Hyperemesis gravidarum

Hyperemesis gravidarum
Classication and external resources
ICD-10
MedlinePlus

O21.1
001499

Hyperemesis gravidarum (HG) is a complication of pregnancy

characterized by intractable nausea, vomiting, and dehydration and is
estimated to aect 0.5-2.0% of pregnant women.[1][2]Malnutrition and
other serious complications, such as uid or electrolyte imbalances, may
result.
Hyperemesis is considered a rare complication of pregnancy but,
because nausea and vomiting during pregnancy exist on a spectrum, it is
often dicult to distinguish this condition from the more common form
of nausea and vomiting experienced during pregnancy known as
morning sickness.

Signs and symptoms

When hyperemesis gravidarum is severe and/or inadequately treated, it
may result in:[1]
Loss of 5% or more of pre-pregnancy body weight
Dehydration, causing ketosis, and constipation
Nutritional disorders such as Vitamin B1 (thiamine) deciency, Vitamin
B6 deciency or Vitamin B12 deciency
Metabolic imbalances such as metabolic ketoacidosis[1] or
thyrotoxicosis[3]
Physical and emotional stress of pregnancy on the body
Diculty with activities of daily living
Symptoms can be aggravated by hunger, fatigue, prenatal vitamins
(especially those containing iron), and diet.[4] Some women with
hyperemesis gravidarum lose as much as 10% of their body weight. [5]
Many suerers of HG are extremely sensitive to odors in their
environment; certain smells may exacerbate symptoms. This is known as
hyperolfaction. Ptyalism, or hypersalivation, is another symptom
experienced by some women suering from HG.

Hyperemesis gravidarum tends to begin somewhat earlier in the

pregnancy and last signicantly longer than morning sickness. While
most women will experience near-complete relief of morning sickness
symptoms near the beginning of their second trimester, some suerers
of HG will experience severe symptoms until they give birth to their
baby, and sometimes even after giving birth.[6]

Causes
While there are numerous theories regarding the cause of HG, the cause
remains controversial. It is thought that HG is due to a combination of
factors which may vary between women and include: genetics,[1] body
chemistry, and overall health.[7]
One factor is an adverse reaction to the hormonal changes of pregnancy,
in particular, elevated levels of beta human chorionic gonadotropin.[8][9]
This theory would also explain why hyperemesis gravidarum is most
frequently encountered in the rst 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).[1]

Pathophysiology

Morning sickness
Although the pathophysiology of HG is poorly understood, the most
commonly accepted theory suggests that levels of hCG are associated
with it.[10]Leptin may also play a role.[11]
Possible pathophysiological processes involved are summarized in the

following table:[12]
Source
Placenta

Etiology

Pathophysiology

hCG

Corpus luteum

Distention of gastrointestinal
tract
Crossover with TSH, causing
gestational thyrotoxicosis[10]

Placenta

Estrogen

Decreased gut mobility

Progesterone

Elevated liver enzymes

Decreased lower esophageal
sphincter pressure
Increased levels of sex steroids in
hepatic portal system[13]

Gastrointestinal
tract

Helicobacter
pylori

Increased steroid levels in

Psychological

Possible eect of culture and

circulation[14]
environment[15]

Diagnosis
Hyperemesis gravidarum is considered an exclusion.[1] HG can be
associated with serious maternal and fetal morbidity, such as Wernicke's
encephalopathy, coagulopathy, peripheral neuropathy,[10]fetal growth
restriction, and even maternal and fetal death.
Women experiencing hyperemesis gravidarum often are dehydrated
and lose weight despite eorts to eat.[16][17] The onset of the nausea and
vomiting in hyperemesis gravidarum is typically before the twentysecond week of pregnancy.[1]

Dierential diagnosis
Diagnoses to be ruled out include:[12]

Type
Infections
(usually accompanied by fever

Dierential diagnoses
Urinary tract infection
Hepatitis

and/or associated neurological

Meningitis

symptoms)

Gastroenteritis

Gastrointestinal disorders
(usually accompanied by abdominal
pain)

