Study Points

Hyperemesis Gravidarum

Course #33173 - $20 • 5 Hours/Credits

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    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
  1. What percentage of pregnant women suffer from hyperemesis gravidarum?

    INTRODUCTION

    Between 50% and 80% of pregnant women experience nausea and vomiting beginning at about the 4th week and ending at about the 12th week of gestation [1,2]. In fact, nausea and vomiting are considered a presumptive sign of pregnancy, and for 10% to 20% of pregnant women, these symptoms may persist throughout the whole pregnancy. While nausea and vomiting are common occurrences, hyperemesis gravidarum is rare, occurring in 0.2% to 3.6% of all pregnancies [1,2,115].

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  2. Which of the following is part of the definition of hyperemesis gravidarum?

    DEFINITION OF HYPEREMESIS GRAVIDARUM

    There is some variation in the literature as to the exact definition of hyperemesis gravidarum. It has been described as intractable nausea and vomiting during pregnancy severe enough to require hospitalization [4,115]. The condition appears during the first trimester and is unassociated with other medical conditions, such as cholestasis, hepatitis, pre-eclampsia, viral syndromes, Ménière disease, or influenza.

    The most commonly accepted definition of hyperemesis gravidarum is a severe form of nausea and vomiting with weight loss greater than 5% of prepregnancy body weight, dehydration, acidosis from starvation, alkalosis from loss of hydrochloric acid, hypokalemia, ketosis, acetonuria, and ptyalism (excessive salivation) [4]. Many patients require hospitalization in order to control the symptoms [5,115]. In most cases, the onset of symptoms is between 4 and 10 weeks' gestation and the symptoms usually subside by 20 weeks' gestation. Clinically, practitioners commonly treat nausea and vomiting in early pregnancy, regardless of whether the patient fits all the criteria of a diagnosis of hyperemesis gravidarum.

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  3. Which of the following statements regarding the effects of hyperemesis gravidarum on the fetus is FALSE?

    EFFECTS OF HYPEREMESIS GRAVIDARUM

    It has been suggested that hyperemesis gravidarum may be associated with low infant birth weight, likely related to maternal nutritional (i.e., weight) maintenance [6,7,8]. Researchers have found a modest association between severe nausea and vomiting in pregnancy and intrauterine growth restriction and low infant birth weight [6]. A maternal weight loss of greater than 5% seems to be the critical factor in fetal growth restriction. However, even insufficient weight gain can have negative repercussions. A weight gain of less than 7 kg (15.4 pounds) during the duration of pregnancy is associated with low birth weight and preterm births [5,7,115,119].

    There also appears to be a correlation between severe hyperemesis during pregnancy and impaired insulin sensitivity in offspring [9]. In one study of healthy children (4 to 11 years of age) who were born at term to mothers who were admitted to hospital with severe hyperemesis gravidarum during their pregnancy, the offspring of the women with hyperemesis had 20% lower insulin sensitivity compared to children of healthy women. Longer term follow-up studies are necessary to determine if this difference persists into adulthood.

    One study found an increased risk for psychologic and behavioral problems in adult offspring of pregnancies affected by hyperemesis [10]. Adult offspring exposed to hyperemesis in utero reported higher likelihood of depression, anxiety, and bipolar disorder diagnoses.

    Various studies have linked a greater risk for birth defects, developmental delays, and serious health problems (e.g., type 2 diabetes, hypertension, high cholesterol, and cardiovascular disease) with maternal hyperemesis gravidarum [8,11]. Other potential fetal complications include [12]:

