HYPEREMESIS GRAVIDARUM AND ITS HOMOEOPATHIC MANAGEMENT

Abstract:
Hyperemesis Gravidarum is a serious complication of pregnancy presenting as
prolonged and severe nausea and vomiting causing dehydration, malnutrition and
significant morbidity. Women with a history of hyperemesis Gravidarum have around
80%chance of suffering in subsequent pregnancies. Careful and thorough planning
in future pregnancy can significantly reduce the overall severity of symptoms. This
article explores the various aspects of thorough prophylactic homoeopathic
medication to optimise the outcomes of future pregnancy and decrease the rate of
morbidity associated with hyperemesis Gravidarum.
KEYWORDS:
Hyperemesis Gravidarum, Nausea, Vomiting, Antiemetic, Homoeopathic medicine.
INTRODUCTION:
Hyperemesis Gravidarum is a severe and potentially life-threatening condition, which
can have profound effects on the mother’s health and wellbeing. Nausea and
vomiting affect around 80-85%of pregnant women to a greater or lesser degree
making it the most common medical condition in pregnancy. Around 30%of women
will be severely affected, however, only 1-15%of pregnant women will be admitted to
hospital with extreme nausea and vomiting, known as Hyperemesis Gravidarum.
HYPEREMESIS GRAVIDARUM AND ITS HOMOEOPATHIC MANAGEMENT
DEFINITION:
 It is a severe type of vomiting of pregnancy which has got deleterious effect on the health of the
mother and/or incapacitates her in day-to-day activities
 The adverse effects of severe vomiting are—
dehydration, metabolic acidosis (from starvation) or alkalosis (from loss of
hydrochloric acid), electrolyte imbalance (hypokalemia) and weight loss.

INCIDENCE:
 There has been marked fall in the incidence during the last 30 years. It is now a
rarity in hospital practice (less than 1 in 1000 pregnancies).
The reasons are 
— (a) Better application of family planning knowledge which reduces the number of
unplanned pregnancies, (b) early visit to the antenatal clinic and (c)potent
antihistaminic, antiemetic drugs.
ETIOLOGY:
 