Appendicitis
Cholecystitis
Pancreatitis
Fatty liver
Peptic ulcer
Small bowel obstruction

Metabolic

Thyrotoxicosis (common in
Asian subcontinent)[10]
Addison's disease
Diabetic ketoacidosis
Hyperparathyroidism

Drugs

Antibiotics
Iron supplements

Investigations
Common investigations include blood urea nitrogen (BUN) and
electrolytes, liver function tests, urinalysis,[17] and thyroid function tests.
Hematological investigations include hematocrit levels, which are usually
raised in HG.[17] An ultrasound scan may be needed to know gestational
status and to exclude molar or partial molar pregnancy.[18]

Management
Because of the potential for severe dehydration and other
complications, HG is treated as an emergency. Treatment may include
antiemetics and intravenous rehydration. If insucient, nutritional
support may be required. In case of failure of all modalities of treatment,
termination of pregnancy may be necessary to preserve health of the
woman.[12] In those who require admission to the hospital,
thromboprophylaxis such as thromboembolic stockings or
low-molecular-weight heparin may be recommended.[12]

Intravenous uids

IV hydration often includes supplementation of electrolytes as persistent

vomiting frequently leads to a deciency. Likewise, supplementation for
lost thiamine (Vitamin B1) must be considered to reduce the risk of
Wernicke's encephalopathy.[19] A and B vitamins are depleted within two
weeks, so extended malnutrition indicates a need for evaluation and
supplementation. In addition, mineral levels should be monitored and
supplemented; of particular concern are sodium and potassium.
After IV rehydration is completed, patients in general progress to
frequent small liquid or bland meals. After rehydration, treatment
focuses on managing symptoms to allow normal intake of food.
However, cycles of hydration and dehydration can occur, making
continuing care necessary. Home care is available in the form of a PICC
line for hydration and nutrition (called total parenteral nutrition).[20]
Home treatment is often less expensive than long-term and/or repeated
hospital stays.

Medications
A number of antiemetics are eective and safe in pregnancy including:
pyridoxine/doxylamine, antihistamines (such as diphenhydramine), and
phenothiazines (such as promethazine).[21] With respect to eectiveness,
it is unknown if one is superior to another.[21]
While pyridoxine/doxylamine, a combination of vitamin B6 and
doxylamine, is eective in nausea and vomiting of pregnancy,[22] some
have questioned its eectiveness in HG.[23]
Ondansetron may be benecial, however, there are some concerns
regarding an association with cleft palate,[24] and there is little high
quality data.[21]Metoclopramide is also used and relatively well
tolerated.[25] 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.[1][26] However, hydrocortisone and prednisolone are
inactivated in the placenta and may be used in the treatment of
hyperemesis gravidarum.[1]

Nutritional support
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 nasojejunum tube). Vitamin B6 has been shown to
improve outcome.[27]Hyperalimentation may be necessary in certain
cases to help maintain volume requirements and allow weight gain. [18] A
physician might also prescribe Vitamin B1 (to prevent Wernicke's
encephalopathy) and folic acid supplementation.[12]

Alternative medicine
Acupuncture has been found to be ineective.[27] Evidence supporting
the use of ginger to provide symptomatic relief of HG is currently
inconclusive due to a lack of study.[28]

Complications
Pregnant woman
If HG is treated inadequately, anemia,[1]hyponatremia,[1]Wernicke's
encephalopathy,[1]renal failure, central pontine myelinolysis,
coagulopathy, atrophy, Mallory-Weiss tears,[1]hypoglycemia, jaundice,
malnutrition, pneumomediastinum, rhabdomyolysis, deconditioning,
deep vein thrombosis, pulmonary embolism, splenic avulsion, and
vasospasms of cerebral arteries are possible consequences. Depression
is a common secondary complication of HG and emotional support can
be of benet.[1]

Infant
The eects of HG on the fetus are mainly due to electrolyte imbalances
caused by HG in mother.[12] 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. 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.[29] There is no signicant dierence in the
neonatal death rate in infants born to mothers with HG compared to
infants born to mothers who do not have HG.[1]

Epidemiology

Vomiting is a common condition aecting about 50% of pregnant

women, with another 25% suering from nausea.[30] However, the
incidence of HG is only 0.31.5%.[10] After preterm labor, hyperemesis
gravidarum is the second most common reason for hospital admission
during the rst half of pregnancy.[1] 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.[1]

History
Thalidomide was prescribed for treatment of HG in Europe until it was
recognized that thalidomide is teratogenic and is a cause of phocomelia
in neonates.[31]

Etymology
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".