    • Shorter length

    • Undescended testes

    • Testicular cancer

    • Behavioral/emotional problems

    • Integumentary abnormalities

    • Neurodevelopmental sequelae

    • Congenital heart disease

    • Neural tube defects

    • Hip dysplasia

    • Perinatal death

    Although it is clear that hyperemesis gravidarum is associated with adverse fetal effects, the exact causation is the subject of debate. Poor maternal health and fetal exposure to stress hormones are thought to play a role, but some have suggested that the fetal complications seen with hyperemesis gravidarum may be the result of maternal risk factors, not the condition itself. In one study, the researchers assert that women who develop hyperemesis gravidarum tend to have pre-existing conditions that could predispose their infants to complications, including younger age, lower socioeconomic status, primiparity, use of assisted reproductive technologies, substance abuse, non-Western decent, and chronic health conditions (e.g., diabetes, hypertension, mental illness) [13]. It is possible that the factors that place women at risk for developing hyperemesis gravidarum are responsible for low infant birth weight and other negative fetal effects associated with the condition.

    Despite the fact that hyperemesis gravidarum may be associated with poor fetal growth and outcome, a large, epidemiologic study found that the likelihood of miscarriage was 70% lower in women who experienced normal nausea and vomiting early in pregnancy [14]. More severe sickness was associated with a greater decrease in the risk of miscarriage. This finding supports the belief that normal nausea and vomiting in the first trimester of pregnancy may be protective against miscarriage [14,15]. This may be a result of robust placental synthesis in a healthy pregnancy [92].

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  4. Thiamine (vitamin B1) deficiency results in which potential maternal complication of hyperemesis gravidarum?

    EFFECTS OF HYPEREMESIS GRAVIDARUM

    Wernicke encephalopathy results from a deficiency of thiamine (vitamin B1) and is manifested by confusion, gait ataxia, ophthalmoplegia (paralysis of the eye muscles), or convulsions. Typically, thiamine is initially lost by prolonged vomiting. When intravenous fluid replacement containing dextrose is given, the body's metabolism of the dextrose quickly consumes the remaining thiamine. Therefore, the cause is usually not the hyperemesis itself but is instead due to fluid replacement without thiamine supplementation. Although the condition is very rare, it is associated with a high mortality rate (20%) [16].

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  5. Which of the following gestational hormones is hypothesized to be correlated with hyperemesis gravidarum?

    THEORIES OF ETIOLOGY

    Human chorionic gonadotropin has been suspected as the cause of hyperemesis gravidarum based chiefly on the observation that its peak concentration in pregnancy coincides with the peak of nausea and vomiting [32]. Another suggestion for the causative role of hCG in persistent nausea and vomiting is the association between increased hCG concentrations and hyperemesis gravidarum in cases of twin and molar pregnancies.

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  6. Which of the following bacteria has been investigated as a cause of hyperemesis gravidarum?

    THEORIES OF ETIOLOGY

    Infection with Helicobacter pylori, a gram-negative spiral bacterium strongly associated with peptic ulcers, has been investigated as a cause of hyperemesis gravidarum. In one study, the investigators found that 89% of pregnant women with hyperemesis gravidarum were seropositive for H. pylori, compared to 30% of the control group [44]. A 2010 study reached a similar conclusion, finding that 87% of women with hyperemesis gravidarum were infected with H. pylori, compared to 32% without the condition [45]. A meta-analysis of 38 cross-sectional and case-control studies, involving 10,289 patients, revealed a significant association between H. pylori infection and hyperemesis gravidarum [121]. As such, screening of H. pylori infection should be added to the investigation of hyperemesis gravidarum cases. IgG antibody testing may detect H. pylori infection in patients presenting with hyperemesis; post-eradication monitoring may be carried out by stool antigen testing. Eradication of H. pylori in pregnant women can significantly improve symptoms. Treatment options include the utilization of triple therapy, consisting of a proton-pump inhibitor and two antibiotics (e.g., amoxicillin or erythromycin and metronidazole) for two weeks [121]. Several case reports have suggested that eliminating H. pylori infection may cure hyperemesis gravidarum or at least modify its course [44,46,47].

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  7. Which of the following conditions increases the risk of hyperemesis gravidarum?