The etiology is obscure but the following are the known facts: 
(1) It is mostly limited to the first trimester (2) It is more common in first pregnancy,
with a tendency to recur again in subsequent pregnancies(3) It has got a familial
history — mother and sisters also suffer from the same manifestation (4) It is more
prevalent in hydatidiform mole and multiple pregnancy (5) It is more common
in unplanned pregnancies but much less amongst illegitimate ones.
THEORIES:
 (1)
Hormonal
—(a) Excess of chorionic gonadotropin or higher biological activity of hCG is
associated. This is proved by the frequency of vomiting at the peak level of hCG and
also the increased association with hydatidiform mole or multiple pregnancy when
the hCG titer is very much raised (b) High serum level of estrogen (c) Progesterone
excess leading to relaxation of the cardiac sphincter and simultaneous retention of
gastric fluids due to impaired gastric motility. Other hormones involved are: thyroxin,
prolactin, leptin and adrenocortical hormones.
(2)Psychogenic
: It probably aggravates the nausea once it begins. But neurogenic element
sometimes plays a role, as evidenced by its subsidence after shifting the patient from the
home surroundings. Conversion disorder, somatization, excess perception of sensations by
the mother are the other theories.
(3)Dietetic deficiency
: Probably due to low carbohydrate reserve, as it happens after a night without food.
Deficiency of vitamin B6 , Vit B1
 and proteins may be the effects rather than the cause.(4)Allergic or immunological
basis.
(5)Decreased gastric motility is found to cause nausea.
Whatever may be the cause of initiation of vomiting, it is probably aggravated by the
neurogenic element. Unless it is not quickly rectified, features of dehydration and
carbohydrate starvation supervene and a viciouscycle of vomiting appears —
vomiting
→
 carbohydrate starvation
→
 ketoacidosis
→
 vomiting.
PATHOLOGY:
 There is no specific morbid anatomical findings. The changes in the various organs as
described by Sheehan are the generalized manifestations of starvation and severe
malnutrition.
Liver:
 There is centrilobular fatty infiltration without necrosis.
Kidneys:
 Usually normal with occasional findings of fatty change in the cells of first
convoluted tubule, which may be related to acidosis.
 Heart:
 A small heart is a constant finding. There may be subendocardial hemorrhage.
Brain:
 Small hemorrhages in the hypothalamic region giving the manifestation of Wernicke’s
encephalopathy. The lesion may be related to vitamin B
1
 deficiency.
METABOLIC, BIOCHEMICAL AND CIRCULATORY CHANGES:
 The changes are due to the combined effect of dehydration and starvation
consequent upon vomiting.
 Metabolic:
 Inadequate intake of food results in glycogen depletion. For the energy
supply, the fat reserve is broken down. Due to low carbohydrate, there is
incomplete oxidation of fat and accumulation of ketone bodies in the
blood. The acetone is ultimately excreted through the kidneys and in the
breath. T h e r e i s a l s o i n c r e a s e i n e n d o g e n o u s t i s s u e p r o t e i n
m e t a b o l i s m r e s u l t i n g i n e x c e s s i v e e x c r e t i o n o f non-protein
nitrogen in the urine. Water and electrolyte metabolism are seriously
affected leading to biochemical and circulatory changes.
Biochemical:
 Loss of water and salts in the vomitus results in fall in plasma sodium, potassium and chlorides.
The urinary chloride may be well below the normal 5 g/liter or may even be absent. Hepatic
dysfunction results in acidosis and ketosis with rise in blood urea and uric acid; hypoglycemia;
hypoproteinemia ; hypovitaminosis and rarely hyperbilirubinemia.
Circulatory:
 There is hemoconcentration leading to rise in hemoglobin percentage, RBC count
and hematocrit values. There is slight increase in the white cell count with increase
in eosinophils. There is concomitant reduction of extracellular fluid.
 
From the management and prognostic point of view, the cases are grouped into:
•
Early
•
Late
 (moderate to severe)
The patient is usually a nullipara, in early pregnancy. The onset is insidious.

EARLY:
Vomiting occurs throughout the day. Normal day-to-day activities are curtailed.
There is no evidence of dehydration or starvation

LATE:
(Evidences of dehydration and starvation are present)

Symptoms:
 Vomiting is increased in frequency with retching. Urine quantity is diminished even
to the stage of oliguria. Epigastric pain, constipation may occur. Complications may appear (see
below) if not treated.
Signs:
Features of dehydration and ketoacidosis:
 Dry coated tongue, sunken eyes, acetone smell in breath, tachycardia,
hypotension, rise in temperature may be noted, jaundice is a late feature. Such late
cases are rarely seen these days.
Vaginal examination and/or ultrasonography
 is done to confirm the diagnosis of pregnancy.
Investigations:
 Urinalysis: 
(1) Quantity—small (2) Darkcolor (3) High specific gravity
with acid reaction
(4) Presence of acetone, occasional presence of protein and rarely bile pigments (5)
Diminished or even absence of chloride.

Biochemical and circulatory changes:

 The changes are mentioned previously. Routine and periodic estimation of the serum
electrolytes (sodium, potassium and chloride) is helpful in the management of the
case.
Ophthalmoscopic examination
 is required if the patient is seriously ill. Retinal hemorrhage and
detachment of the retina are the most unfavorable signs.

