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Hyperemesis Gravidarum

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Update Me E-mail alerts The Merck Manual Minute Print This Topic Email This Topic Hyperemesis gravidarum is uncontrollable vomiting during pregnancy that results in dehydration and ketosis. Diagnosis is clinical and by measurement of urine ketones, serum electrolytes, and renal function. Treatment is with IV fluids, antiemetics, and temporary suspension of oral intake. Pregnancy frequently causes nausea and vomiting; the cause appears to be rapidly increasing levels of estrogens Some Trade Names PREMARIN Click for Drug Monograph or the β subunit of human chorionic gonadotropin (β-hCG). Most cases are morning sickness; ie, women continue to gain weight and do not become dehydrated. Hyperemesis gravidarum is distinguished from morning sickness by weight loss (> 5% of weight) and development of dehydration and ketoacidosis. Psychologic factors (eg, ambivalence, anxiety) may trigger hyperemesis gravidarum. Hyperemesis gravidarum that persists past 16 to 18 wk is uncommon but may seriously damage the liver, causing severe centrilobular necrosis, widespread fatty degeneration, Wernicke's encephalopathy, or esophageal rupture. Diagnosis If hyperemesis gravidarum is suspected, urine ketones, thyroid-stimulating hormone, serum electrolytes, AST, ALT, BUN, serum creatinine, Mg, P, and sometimes body weight are measured. Obstetric ultrasonography should be done

to rule out hydatidiform mole and multifetal pregnancy. Other disorders that can cause vomiting and that may be hard to diagnose during pregnancy should be considered: eg, hepatitis, pyelonephritis, pancreatitis, intestinal obstruction, GI tract lesions, hyperthyroidism, gestational trophoblastic disease, and increased intracranial pressure. Tests for these disorders are done based on laboratory, clinical, or ultrasound findings. Treatment IV 0.9% normal saline solution with 5% dextrose is given, typically about 2 L over 2 h, the 1st liter containing 100 mg of thiamin; subsequent fluid rate requirements vary with patient response but may be as much as 1 L q 4 h or so for up to 3 days. This dose of thiamin should be given daily for 3 days. Electrolyte deficiencies are treated; K, Mg, and P are replaced as needed. Care must be taken not to correct low plasma Na levels too quickly as this can cause central pontine myelinolysis. At first, patients are given nothing by mouth. Vomiting that persists after initial fluid and electrolyte replacement is treated with an antiemetic (eg, pyridoxine 10 to 25 mg po tid; promethazine Some Trade Names PHENERGAN Click for Drug Monograph 12.5 to 25 mg po, IM, or rectally q 4 to 8 h; metoclopramide Some Trade Names REGLAN Click for Drug Monograph 5 to 10 mg IV or po q 8 h; ondansetron Some Trade Names ZOFRAN Click for Drug Monograph 8 mg po or IM q 12 h; prochlorperazine Some Trade Names COMPAZINE Click for Drug Monograph 5 to 10 mg po or IM q 3 to 4 h). After dehydration and acute vomiting resolve, small amounts of oral liquids are given. Patients who cannot tolerate any oral fluids after IV rehydration and antiemetics may need to be hospitalized or given home IV therapy and take nothing by mouth for a longer period (sometimes several days or more). Once patients tolerate fluids, they can eat small, bland meals, and diet is expanded as tolerated. IV vitamin therapy is required initially and until vitamins can be taken by mouth. If treatment is ineffective, total parenteral nutrition or corticosteroids may be necessary. If progressive weight loss, jaundice, or persistent tachycardia occurs despite treatment, termination of the pregnancy should be considered.

Question: What Can I Do for Morning Sickness, Nausea, and Vomiting? Approximately 70 to 85 percent of pregnant women suffer from morning sickness or nausea and vomiting during pregnancy. Morning sickness typically occurs only during the first trimester (three months) of pregnancy and is often the first sign of pregnancy that women experience. Answer: Fortunately, most morning sickness is manageable with a few dietary and lifestyle changes. • • • •

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Eating smaller meals more frequently is often helpful for reducing the amount and severity of morning sickness suffered during pregnancy. Drinking liquids only between meals and not with meals is beneficial for reducing nausea and vomiting during pregnancy for many women. Foods that are greasy, fried, and / or spicy often result in substantial bouts of morning sickness and pregnant women should avoid these foods. Odors that seem foul or unpleasant many times led to uncomfortable attacks of nausea and vomiting during pregnancy. I know of one woman whose pregnancy was inundated by nausea brought on by the “smell” of her microwave oven. During pregnancy, the female body undergoes an enormous amount of rapid changes, which can lead to extreme tiredness and fatigue. Getting plenty of rest before excessive tiredness arises is helpful for decreasing nausea and vomiting during pregnancy.