    POPULATIONS AT RISK

    High prepregnancy body weight and nulliparity (having not given birth to a child) have been cited as risk factors for hyperemesis, and as discussed, a high-fat diet has been found to greatly increase the odds [4,63]. Maternal age younger than 20 years and twin gestation are also noted as risk factors [4]. The condition can repeat itself in subsequent pregnancies and is more common in women with a history of spontaneous abortions [13]. Trogstad et al. found that if a woman experienced hyperemesis in her first pregnancy, there was a 15.2% risk that she would experience it in subsequent pregnancies [64]. Those never having suffered from the condition have a 0.7% risk in later pregnancies.

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  8. Which of the following statements is TRUE regarding demographic data related tohyperemesis gravidarum?

    POPULATIONS AT RISK

    There is limited demographic data relating to hyperemesis gravidarum, but some (also limited) evidence suggests a higher rate among certain racial/ethnic minority groups [67]. One study did note an increased risk among Pacific Islander women [68]. Eskimo and Native American populations tend to have a lower incidence of hyperemesis gravidarum [10]. In a study of 67 women with hyperemesis presenting at Los Angeles Women's Hospital, 94% were Hispanic [23]. However, the authors did not evaluate the racial mix of the general population served by this facility. Several studies have shown no clear racial predominance for hyperemesis gravidarum [10]. However, a large study of 417,028 pregnancies in England showed a statistical predominance in Asian and Black women [118,119].

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  9. Nurses should make which of the following recommendations regarding prenatal vitamins to the patient with hyperemesis gravidarum?

    INTERVENTION STRATEGIES

    Nausea and vomiting of pregnancy is usually initially treated conservatively with diet in the hopes that the problem will not progress to hyperemesis gravidarum. General recommendations include choosing a bland diet, increasing carbohydrate intake, decreasing fat intake, avoiding offensive food odors, and avoiding iron supplementation, if possible. Omitting prenatal vitamins containing iron until the nausea resolves may also be helpful.

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  10. Which of the following dietary recommendations are effective in the management of hyperemesis gravidarum?

    INTERVENTION STRATEGIES

    Specific suggestions are to eat bread or crackers before getting out of bed in the morning, when nauseated, and before retiring for the night. Experts also recommend eating small meals every two to three hours; drinking liquids between meals rather than with meals to avoid gastric distention; eating low-fat, high-protein foods; avoiding fried foods; and salting food to taste.

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  11. Which of the following statements about the management of hyperemesis gravidarum is FALSE?

    INTERVENTION STRATEGIES

    Intractable cases may require total parenteral nutrition (TPN) via a central venous catheter or parenteral nutrition via a percutaneous endoscopic gastrostomy (PEG) tube. This may be continued as long as oral feeding is not tolerated.

    While treatment strategies to this point have focused on symptomatic management of women already experiencing hyperemesis gravidarum, one study shows promise for pre-emptive treatment for women who experienced hyperemesis in a previous pregnancy [69]. In this study, women who had hyperemesis in a previous pregnancy were assigned to either the treatment group or the control group. Women in the treatment group received a standard form of antiemetic pharmacologic therapy prior to the onset of symptoms, while those in the control group received treatment only after the onset of symptoms. The authors found that there was a substantial decrease in the symptoms of hyperemesis in the treatment group versus the control group [69]. In a subsequent randomized controlled trial, the authors again found pre-emptive treatment to be superior in decreasing the risk of hyperemesis when compared with treatment that begins after the onset of symptoms [70].

    Nausea and vomiting of pregnancy is usually initially treated conservatively with diet in the hopes that the problem will not progress to hyperemesis gravidarum. General recommendations include choosing a bland diet, increasing carbohydrate intake, decreasing fat intake, avoiding offensive food odors, and avoiding iron supplementation, if possible. Omitting prenatal vitamins containing iron until the nausea resolves may also be helpful.

