2. Vajiheh Marsoosi, M.D Associate Prof. of TUMS Dr. Shariati Hospital

3. Definition  Nausea and vomiting severe enough to produce:  Weight loss  Dehydration  Ketosis  Alkalosis from loss of hydrochloric acid  Hypokalemia  Acidosis develops from partial starvation  In some women hepatic dysfunction develops, and there is accumulation of biliary sludge

4. Etiopathogenesis  High rapidly rising serum levels of pregnancy- related hormones: HCG, estrogens, progestrone, leptin, placental growth factor, prolactin, thyroxine, adrenocortical hormones.  Psychological components  Hyperthyroidism  Previous molar pregnancy  Diabetes  Gastrointestinal illnesses  Some restrictive diets  Asthma and other allergic disorders  Female fetus  Association with preterm labor, placental abruption, and preeclampsia

5. Complications  Acute Kidney injury-may require dialysis  Depression- cause versus effect?  Diaphragmatic rupture  Esophageal rupture  Hypoprothrombinemia-vitamin K deficiency  Hyperalimentation complications  Mallory –Weiss tears- bleeding, pneumothorax, pneumomediastinum, pneumopericardium  Wernicke encephalopathy-thiamine deficiency

6. Mineral and Vitamin deficiencies  Zinc ↑, Copper ↓, Vitamin B1 ↓ ( Wernicke encephalopathy), vitamin K ↓ ( maternal coagulopathy, and fetal intracranial hemorrhage)

7. Management Mild:  Dietary management:  Ginger extract,  Vitamin B6 plus,  Doxylamine,  Diphenhydramine, or  Dimenhydrinate.

8. Moderate  Promethazine,  Prochlorperazine,  Trimethobenzamide,  Chlorpromazine,  Metoclopramide, or  Ondansetron  (oral, rectal, parentral)

9. Severe  Intravenous hydration with thiamine;  Parenteral:  Metoclopramide,  Prometazine, or  Ondansetron

10. Intractable  Entral or parentral nutrition