Hyperemesis gravidarum is the medical term used to describe the most intense type of nausea and vomiting during pregnancy. It is distinguished by chronic nausea and vomiting unrelated to other causes and symptoms, including ketosis and weight loss of at least >5% of pre-pregnancy weight. Volume depletion, electrolyte, acid-base imbalances, nutritional deficits, and even mortality can result from this condition. In 0.3-3 percent of pregnancies, severe hyperemesis necessitates hospitalization.
There is a common misconception that hyperemesis gravidarum is the same as morning sickness. However, these are two completely different conditions.
Although pregnancy can cause both of these conditions, it is still essential to distinguish the difference between them to treat the symptoms effectively.
Morning sickness is generally no cause for worry as it is a common experience during pregnancy. In contrast, a rarer condition, hyperemesis gravidarum, is the extreme form of morning sickness that only occurs once every thousand pregnancies.
Morning Sickness Versus Hyperemesis Gravidarum
Pregnant women experience nausea associated with morning sickness. They may even vomit several times a day. Although they may feel tired and lose their appetite, nausea and vomiting are never severe enough to induce complications such as dehydration.
Morning sickness subsides typically by week 12 to 14, so women often feel relieved when they reach the second trimester. On the other hand, hyperemesis gravidarum is a severe disorder marked by intense and persistent nausea and vomiting.
Hyperemesis gravidarum causes women to lose weight, resulting in dehydration, which is particularly harmful during pregnancy. It can also be challenging to consume food and beverages.
Hyperemesis gravidarum typically begins within the first six weeks of pregnancy and can linger for several weeks or even months. The nausea is continuous, and women suffering from the illness are frequently exhausted over time. Overall, hyperemesis gravidarum can considerably influence a woman’s daily life.
Sign and Symptoms of Hyperemesis Gravidarum
Pregnant patients with hyperemesis gravidarum may experience the following signs and symptoms:
- constant nausea
- constant vomiting
- loss of appetite
- sleep disturbance
- hyperolfaction
- dysgeusia (taste disorder)
- decreased gustatory discernment (decreased perception of taste)
- dehydration (dark urine and dry skin)
- lightheadedness
- dizziness
- losing a few percentages of body weight (due to constant nausea and vomiting)
- salivation
- increased heart rate
- jaundice
- low blood pressure
- depression and anxiety
Discuss current symptoms with the patient when taking a history. Obtain information on the onset, intensity, frequency, and mitigating and aggravating factors such as relationship with food, medications, prenatal supplements, stress, and other triggers.
It is critical to thoroughly examine the patient for any symptoms that may indicate other digestive, renal, endocrine, or central nervous system diseases.
Causes of Hyperemesis Gravidarum
- Human chorionic gonadotropin. Hyperemesis gravidarum has no known etiology. Several studies, however, have suggested that it may be linked to human chorionic gonadotropin or hCG. Pregnancy causes the body to create significant levels of this hormone at a rapid rate.
- Pregnancy with twins. A woman with twins or more babies is much more likely to suffer from this condition, although the condition can occur in any pregnancy.
- Increased estrogen and progesterone levels. Digestion problems and nausea are associated with higher estrogen and progesterone levels.
- Increase in thyroxine levels in the blood. Some studies show that women with hyperemesis gravidarum have high thyroxine levels in the blood.
- Molar pregnancy. Elevation in blood beta-human chorionic gonadotropin levels could cause hyperemesis gravidarum in molar pregnancy.
Risk Factors to Hyperemesis Gravidarum
- Multiple gestations. In this case, more than one baby is being carried at once, which is a high-risk pregnancy. This type of pregnancy may trigger hyperemesis gravidarum.
- Hydatidiform Mole or Molar Pregnancy. Hyperemesis gravidarum has been documented in up to 26% of molar pregnancies.
- Insufficient prenatal vitamin intake. Prenatal vitamins can lessen terrible nausea and vomiting during pregnancy.