    Specific suggestions are to eat bread or crackers before getting out of bed in the morning, when nauseated, and before retiring for the night. Experts also recommend eating small meals every two to three hours; drinking liquids between meals rather than with meals to avoid gastric distention; eating low-fat, high-protein foods; avoiding fried foods; and salting food to taste.

    One controversial approach involves feeding patients with hyperemesis potato chips and lemonade [71]. The study found that potato chips were superior to the commonly prescribed saltine crackers in that they supplied more folic acid, vitamin C, and potassium. Potato chips also drive thirst, particularly for cold, tart, or sweet liquids. Researchers found that lemonade was better tolerated by patients than either ginger ale or plain water.

    Because of the electrolytes lost in vomiting, consuming foods high in potassium and magnesium is recommended, as well as salting food, as tolerated, to replace chloride. Chewing one milk of magnesia tablet two to three times per day may help to settle the stomach and replace magnesium stores. Other frequently recommended foods are legumes, dairy products, nuts, oral nutrition supplements, and electrolyte-replacement drinks to preserve the body's electrolyte balance [46].

    Behavioral changes recommended for patients with hyperemesis gravidarum are to take frequent rests, get plenty of fresh air, avoid sudden movements, avoid brushing teeth immediately after eating, and sit upright for some time after meals to reduce the frequency of gastric reflux. Acupressure wristbands, which are sometimes used by passengers on boats to prevent seasickness, have been found to be helpful for some women with nausea in pregnancy [72].

    Avoiding offensive odors is of special importance. An overly sensitive sense of smell is common in pregnancy, possibly due to increased estrogen levels. Offensive odors commonly are food odors but can also be perfumes or chemicals. Minimizing odors and increasing fresh air are key ways to avoid nausea.

    Patients with hyperemesis should also have psychologic support, including reassurance, perhaps family and individual counseling, and a reduction in demands of daily living and environmental stimulation. Because the smell of hot or cooking food often induces nausea, it may be helpful for a partner, spouse, friend, or other person to prepare meals [32]. If eating hot foods cause patients to feel ill, it is recommended they stick with cold foods, such as sandwiches [73].

    It is important that healthcare professionals accept patients' complaints of nausea and vomiting as a real physical problem and not necessarily psychologic in origin. Women who think their providers do not believe their complaints of nausea and vomiting may feel anger, diminished self-esteem, and confusion [54]. Acceptance of the patient's complaint and the assurance that it is not all in her head are paramount to establishing a therapeutic relationship.

    A nursing assessment should first evaluate the frequency of vomiting episodes. Next, the nurse should determine any patterns to the nausea and vomiting episodes, such as what time of day or night they occur. It should also be determined which conditions lead to vomiting, such as an empty stomach or certain smells. Assessment must also include which, if any, foods seem to make the situation worse or better. Finally, the nurse must determine which measures the patient has already tried to alleviate the symptoms.

    A dietary plan may be created using most of the discussed strategies (e.g., eating small meals every two to three hours, avoiding an empty stomach, avoiding fried or highly seasoned foods, and maintaining adequate hydration). The nurse can suggest that the patient keep a log of the type and amount of food consumed, as well as any episodes of nausea and vomiting. This may help both the patient and the nurse find patterns and dietary solutions to the problem.

    Evaluation of a dietary plan should be ongoing at every prenatal visit. The goal is normal weight gain, fewer episodes of nausea and vomiting, normal vital signs, and no ketonuria. The dietary plan is also an important adjunct to pharmacologic therapy for hyperemesis.

    If diet and lifestyle changes do not resolve the problem of nausea and vomiting, drug therapy may be indicated (Table 1). Approximately 10% of women with hyperemesis require pharmacologic treatment [74].

    The dilemma in treating hyperemesis gravidarum pharmacologically is the fear of possible teratogenic effects; both providers and pregnant women are reluctant to use pharmacologic agents with possible fetal effects, especially in the first trimester of pregnancy. This is complicated by the fact that only one drug (Diclegis) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of nausea and vomiting of pregnancy [83].

