhibit signs and symptoms such as weak pulse, reduced skin turgour, hypotension, confusion, tachycardia

Pathophysiology of dehydration

Etiological factors for dehydration vomiting, diarrhea, and hyperthermia. Other causes include diabetes, diuretic and climate such as increased temperature, hemorrhage

Due to etiological factor such as vomiting, infectious disease such as cholera, hyperthermia

                                  Causes loss of intravascular fluid

Shift of blood volume from interstitial to intravascular compartment for compensation

                                       Increased loss interstitial fluids in case of compensation mechanism failure

                                                  Reduction of plasma volume that leads to

                         There is imbalance of electrolyte such as sodium and potassium and bicarbonate in the body

                                           Signs and symptom dehydration occurs if etiology of dehydration is not treated

                              

Cellular dehydration that leads to cellular dehydration anoxia occur. If not treated , cell death occurs

                              Finally shock occurs if not treated

Management of dehydration

· Identify the etiological factors that causes dehydration.

· Patient can be monitored for any respiratory and neurological and cardiovascular symptoms. that helps to assess the severity of dehydration

· Treat etiological factor there by progression of dehydration can be arrested

· Oral rehydration solution to be given in case of dehydration.

· Oral fluids and foods can be withheld in case of severe vomiting and diarrhea. Because oral intake of foods and fluids may be irritant to the gastrointestinal system.

· Administer intravenous fluids according to severity of dehydration and type of dehydration. Severity of dehydration may be mild and moderate and severity of dehydration. Type of dehydration may be hypotonic, isotonic, hypertonic dehydration. to combat fluid loss through vomiting, diarrhea

· Administer antibiotics in case of infectious diarrhea, mainly antidiarrheals, antimicrobials.to treat infection

· Antiemetic can be started in case of vomiting induced dehydration such as metoclopramide, ondensetron in order to reduce vomiting

· Administer hypotonic solutions such as o.45% normal saline in case of hypertonic dehydration; isotonic dehydration is treated with isotonic fluids 0.9% normal saline, ringer lactate solution and hypotonic dehydration can be treated with hypertonic solutions such as 5% in normal saline, 5% in 0.45 % normal saline.

· Laboratory values such as potassium, sodium and bicarbonate values can be monitored throughout therapy. to identify the changes in biochemical values and helps to correct the electrolyte

bed rest is advised for patient. because dehydartion that causes fatique.