- Heartburn and acid reflux. Heartburn and acid reflux during pregnancy may be triggered by hormonal changes that disrupt normal stomach motility, resulting in nausea and vomiting.
- Nulligravida. First-time pregnancy can increase the chances of having hyperemesis gravidarum.
- Morning sickness. Low blood sugar and high levels of hCG might trigger morning sickness, which may lead to hyperemesis gravidarum.
- Migraine. Some patients who constantly experience migraine during pregnancy are more prone to hyperemesis gravidarum.
- Female fetus. According to research, women with hyperemesis gravidarum are more likely to have a female fetus. Thus, women with hyperemesis gravidarum with a female fetus have ketonuria and a higher likelihood of getting hospitalized.
- Family history of hyperemesis gravidarum.
Complications of Hyperemesis Gravidarum
- Thrombosis. Pregnancy, dehydration, and immobility accompanied by hyperemesis gravidarum increase venous thromboembolic disease risk.
- Esophageal injuries. There is a risk of esophageal trauma and Mallory-Weiss tears in hyperemesis patients who experience severe retching.
- Complications of TPN: In some cases, patients with hyperemesis gravidarum who cannot consume oral nutrients may require TPN. There is a high likelihood that patients who require TPN for nutritional support will need a central line implanted.
- Vasospasm of cerebral arteries: On MRI, two pregnant women with severe hyperemesis gravidarum who had not responded to intravenous fluid therapy or multivitamin replacement had vasospasm of the middle cerebral arteries.
- Risk of recurrence: Several pieces of research concluded that women with a history of hyperemesis gravidarum are more likely to experience it in subsequent pregnancies than women without a past medical history of it. Furthermore, it appears that women may choose to avoid subsequent pregnancies if they wish to avoid the psychosocial impact of hyperemesis gravidarum in the future.
Diagnosis of Hyperemesis Gravidarum
- Physical Examination. Physical examination is frequently unremarkable in women with probable hyperemesis gravidarum. The findings may be more useful if the patient has atypical symptoms suggestive of other illnesses, such as bleeding or abdominal pain.
- Laboratory Tests
- Blood tests. The doctor may ask to perform several blood tests to assess signs of dehydration.
- Complete blood count. It will help identify and count all types of cells in the blood.
- Serum electrolyte test. It will help measure the levels of all types of electrolytes in the blood.
- Urinalysis. It is a laboratory test of urine that will help detect signs of dehydration.
- Ketones urine test. It will help identify whether the body has increased waste products or ketones.
- Imaging Studies. The following imaging procedures may be used to evaluate women suffering from hyperemesis gravidarum:
- Obstetric ultrasonography. This procedure is typically used to screen for multiple gestations, molar pregnancy, or trophoblastic illness.
- Upper abdominal ultrasonography. This procedure assesses the pancreas and biliary tree when clinically required.
- Abdominal CT Scan or MRI. If appendicitis is suspected of causing nausea and vomiting during pregnancy, abdominal computed tomography scanning or magnetic resonance imaging should be performed.
Treatment of Hyperemesis Gravidarum
- Hospital Treatment
- Intravenous fluids. The goal of IV fluids is to restore the pregnant patient’s hydration, electrolytes, vitamins, and nutrients.
- Tube feeding
- Nasogastric. This tube feeding method replenishes nutrients via a tube that passes through the nose and into the stomach.
- Percutaneous endoscopic gastrostomy. This tube feeding restores nutrition via a tube that passes through the abdomen and into the stomach; a surgical operation is required.
- Total parenteral nutrition. In the most severe instances of hyperemesis gravidarum, complex, balanced nutrient solutions may be administered through IV throughout pregnancy. This medication is known as total parenteral nutrition (TPN).
- Pharmacotherapy. In women with hyperemesis gravidarum, the following medications may be used:
- Prenatal vitamins
- Supplements made from herbs
- Antiemetics
- Corticosteroids
- Antihistamines
- Surgery. Terminating the pregnancy may be considered in some severe refractory cases of hyperemesis gravidarum, if mother survival is threatened, or if hyperemesis gravidarum inflicts severe physical and psychological strain.