    A 1953 report indicated that cortisone relieved chemotherapy-related nausea and vomiting and hyperemesis gravidarum. However, only in 2000 did randomized clinical trials support the use of steroids as treatment. Corticosteroids are thought to affect a chemoreceptor trigger zone in the brain to reduce nausea and vomiting. An alternative explanation is that corticosteroids correct an adrenal insufficiency that is caused by increased adrenal demands during pregnancy [94]. A controlled study compared treatment of hyperemesis gravidarum with oral methylprednisolone to treatment with oral promethazine. The methylprednisolone was given for three days and then tapered for two weeks, while the dosage of promethazine remained the same. The study showed that methylprednisolone was more effective at three days than treatment with promethazine [95]. However, the regimen should be discontinued if the condition does not improve within three days [82]. Prednisolone has been shown to improve symptoms after the first two days, with few side effects [96].

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  12. Which of the following statements regarding the use of Bendectin is FALSE?

    INTERVENTION STRATEGIES

    Among the antihistamines used by women for nausea and vomiting during pregnancy is doxylamine in combination with pyridoxine hydrochloride (vitamin B6). It carries an FDA pregnancy Category B, which indicates that human fetal risk is relatively unlikely [76]. The FDA approved the combination of 10 mg doxylamine and 10 mg pyridoxine (marketed as Diclegis) in 2013 for the treatment of hyperemesis gravidarum. It is the only drug specifically approved for this indication and has become a first-line therapy [83,92]. A version of this combination that also included dicyclomine hydrochloride (marketed as Bendectin) was originally introduced in 1956 and was taken off the market in 1983 [86]. Despite the fact that controlled studies found no increased risk of birth defects, highly publicized lawsuits in the 1970s, involving neonates with severe malformations whose mothers had taken Bendectin, were judged unfavorably against the manufacturer. It is interesting to note that after Bendectin was removed from the market, the incidence of the type of limb deformities and congenital heart disease attributed to the medication did not decrease [86].

    The individual components of Bendectin have been available in both over-the-counter and prescription forms and have not demonstrated to be teratogenic [87]. Moreover, a form of Bendectin has remained available in the United Kingdom and in Canada. This, along with the fact that Bendectin has not been conclusively shown to be teratogenic, initiated the move to reintroduce combination doxylamine/pyridoxine [86].

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  13. Thiamine replacement is essential prior to initiating hydration therapy in the patient with hyperemesis gravidarum because

    INTERVENTION STRATEGIES

    Thiamine stores must be restored before intravenous therapy begins, as the dextrose in the solution causes the body to metabolize thiamine. As previously mentioned, thiamine deficiency can lead to Wernicke encephalopathy. Signs and symptoms of Wernicke encephalopathy include visual disturbances, such as diplopia or nystagmus, as well as disorientation, delusion, and gait ataxia. While there is no specific treatment regimen, some experts recommend parenteral thiamine 100–500 mg daily for three days and 2–3 mg per day thereafter [100].

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  14. Which of the following is inappropriate for the patient receiving intravenous therapy for hyperemesis?

    INTERVENTION STRATEGIES

    Nursing assessments should include starting and maintaining the patency of the intravenous infusion, maintaining the infusion rate, and assessing the IV site for infection or infiltration. Venipuncture can be difficult in dehydrated patients, but placing the site in a dependent position and warming the area with warm compresses may cause enough vasodilatation to enable an easy insertion. Warming the first liter of fluid may prevent the feeling of coldness that dehydrated patients experience.

    Assessments might also include intake and output, as well as assessing for episodes of vomiting. Vital signs are one marker of hydration status and should be monitored per protocol. Antiemetic therapy is often initiated as well as IV hydration; therefore, ongoing assessments for side effects should be included.

