Hyperemesis gravidarum

• Epidemiology[edit]
• Vomiting is a common condition affecting about 50% of
pregnant women, with another 25% having
nausea.[39] However, the incidence of HG is only 0.3–
1.5%.[5] After preterm labor, hyperemesis gravidarum is
the second most common reason for hospital
admission during the first half of pregnancy.[11] Factors
such as infection with Helicobacter pylori, a rise
in thyroid hormone production, low age, low body
mass index prior to pregnancy, multiple
pregnancies, molar pregnancies, and a past history of
hyperemesis gravidarum have been associated with the
development of HG.[11]
• Etymology[edit]
• Hyperemesis gravidarum is from
the Greek hyper-, meaning excessive,
and emesis, meaning vomiting, and
the Latin gravidarum, the feminine genitive
plural form of an adjective, here used as a
noun, meaning "pregnant [woman]".
Therefore, hyperemesis gravidarum means
"excessive vomiting of pregnant women".
• Morning sicknessSynonymsNausea and vomiting of pregnancy, nausea
gravidarum, emesis gravidarum, pregnancy
sicknessSpecialtyObstetricsSymptomsNausea, vomiting[1]ComplicationsWe
rnicke encephalopathy, esophageal rupture[1]Usual onset4th week of
pregnancy[2]DurationUntil 16th week of
pregnancy[2]CausesUnknown[2]Diagnostic methodBased on symptoms
after other causes have been ruled out[3]Differential diagnosisHyperemesis
gravidarum[1]PreventionPrenatal vitamins[3]TreatmentDoxylamine and
pyridoxine[3][4]Frequency~75% of pregnancies[4][5]Morning sickness, also
called nausea and vomiting of pregnancy (NVP), is a symptom of
pregnancy that involves nausea or vomiting.[1] Despite the name, nausea
or vomiting can occur at any time during the day.[2] Typically these
symptoms occur between the 4th and 16th week of pregnancy.[2] About
10% of women still have symptoms after the 20th week of pregnancy.[2] A
severe form of the condition is known as hyperemesis gravidarum and
results in weight loss.[1][6]
• Hyperemesis gravidarum (HG) is a pregnancy
complication that is characterized by
severe nausea, vomiting, weight loss, and
possibly dehydration.[1] Signs and symptoms may also
include vomiting several times a day and feeling
faint.[2] Hyperemesis gravidarum is considered more
severe than morning sickness.[2] Often symptoms get
better after the 20th week of pregnancy but may last
the entire pregnancy duration.[2]
•
• The exact causes of hyperemesis gravidarum
are unknown.[3] Risk factors include the first
pregnancy, multiple pregnancy, obesity, prior
or family history of HG, trophoblastic disorder,
and a history of eating disorders.[3][4] Diagnosis
is usually made based on the observed signs
and symptoms.[3
• HG has been technically defined as more than
three episodes of vomiting per day such that
weight loss of 5% or three kilograms has
occurred and ketones are present in the
urine.[3] Other potential causes of the
symptoms should be excluded
including urinary tract infection and high
thyroid levels.[5]
• Treatment includes drinking fluids and a bland
diet.[2] Recommendations may
include electrolyte-replacement drinks, thiamine,
and a higher protein diet.[3][7] Some women
require intravenous fluids.[2] With respect to
medications pyridoxine or metoclopramide are
preferred.[5] Prochlorperazine, dimenhydrinate,
or ondansetron may be used if these are not
effective.[3][5] Hospitalization may be
required.[3] Psychotherapy may improve
outcomes.[3] Evidence for acupressure is poor.[3]
• While vomiting in pregnancy has been described
as early as 2,000 BC, the first clear medical
description of hyperemesis gravidarum was in
1852 by Antoine Dubois.[8] Hyperemesis
gravidarum is estimated to affect 0.3–2.0% of
pregnant women.[6] While previously known as a
common cause of death in pregnancy, with
proper treatment this is now very rare.[9][10] Those
affected have a low risk of miscarriage but a
higher risk of premature birth.[4] Some pregnant
women choose to have an abortion due to HG's
symptoms.[7]
• Signs and symptoms[edit]
• When vomiting is severe it may result in the following:[11]
• Loss of 5% or more of pre-pregnancy body weight
• Dehydration, causing ketosis,[12] and constipation
• Nutritional disorders such as vitamin B1 (thiamine)
deficiency, vitamin B6 deficiency or vitamin B12 deficiency
• Metabolic imbalances such as
metabolic ketoacidosis[11] or thyrotoxicosis[13]
• Physical and emotional stress of pregnancy on the body
• Difficulty with activities of daily living
• Symptoms can be aggravated by hunger, fatigue, prenatal
vitamins (especially those containing iron), and diet.[14] Many
people with HG are extremely sensitive to odors in their
environment; certain smells may exacerbate symptoms. Excessive
salivation, also known as sialorrhea gravidarum, is another
symptom experienced by some women.
• Hyperemesis gravidarum tends to occur in the first trimester of
pregnancy[12] and lasts significantly longer than morning sickness.