- Nonpharmacological treatments
- Dietary modification. Eating small, frequent, bland, and dry meals such as crackers is one of the best ways to manage hyperemesis gravidarum non-pharmacologically.
- Bed rest. Bed rest may bring comfort, but be wary of the implications of muscle and weight loss caused by excessive bed rest.
- Acupressure. The pressure point for nausea relief is placed in the middle of the inner wrist, three finger lengths away from the wrist crease and between the two tendons. For three minutes, locate and push firmly on one wrist at a time. Sea bands can be obtained at any local medicine store and aid acupressure.
- Herbal supplements. Herbs such as ginger or peppermint
- Homeopathic treatment. Homeopathic remedies are a non-toxic medical system.
Prevention of Hyperemesis Gravidarum
- Diet modifications. Nausea and vomiting can be exacerbated by overeating or extreme hunger. Overeating, skipping meals entirely, or not eating enough may aggravate nausea. Therefore advise the patient to :
- Eat as soon as the stomach feels empty.
- Practice to eat small frequent meals instead of big meals three times a day.
- Maintain a bland diet.
- Stay hydrated.
- If symptoms persist, seek medical attention right away to avoid severe complications of hyperemesis gravidarum.
- Lifestyle changes. These may include:
- Avoid the things or foods that trigger nausea and vomiting. Avoiding scents, tastes, and other activities that cause nausea is one of the most significant interventions for pregnancy-related nausea and vomiting. Some women benefit from avoiding food triggers such as hot, sweet, and high-fat foods.
- Avoid lying down immediately following a meal and changing positions quickly.
- Avoid taking too many iron supplements because they might cause nausea and vomiting if taken in excess.
Nursing Diagnosis Hyperemesis Gravidarum
Nursing Care Plan for Hyperemesis Gravidarum 1
Nursing Diagnosis: Nausea related to pregnancy secondary to hyperemesis gravidarum as evidenced by sagging sensation, increased swallowing, vomiting, a sour taste in the mouth, and increased salivation.
Desired Outcome: The patient will report a reduction in the severity of nausea, or its absence.
| Hyperemesis Gravidarum Nursing Interventions | Rationale |
| Other than pregnancy, look for other possible causes of the patient’s nausea. | Assessing the patient’s causes of nausea will influence the choice of interventions. This strategy seeks to prevent nausea from becoming severe. |
| Inform the patient or caregiver to seek medical attention if vomiting develops or persists for an extended period. | Vomiting during pregnancy on a regular basis can cause dehydration, electrolyte imbalances, and nutritional deficiencies. If nausea and vomiting are not treated promptly, complications might occur. |
| Examine the patient’s nausea characteristics: HistoryDurationFrequencySeverityPrecipitating variablesOTC and Prescription medications that the patient takesWhat are the measures taken to alleviate nausea | A detailed evaluation and assessment of nausea can assist in determining interventions to minimize or alleviate the problem. |
| Make an emesis basin easily accessible to the patient. | Vomiting and nausea are strongly related. If the pregnant patient is nauseous most of the time, keep the emesis basin out of sight but within reach. |
| Remove any thing or food with a strong odor from the patient’s surroundings. | Pregnant women are usually sensitive to odors. As a result, strong and unpleasant odors can exacerbate the patient’s hyperemesis gravidarum. |
| Allow the patient to use non pharmacological nausea management methods, including meditation, guided visualization, music therapy, diversion, or deep breathing exercises. | These strategies have helped pregnant women with hyperemesis gravidarum, but they must be used before nausea begins. |
| Examine the prenatal vitamins that the patient is taking. | Excessive iron intake may induce hyperemesis gravidarum. Therefore, switching to a different vitamin may be beneficial. |
| Maintain enough ventilation in rooms. Encourage the patient to get fresh air if possible. | A well-ventilated space or having a fan nearby facilitates breathing. |
Nursing Care Plan for Hyperemesis Gravidarum 2
Nursing Diagnosis: Deficient Fluid Volume related to increased gastric secretions and decreased intravascular and intracellular fluid as a result of nausea and vomiting secondary to hyperemesis gravidarum as evidenced by vertigo, inability to urinate (oliguria), dry mouth, dry skin problems, extreme thirst, fatigue, lack of strength, and weight loss.