    Shortly after IV therapy is initiated, oral feeding may be resumed. The diet is usually initiated with clear liquids and proceeds to small, frequent meals. Nurses should monitor dietary intake and advance the diet as tolerated. If the diet is not tolerated, enteral feeding may be an option [99].

    Discharge planning should be initiated on admission. The goal is to discharge the patient to home as soon as dehydration is treated, vomiting has subsided, and the patient is able to keep food down. Discharge planning should include counseling regarding diet, as well as educating the patient regarding her medications, side effects, and warning signs.

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  15. Which alternative therapy has been best studied in the management of hyperemesis gravidarum?

    INTERVENTION STRATEGIES

    Acupressure has been used for the treatment of morning sickness, as well as motion sickness and post-chemotherapy nausea and vomiting. As such, it is the best-studied alternative therapy. Treatment includes wearing wristbands that apply pressure to the inner forearm approximately three finger breadths proximal to the wrist (e.g., Sea-Bands). A 2014 Cochrane review did not find P6 acupuncture or acupressure wristbands significantly more effective than placebo for the treatment of nausea and vomiting in early pregnancy, but it is unclear if the approach would be more effective for women with hyperemesis gravidarum [106]. While many clinical trials show statistically significant improvement in nausea, fewer studies show improvement in vomiting [90]. However, many of the studies are flawed, having small sample sizes, inadequate control groups, and little if any blinding [90].

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  16. Which of the following signs and symptoms would the nurse expect to find in a patient with hyperemesis gravidarum?

    NURSING IMPLICATIONS

    On physical examination, the patient may appear weak, pale, and with dry mucous membranes. A ketotic breath smell may be noted. Infrequently, jaundice might be noted. A weight check may reveal weight loss, as much as 5 pounds in a week. Blood pressure may manifest orthostatic changes, and pulse may be elevated secondary to dehydration.

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  17. Which of the following might the nurse find evidence of in a urine dipstick analysis in the patient with hyperemesis gravidarum?

    NURSING IMPLICATIONS

    A urine dipstick analysis should be performed, with particular attention to the presence of ketones. Specific gravity will be increased [109].

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  18. According to the North American Nursing Diagnosis Association (NANDA), an appropriate nursing intervention for the patient with nausea is

    NURSING IMPLICATIONS

    Nausea is defined as "a subjective unpleasant, wave-like sensation in the back of the throat, epigastrium, or abdomen that may lead to the urge or need to vomit" [111]. Olfactory stimulation can sometimes trigger nausea. Interventions include avoiding unpleasant odors and food smells, particularly those that trigger the nausea. The patient should avoid fried or greasy meals because these also promote nausea. The patient should attempt small, frequent meals and drink fluids in between meals to help reduce the amount of food in the stomach and avoid the feeling of fullness that can aggravate nausea. The patient should avoid lying supine for at least 30 minutes after eating, because this position applies pressure on the diaphragm and digestion is improved by gravity.

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  19. If a patient with hyperemesis gravidarum is at risk for fluid volume deficit, nursing assessment may reveal

    NURSING IMPLICATIONS

    Dehydration is a state in which an individual is at risk for or experiencing fluid depletion. The nursing assessment may reveal dry mucous membranes, decreased skin turgor, tachycardia, hypotension, increased body temperature, and ketonuria. The hemoglobin and hematocrit may be elevated, but sodium, potassium, and chloride may be reduced due to vomiting.

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  20. The diagnosis of impaired tissue integrity, especially in the oral mucous membranes, is due to

    NURSING IMPLICATIONS

    This nursing diagnosis includes impaired oral mucous membrane integrity, due to both dehydration and vomiting. Nursing assessments might reveal a complaint of dry mouth, bad taste, or even excessive salivation. Inspection may reveal dry or cracked mucous membranes, pallor, ulcerations, edema, coated tongue, or hemangiomas (a network of small blood-filled capillaries near the surface of the skin).

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  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.