ECG 
when thereisabnormalserumpotassiumlevel.
DIAGNOSIS:
 
The pregnancy is to be confirmed first
. Thereafter, all the associated causes of vomiting(enumerated before) are to be
excluded.
Ultrasonography
 is useful not only to confirm the pregnancy but also to exclude other,
obstetric (hydatidiform mole, multiple pregnancy), gynecological, surgical or medical
causes of vomiting

Differential diagnosis:
 When vomiting is persistent in spite of usual treatment other causes of severe
vomiting (medical or surgical) should be considered and investigated.
COMPLICATIONS:
 The majority of the clinical manifestations are due to the effects of dehydration and
starvation with resulting ketoacidosis. Leaving aside those symptomatology,
the following complications may occur which are fortunately rare now-a-days.
(1) Neurologic complications — (a) Wernicke’s encephalopathy d u e t o t h i a m i n e
deficiency (b) Pontine myelinolysis (c) Peripheral neuritis (d)
K o r s a k o f f ’ s p s y c h o s i s . (2) Stress ulcer in stomach (3) Esophageal
tear (Mallory-Weiss syndrome) (4) Jaundice (5) Convulsions and (6)Coma and (7)
Renal failure.
PREVENTION:
The only prevention is to impart effective management to correct simple vomiting of pregnancy.
MANAGEMENT
The principles in the management are:
• To control vomiting•To correct the uids and electrolytes imbalance•
To correct metabolic disturbances (acidosis or alkalosis)
•To prevent the serious complications of severe vomiting•
Case of pregnancy.
 Hospitalization:
 Whenever a patient is diagnosed as a case of hyperemesis gravidarum, she is
admitted.Surprisingly, with the same diet and drugs used at home, the patient
improves rapidly. The relatives may betoo sympathetic or too indifferent.

  Fluids: 
Oral feeding is withheld for at least 24 hours after the cessation of vomiting. During
this period, fluid is given through intravenous drip method.
The amount of fluid to be infused in 24 hours is calculatedas follows
: The total amount of fluid approximates 3 liters, of which half is 5% dextrose and half
is Ringer’s solution. Extra amount of 5% dextrose equal to the amount of vomitus
and urine in 24 hours, is to be added.
With this regime — dehydration, ketoacidosis, water and electrolyte imbalance
are likely to be rectified. Serum
electrolyte should be estimated and corrected if there is any abnormality. Enteral
nutrition through nasogastric tube may also be given.
Drugs:
 ( a ) A n t i e m e t i c d r u g s p r o m e t h a z i n e ( P h e n e r g a n ) 2 5 m g o r
P r o c h l o r p e r a z i n e ( S t e m e t i l ) 5 m g o r trifluopromazine
 (Siquil) 10 mg may be administered twice or thrice daily intramuscularly.
Trifluoperazine(Espazine) 1 mg twice daily intramuscularly is a potent antiemetic
therapy. Vitamin B6and doxylamine are also safe and effective.
Metoclopramide
 stimulates gastric and intestinal motility without stimulating the secretions. It is found
useful.(b)Hydrocortisone100 mg IV in the drip is given in a case with hypotension or in
intractable vomiting.Oral method prednisolone is also used in severe cases.(c)
Nutritional support—
with vitamin B1, Vit B6, Vit C and Vit B12
 are given.

Nursing care:
 Sympathetic but firm handling
 of the patient is essential. Social and psychological support should be extended.
Hyperemesis progress chart
 is helpful to assess the progress of patient while in hospital.
Daily record
 Of pulse, temperature, blood pressure at least twice daily, intake-output,
urine
 for acetone, protein, bile, blood biochemistry and ECG (when serum potassium is
abnormal) are important.
Clinical features of improvement are evidenced by
 — (a) subsidence of vomiting (b) feeling of hunger(c) better look (d) disappearance
of acetone from the breath and urine (e) normal pulse and blood pressure and(f)
normal urine output.
Diet 
: Before the intravenous fluid is omitted, the foods are given orally. At first, dry
carbohydrate foods like biscuits, bread and toast are given. Small but frequent
feeds are recommended. Gradually full diet is restored.
Termination of pregnancy
is rarely indicated. Intractable hyperemesis gravidarum inspite of therapy is rare
these days.
HOMOEOPATHIC MANAGEMENT:

– Arsenicum album, Carbolic Acid, Cocculus, Graphites, Kreosote, Ipecacuanha,

Natrum Mur, Nux vomica, Pulsatilla , Phosphorous,
Sepia, Thalapsi bursa, Veratrum album, etc.