Desired Outcome: The patient will begin to show indications of appropriate hydration, such as decreased emesis, balanced intake and output, and improvements in acid-base balance and electrolyte status within 24 hours of starting treatment.
| Hyperemesis Gravidarum Nursing Interventions | Rationale |
| Examine the following characteristics of the patient’s vomiting and nausea: FrequencyDurationIntensityAmount and color of vomitusAssociated symptoms such as abdominal discomfort, diarrhea, indigestionOther triggering causes. Reevaluate the patient every 8 hours or as directed. | This detailed first assessment serves as the foundation for nursing interventions or education and a subsequent comparison of changes. |
| Examine the patient for indications of low fluid volume such as dry mucosal surface, poor skin turgor, reduced blood pressure (BP), elevated pulse, probable low-grade fever, and elevated BUN and hematocrit. | Increased fluid loss causes blood and urine to become too concentrated, blood volume to decrease, blood pressure to decline, and the heart rate to accelerate. |
| Monitor the results of recommended laboratory studies and look for indicators of electrolyte imbalance (muscle cramps, spasms, restlessness, irregular heartbeats) every 8 hours. | With prolonged vomiting, potassium and magnesium are lost. The loss of these electrolytes weakens muscles, especially the myocardium. Severe potassium loss hampers the ability of the kidneys to concentrate urine. |
| If the pregnant woman is admitted to the hospital, start and evaluate IV hydration while retaining the patient in NPO (nothing by mouth) for 48 hours, as directed by the doctor. | This method aids in treating dehydration and correcting electrolyte balance caused by persistent hyperemesis gravidarum. |
| If the patient has severe hyperemesis gravidarum, administer parenteral nourishment as directed by the doctor. Obtain the help of the hyperalimentation team to supervise the patient’s nutrition. | Parenteral nutrition can meet all nutritional needs, ensuring normal fetal growth and preventing maternal malnutrition. |
Nursing Care Plan for Hyperemesis Gravidarum 3
Imbalanced Nutrition: Less than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements related to the inability to swallow, digest, and absorb adequate nutrients and calorie deficiency due to continuous vomiting secondary to hyperemesis gravidarum as evidenced by muscle weakness, fatigue, and weight loss.
Desired Outcome: The patient will demonstrate improvements in her nutritional status within a week after the interventions.
| Hyperemesis Gravidarum Nursing Interventions | Rationale |
| Examine the patient for indicators of malnutrition every 8 hours, such as jaundice, mucous membrane hemorrhage, and ketonuria. | Inadequate nutrition can result in hypothrombinemia, vitamin C and B complex deficiency, and ketosis, which are all dangerous to the patient’s pregnancy. |
| Suggest to the patient to eat meals with the most significant protein or calorie intake when the nausea is the least bothersome, maybe within 30 minutes to 1 hour after taking nausea and vomiting medication. | When the most nutritious meal is ingested, and the patient is most likely to consume it, the patient may be capable of absorbing the high protein content and nutritional levels required for pregnancy. |
| Suggest other food patterns to the patient, such as six or more short and dry meals per day, followed by clear liquids. | Small, regular, dry meals may help to relieve nausea and vomiting caused by a bloated stomach. |
| If the pregnant patient is in the hospital, initiate and titrate enteral (nasogastric feeding) or hyperalimentation (parenteral nutrition via intravascular treatment) as directed by the health care practitioner and agency guidelines. | When oral consumption of food and fluids is not possible, these are excellent strategies for administering nutrition and hydration. |
| When the patient’s severe nausea has subsided, commence oral intake with clear liquids (broth and diluted juices) and progress to solid foods as tolerated. | Since everyone tolerates liquids and foods differently, it is critical to gradually evaluate which food(s) and eating routine is most appropriate for the patient. |
| Make a suggestion to the patient to consume high-protein supplementary beverages as an alternative to solid foods if she cannot tolerate them. | For women who experience hyperemesis gravidarum, solid foods may be more difficult to tolerate than liquids. |
Nursing Care Plan for Hyperemesis Gravidarum 4
Deficient Knowledge about Hyperemesis Gravidarum
Nursing Diagnosis: Deficient Knowledge related to a lack of understanding about the problem and a lack of familiarity regarding the causes, therapy, and remedies of nausea and vomiting secondary to hyperemesis gravidarum, as evidenced by the appearance of apparently avoidable complications and increased severity of vomiting.