While most women will experience near-complete relief of morning
sickness symptoms near the beginning of their second trimester,
some sufferers of HG will experience severe symptoms until they
give birth to their baby, and sometimes even after giving birth.[15]
• A small percentage rarely vomit, but the nausea still causes most (if
not all) of the same issues that hyperemesis with vomiting
does.[citation needed]
• Causes[edit]
• There are numerous theories regarding the cause of HG, but the
cause remains controversial. It is thought that HG is due to a
combination of factors which may vary between women and
include genetics.[11] Women with family members who had
Hyperemesis are more likely to develop the disease.[16]
• One factor is an adverse reaction to the hormonal changes of
pregnancy, in particular, elevated levels of beta human chorionic
gonadotropin (hCG).[17][18] This theory would also explain why
hyperemesis gravidarum is most frequently encountered in the first
trimester (often around 8–12 weeks of gestation), as hCG levels are
highest at that time and decline afterward. Another postulated
cause of HG is an increase in maternal levels
of estrogens (decreasing intestinal motility and gastric emptying
leading to nausea/vomiting).[11]
• Although the pathophysiology of HG is poorly
understood, the most commonly accepted
theory suggests that levels of hCG are
associated with it.[5] Leptin may also play a
role.[19]
• Possible pathophysiological processes
involved are summarized in the following
table:[20]
• Complications[edit]
• Pregnant woman[edit]
• If HG is inadequately treated, anemia,[11] hyponatremia,[11] Wernicke's encephalopathy,[11] kidney
failure, central pontine myelinolysis, coagulopathy, atrophy, Mallory-Weiss
tears,[11]hypoglycemia, jaundice, malnutrition, pneumomediastinum, rhabdomyolysis, deconditioni
ng, deep vein thrombosis, pulmonary embolism, splenic avulsion, or vasospasms of cerebral
arteries are possible consequences. Depression and PTSD [36] are common
secondary complications of HG and emotional support can be beneficial.[11]
• Infant[edit]
• The effects of HG on the fetus are mainly due to electrolyte imbalances caused by HG in the
mother.[20] Infants of women with severe hyperemesis who gain less than 7 kg (15.4 lb) during
pregnancy tend to be of lower birth weight, small for gestational age, and born before 37 weeks
gestation.[12] In contrast, infants of women with hyperemesis who have a pregnancy weight gain of
more than 7 kg appear similar to infants from uncomplicated pregnancies.[37] There is no significant
difference in the neonatal death rate in infants born to mothers with HG compared to infants born
to mothers who do not have HG.[11] Children born to mothers with undertreated Hyperemesis have
a fourfold increase in neurobehavioral diagnoses.[38]
• Diagnosis[edit]
• Hyperemesis gravidarum is considered a diagnosis of
exclusion.[11] HG can be associated with serious
problems in the mother or baby, such as Wernicke's
encephalopathy, coagulopathy, peripheral
neuropathy.[5]
• Women experiencing hyperemesis gravidarum often
are dehydrated and lose weight despite efforts to
eat.[23][24] The onset of the nausea and vomiting in
hyperemesis gravidarum is typically before the twenty-
second week of pregnancy.[11]
• Management[edit]
• Dry bland food and oral rehydration are first-line
treatments.[26] Due to the potential for severe
dehydration and other complications, HG is treated as
an emergency. If conservative dietary measures fail,
more extensive treatment such as the use
of antiemetic medications and
intravenous rehydration may be required. If oral
nutrition is insufficient, intravenous nutritional support
may be needed.[12] For women who require hospital
admission, thromboembolic stockings or low-
molecular-weight heparin may be used as measures to
prevent the formation of a blood clot.[20]
• Medications[edit]
• A number of antiemetics are effective and safe in pregnancy
including: pyridoxine/doxylamine, antihistamines (such as diphenhydramine),
and phenothiazines (such as promethazine).[29] With respect to effectiveness, it is
unknown if one is superior to another for relieving nausea or vomiting.[29] Limited
evidence from published clinical trials suggests the use of medications to treat
hyperemesis gravidarum.[30]
• While pyridoxine/doxylamine, a combination of vitamin B6 and doxylamine, is
effective in nausea and vomiting of pregnancy,[31] some have questioned its
effectiveness in HG.[32]Ondansetron may be beneficial, however, there are some
concerns regarding an association with cleft palate,[33] and there is little high-
quality data.[29] Metoclopramide is also used and relatively well
tolerated.[34] Evidence for the use of corticosteroids is weak; there is some
evidence that corticosteroid use in pregnant women may slightly increase the risk
of oral facial clefts in the infant and may suppress fetal adrenal
activity.[11][35] However, hydrocortisone and prednisolone are inactivated in the
placenta and may be used in the treatment of hyperemesis gravidarum after 12
weeks.[11]
• Nutritional support[edit]
• Women not responding to IV rehydration and
medication may require nutritional support. Patients
might receive parenteral nutrition (intravenous feeding
via a PICC line) or enteral nutrition (via a nasogastric
tube or a nasojejunal tube). There is only limited
evidence from trials to support the use of vitamin B6 to
improve outcome.[30] Hyperalimentation may be
necessary in certain cases to help maintain volume
requirements and allow weight gain.[25] A physician
might also prescribe Vitamin B1 (to prevent Wernicke's
encephalopathy) and folic acid supplementation.[20]
• Alternative medicine[edit]
• Acupuncture (both with P6 and traditional
method) has been found to be
ineffective.[30] The use of ginger products may
be helpful, but evidence of effectiveness is
limited and inconsistent, though three recent
studies support ginger over placebo.[30]