1) Arsenicum album:

 Cannot bear the sight or smell of food

 Nausea, retching, vomiting after eating or drinking
 Vomiting of blood, bile, green mucus, brown-black mixed with blood
  Anxiety in the pit of the stomach
 Craves acids and coffee
 Mentally, very anxious and fearful
 Aggravation: Cold food, cold drinks, mid-day
 Amelioration: Warm drinks, warmth in general, raising the head

2) CARBOLIC ACID:

 Excessive vomiting in the early months of pregnancy

 Vomit contains undigested food material, foul-smelling liquid
 Vomitus; dark, olive green, offensive
 Constant belching, nausea, vomiting
 Mental; does not like any mental work
 Aggravation: while walking, mental exertion
 Amelioration: Smoking, strong tea, rubbing

3) FERRUM METALICUM

 Nausea and vomiting immediately after eating

 Spits up food by the mouthful
 Heat and burning in stomach
 Attempts to eat bring on diarrhoea
 The desire for sour things
 Irritable lady, slight noises unbearable
 Aggravation: Rest, Mid-night, sweating
 Amelioration: Walking slowly, warm

4) PHOSPHORUS:

 Vomiting, water is thrown up as soon as it gets warm in stomach

 Throws up ingesta by the mouthfuls
 Post-operative vomiting
 A very weak, empty, all-gone sensation felt in the whole abdomen
 The desire for salts, cold drinks, ice
 Desire to be Magnetized
 Aggravation: warm food, drink, lying on Lt .side
 Amelioration: Rt .side, Dark, cold things

5) SEPIA
 Nausea in the morning before eating
 Nausea with bulky, curd-like vomitus in morning
 Nausea at smell or sight of food
 Rumbling and gurgling in the abdomen with profuse vomiting in the first trimester
makes lady too weak
 Indifferent to those loved best
 Aggravation: forenoon, evenings, Lt. side, cold air
 Amelioration: exercise, pressure, drawing limbs up

6) COCCULUS INDICUS
 Nausea from riding in cars, looking boat in motion
 Sensation as if one had been a long time without food until hunger was gone
 Nausea, with faintness and vomiting
 She cannot bear any contraindication
 Aggravation: sleep, motion, eating
7) IPECACUANHA
 Constant nausea and vomiting
 Vomits food, bile, blood, mucus
 Stomach feels relaxed as if hanging down
 Very irritable takes everything is bad parts
 Aggravation: every winter, rest

8) NUX VOMICA
 Nausea and vomiting, with much retching
 Sour taste, and nausea in the morning, after eating
 Wants to vomit, but cannot
 Very irritable, sensitive to all impression
 Aggravation: morning, after eating, spices
 Amelioration: rest, strong pressure

9) GRAPHITES
 Nausea and vomiting after each meal
 Sweets nauseate
 Aversion to meat
 Morning sickness during menstruation
 Aggravation: at night, warmth
 Amelioration: wrapping up, in dark
10) KREOSOTUM
 Nausea; vomiting of food several hours after eating
 Sweetish water in the morning
 Feeling of coldness, as of ice water in the stomach
 Greenish vomitus, offensive
 Aggravation: in the open air, when lying, rest

CONCLUSION:
Hyperemesis Gravidarum has been found as an important risk factor for morbidity
during pregnancy. Despite treatment in other system hyperemesis Gravidarum
remain suboptimally controlled. Homoeopathic treatment is the most appropriate,
beneficial and effectively utilised within the health system as this could improve care
whilst reducing the symptoms as well mental well-being of the patient.
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Dr. Sohera Talat khan

Asso. Professor
Department of Homoeopathic Materia Medica
Guru Mishri Homoeopathic Medical College PG Institute, Shelgaon, Jalna,
Maharashtra
Dr. Amareen Kausar
khan
MD (Hom) part II
Department of Homoeopathic Materia Medica
Guru Mishri Homoeopathic Medical College PG Institute, shelgaon, Jalna,
Maharashtra