Notable cases
Author Charlotte Bront is often thought to have suered from
hyperemesis gravidarum. She died in 1855 while four months pregnant,
having been aicted by intractable nausea and vomiting throughout her
pregnancy, and was unable to tolerate food or even water.[32]
In December 2012, Catherine, Duchess of Cambridge, was hospitalized
with the condition.[33]
Queen Victoria of the United Kingdom of Great Britain, who is known by
many as the rst medical marijuana pharmacologist, used marijuana to
treat the worst symptoms associated with her pregnancies.[34][35]

References
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(pdf). Retrieved 26 July 2012.

6. ^ "Do I Have Morning Sickness or HG?" . H.E.R. Foundation.

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Helicobacter pylori infection.". International journal of gynaecology and

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18. ^ a b Manual of obstetrics (7th ed. ed.). Philadelphia: Wolters Kluwer
/ Lippincott Wiliams & Wilkins. 2007. pp. 265268.
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nausea and vertigo Vomiting of pregnancy". BNF (45 ed.).
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doi:10.1097/01.AOG.0000195060.22832.cd . PMID 16449113 .
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32. ^ McSweeny, Linda (2010-06-03). "What is acute morning
sickness?" . The Age. Retrieved 2012-12-04.
33. ^ Melanie Haiken (December 3, 2012). "Pregnant Kate Middleton
Hospitalized for Hyperemesis Gravidarum - Which Is What?" .
forbes.com. Retrieved December 3, 2012..
34. ^ Hartley-Parkinson, Richard; Brown, Larisa; Nolan, Steve (3
December 2012). "Bulimia, cannabis and a minister in the next room
for the birth: Trials and traditions of Royal mothers-to-be from Diana
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Pathology of pregnancy, childbirth and the puerperium (O,

630679)
Pregnancy with Ectopic pregnancy
abortive
(Abdominal pregnancy Cervical pregnancy
outcome
Interstitial pregnancy Ovarian pregnancy) Molar
pregnancy Miscarriage
Oedema,
proteinuria
and
hypertensive
disorders

Gestational diabetes Gestational hypertension

(Pre-eclampsia Eclampsia HELLP syndrome)

Digestive
system

Acute fatty liver of pregnancy

Hepatitis E
Hyperemesis gravidarum
Intrahepatic cholestasis of
pregnancy

Integumentary Gestational pemphigoid Impetigo

system /
herpetiformis Intrahepatic
dermatoses of cholestasis of pregnancy Linea
pregnancy
nigra Prurigo gestationis Pruritic
folliculitis of pregnancy Pruritic
urticarial papules and plaques of
pregnancy (PUPPP) Striae
gravidarum
Nervous
system

Chorea gravidarum

Blood

Gestational thrombocytopenia
Pregnancy-induced
hypercoagulability

Other,
predominantly
related to
pregnancy

Maternal care amniotic uid

related to the (Oligohydramnios Polyhydramnios) Braxton Hicks
fetus and
contractions chorion / amnion
amniotic cavity
(Amniotic band syndrome Chorioamnionitis
Chorionic hematoma Monoamniotic twins
Premature rupture of membranes) Obstetrical
hemorrhage
(Antepartum) placenta
(Circumvallate placenta Monochorionic twins
Placenta praevia Placental abruption Twin-to-twin
Pregnancy
Labor

transfusion syndrome)
Amniotic uid embolism Cephalopelvic disproportion Dystocia
(Shoulder dystocia) Fetal distress Obstetrical hemorrhage

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