HYPEREMESIS GRAVIDARUM CASE STUDY

HYPEREMESIS GRAVIDARUM CASE STUDY

Antenatal History

Amber a 30 years old lady was brought to the hospital with complaints of nausea, excessive vomiting, dehydration, and general body weakness at a gestational of 6 weeks 4days (by scan). Her blood pressure was 98/61 mmHg; heart beat 90 beat/minute regular but weak, and temperature of 37.9oC.

History of Present Pregnancy

Amber used injectable Depo-Provera for over seven years as her preferred contraceptive method. After getting married two and a half year ago, she stopped using the contraceptives in preparation for getting a baby. The cessation of Depo-Provera was followed by a period of irregular periods sometimes missing the period or other times receiving very little flow that she used just one pad in a period lasting one day. As a result, she could not tell her exert last menstrual period (LMP), but figure it was 7 - 6 weeks before. Her pregnancy was confirmed in the hospital with an ultrasound scanning, and the gestation age was six weeks four days; thus, LMP was 28/ 11 /2014. She started having nausea approximately five weeks earlier, but vomiting started two weeks ago, which has accelerated in the last one week, which she attributed to environmental changes following a trip to Africa. Her menarche was at the age 14 years.  Her expected date of delivery was 04/09/2015

She was hospitalized for three days rehydration and electrolyte correction following her diagnosis of hyperemesis gravidarum. Her actual antenatal visit started at 12 weeks, and her baseline examinations were done. The hemoglobin level was at 14, urinalysis normal, TORCH findings were normal, and VDRL findings also normal. Her blood group is O and Rhesus factor was positive. The rest of her first trimester she experienced nausea, loss of appetite, and occasional vomiting with no further complication, but she was under close monitoring.

During her second trimester antenatal visit at gestational age 26 weeks three days, her vitals were normal (blood pressure 125/80 mmHg, pulse rate 76 beats per minute, respirations 18 breaths/minute, and temperature 36.6oC). The fetus presentation was cephalic; position - left occipital anterior; lie - longitudinal, and fundal height of 26 weeks. However, complaints of nausea, anorexia, and occasional vomiting were also noted.

In her third trimester, nausea and vomiting were occasional, but she had managed to rehydrate herself and reduce cases of dehydration or electrolyte imbalance.

The past Obstetric History

This is Amber’s first pregnancy (primigravida), and she has no history of miscarriages (para 0+0).

Past Gynecological History

Amber is married, used Depo-Provera Injection as her family planning method for seven years before stopping roughly two and a half years before this pregnancy. Have no history of sexually transmitted disease, no post-coital bleeding, and no dyspareunia. The last Pap smear was done 2014 February. She understands the importance of self-breast examination, which she often does. She received Cervarix vaccine at the age of nine years.

Past Medical and Surgical History

Amber was hospitalized for four days following a case of pneumonia at age three years. She has no history of surgical operations.

Drug History and Allergies

She occasionally used over-the-counter medication for pain management. She was prescribed promethazine 25mg daily dose for three days following an episode of vomiting or excessive nausea.

Family History

Her mom and dad divorced when she was eleven years. She has a younger brother. Both parents and the brother are alive and well.

Social History

She is an elementary teacher in a local school. She used to smoke and drink alcohol, which she stopped six years age. She has good family and friends support. She lives with her husband. She often exercises while playing with children at school during PE time.

Systemic Review

The circulatory system is compromised by body fluid and electrolyte imbalance. The patient feels weak due to reduced energy secondary to cell starvation due to ineffective feeding pattern caused by nausea and vomiting. The body temperature is high due to poor temperature regulation mechanism caused by dehydration.

Examination at Gestation 38 weeks

General

Amber looked weak, dehydrated, and sickly. Her abdomen was slightly less for term temperature is slightly elevated at (37.7oC), blood pressure of 115/85 mmHg, pulse rate 88b/min. She reported having mild contractions but reported early to avoid complications.

Abdominal

The abdomen is globular, and the fundal height appear small for her gestation. Striae gravidarum present and linear nigra also notices, no visible scars, and no masses. On auscultation bowel sounds are present; the fetal heart rate is 136beats/minute, clear and regular. The fetal presentation is cephalic, lie - longitudinal, position - left occipital anterior, and head engagement two parts in.

Summary of Examination

He reported having vomited four times in the last two days. She is weak and with mild dehydrated from vomiting. The fetal condition is okay with no signs of fetal distress, but signs of maternal distress and exhaustion.

Case Discussion

Amber a primigravida was admitted for observation after complaining of lower abdominal pain radiated to the back. She was rehydrated using normal saline and 10% intravenous glucose solution. For her nausea, she was injected metoclopramide 10 mg stat. Her active phase of labor set in six hours after admission with regular, coordinated contractions increasing in strength, frequency, and duration.

A Bishop Score was conducted 10 hours following admission, and her score was 9, which justified the go-ahead for induction of labor done by artificial rupture of membranes. The maternal vital signs were observed hourly and vaginal examination done 4houly. Fetal observations were monitored as per the partoghraph guidelines. The readings were charted in a partograph for enhanced monitoring and interpretation of labor progress. She continued to have the good progress of labor. There was no indication of oxygenation, but rehydration continued throughout the labor process. The lasted for approximately 5 hours, which the client was on epidural analgesia to relief her from contraction pains; thus, reduce maternal exhaustion, reduce anxiety, and enhance relaxation.

Labour continued following the expected course and to the right of the alert line. Any indications of labor course approaching the action line would have indicated complicated spontaneous vertex delivery; thus, need for either emergency cesarean section or instrumental delivery. Luckily, Amber’s labor progressed successfully.

The second stage took 48 minutes. The client was advised to push, and having saved her energy during the first stage she was effective in pushing. Every contraction was followed by active pushing with the mother holding feet, bending forward, and pushing using her abdominal muscles. A progress of over 2 hours would have indicated a problem with the progress of the labor necessitating vacuum delivery. The management involved encouraging the mother to push with every contraction and urge to push and flexing the fetal head. After crowning, and restitution, the head was grasp by both hand, anterior shoulder delivered and a live female infant was delivered.

The third stage took 7 minutes. Immediately after the baby was delivered, syntometrine 1cc was injected intramuscularly into the right outer quadrant of the thigh to enhance the third stage of labor and reduce risks of postpartum delivery. Other approaches available include the use of syntocinon, especially for hypertensive patients, or traditional management that does not involve medication hence associated with high risk of postpartum hemorrhage and prolonged third stage of labor.

Estimated blood loss was 100ml. A loss of over 500mls would have indicated postpartum hemorrhage. The placenta was expelled completely with no missing lobes. It had no infarcts, which would have suggested compromised fetal circulation. There no active bleeding per vagina, which was packed with pads for bleeding monitoring. The mother was cleaned and allowed to relax to await her motherly course.

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