Desired Outcome: The patient will learn how to manage vomiting to prevent its progression to hyperemesis gravidarum.
| Hyperemesis Gravidarum Nursing Interventions | Rationale |
| Educate the patient about other possible causes that trigger nausea and vomiting during pregnancy. Aside from the HCG hormone that causes the nauseous feeling, it may also be caused by a particular food, odor, or maybe due to low blood sugar that the pregnant patient usually experiences. | If the patient knows the factors contributing to nausea and vomiting during pregnancy, hyperemesis gravidarum will be prevented. |
| Educate the patient that persistent and severe vomiting is an emergency case for pregnant women as it may cause dehydration and could be fatal for the baby. | Vomiting is normal for some pregnant patients but not to the extent that it happens continuously and severely. This intervention aims to educate the patients when it is the right time to seek medical attention. The patients must learn to recognize whether the vomiting they are experiencing is just because of the hormone or it is already hyperemesis gravidarum. |
| Educate the patient about the signs and symptoms of hyperemesis gravidarum, such as severe and persistent nausea and vomiting, dehydration, thirst, tiredness, dizziness, or lightheadedness. | Knowing the typical clinical manifestations of hyperemesis gravidarum can prevent the condition from further complications. |
| Motivate the patient to eat small frequent meals every 2 hours rather than having big meals three times a day. | This intervention is one of the best ways to alleviate nausea and vomiting during pregnancy. |
| Educate the patient about different ways to manage dehydration when persistent nausea and vomiting arise. | This intervention aims to prevent severe dehydration that could be fatal both for the mother and the baby. |
Nursing Care Plan for Hyperemesis Gravidarum 5
Nursing Diagnosis: Activity Intolerance related to dehydration, generalized weakness, and severe fatigue due to persistent vomiting secondary to hyperemesis gravidarum as evidenced by the inability to perform activities of daily living (ADLs) and lack of energy to execute life priorities.
Desired Outcome: The patient will demonstrate an increased capacity and energy in doing ADLs.
| Hyperemesis Gravidarum Nursing Interventions | Rationale |
| Determine whether the pregnant patient requires more assistance at home, especially when she is exhausted due to persistent nausea and vomiting. | This intervention aims to assist the pregnant patient. When the patient feels weak or over fatigued, she may be unable to perform activities independently. |
| Ensure that the patient consumes healthy foods and enough nutrients that her body and baby typically need. | Pregnant women’s bodies require more food and nutrients to optimize energy. This intervention will help her to have the capacity to execute daily activities. |
| Explain why bed rest and activity limitations are necessary. | Bed rest is recommended because it helps prevent hyperemesis gravidarum and is safe for the fetus and the mother. |
| Provide the patient with comfort measures such as back rubs, posture modifications, and reduced stimuli in the room. | Comfort measures and relaxation strategies help the patients feel relieved. Relaxation techniques can also benefit pregnant patients with nausea and vomiting. |
| Refrain the pregnant patient from engaging in unnecessary and tiring activities or procedures. | Patients who have a low activity tolerance should prioritize necessary tasks first. Tiring activities might trigger the patient’s hyperemesis gravidarum. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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