Guidelines from the American College of Obstetricians and Gynecologists (ACOG) for treating the symptoms morning sickness include taking a multivitamin at the time of conception, taking Vitamin B6 or Vitamin B6 plus doxylamine, an antihistamine, and using ginger (ginger supplements, ginger ale, ginger cookies) a proven beneficial treatment for nausea and vomiting during pregnancy. These methods of preventing nausea and vomiting during pregnancy are both safe and effective. Of course, you should always consult your health care provider before using any type of over-the-counter vitamins, supplements, or medications during pregnancy. Make sure to tell your health-care provider about any morning sickness symptoms you experience during your pregnancy, even if they are only mild. The best morning sickness treatment results occur when treatment starts early, before mild symptoms progress to severe nausea or vomiting. If you experience severe nausea accompanied by vomiting during your pregnancy, or if you think morning sickness is keeping you from eating properly or gaining the weight that is necessary for a healthy pregnancy consult your health-care provider. Untreated, severe vomiting can cause dehydration. Inform your health-care provider of any severe vomiting you experience immediately to reduce your risk hospitalization or other potentially serious complications that dehydration during pregnancy may cause in either you or your unborn baby.

Tip: Many pregnant women find keeping a package of saltine crackers at their bedside and eating a few before getting up is an effectively relieves and reduces the severity of their morning sickness symptoms.

Hyperemesis Gravidarum What is hyperemesis gravidarum? Hyperemesis gravidarum is severe nausea and vomiting during pregnancy. It causes the loss of 5 percent or more of your body weight. It can also lead to a decrease in body fluid and nutrients. The nausea and vomiting may go away and come back again. It may take a while, but most of the time the nausea and vomiting are over by 20 weeks of pregnancy. What causes hyperemesis gravidarum? The cause of hyperemesis gravidarum is not known. Women who are less than 20 years old, have increased body weight, are carrying twins, had hyperemesis gravidarum in a previous pregnancy or are pregnant for the first time are more likely to have hyperemesis gravidarum. If I cannot eat enough, will my baby grow? Your baby will most likely be fine. Hyperemesis gravidarum usually has no affect on the baby. There is a chance that your baby could be small. The goal of treatment is to keep you well nourished. Keeping you well nourished will allow your baby to keep growing. What is the treatment for hyperemesis gravidarum? It is important to be weighed frequently to be sure that you do not continue to lose weight and to see if you are gaining weight. Your blood and urine may be tested to be sure that you are getting enough calories and nutrients for you and your baby. When vomiting becomes such a problem that you are losing too much weight and body fluids, you will need to be cared for in the hospital. You will be given nothing by mouth until the vomiting has stopped. An intravenous line (IV) will be started so that you can be given fluids directly into your blood stream.

Medicines such as Phenergan®, Compazine®, Reglan®, or Zofran® may be given to stop the nausea and vomiting. Medicines given to decrease acid in your stomach such as Axid®, Tagamet®, Zantac®, Propulsid® may also be given. Once you have stopped vomiting, you will be able to slowly start eating again. Most women feel better in time. Small frequent meals, avoiding greasy and highly seasoned foods, and taking fluids between meals instead of with meals can help. Rarely, some women are not able to eat enough by mouth, even with medications, and need to be fed in other ways. Total parenteral nutrition (TPN) is a special IV fluid with sugar, protein, vitamins and minerals that can be given to be sure that you are getting enough food and fluids. It is usually given through a special IV line that is placed below your collarbone or through a special long IV line that is placed in the skin on the front side of your elbow (PICC line). Tube feeding is another way to provide nutrition. A tube can be put through your nose, past your stomach and into your intestines. A liquid diet is given through the tube. TPN and tube feedings can be done at home, after you leave the hospital. Questions? If you have any questions about hyperemesis gravidarum or your care at North Carolina Women’s Hospital, please feel free to ask your doctor or nurse for more information.

Treatments for Hyperemesis Gravidarum Treating hyperemesis as anything but a physiological disease would be of great detriment to the mother and unborn baby, and if this disease is left untreated, the woman may go as far as terminating a wanted pregnancy for the sole purpose of putting an end to her misery. Depression and anxiety are secondary psychological challenges which result and complicate the management of hyperemesis. Depression occurs as a natural outcome of being confined to home or bed, and being unable to carry out straightforward everyday activities never mind taking care of the family. Furthermore, the accompanying anxiety often results from the worry of retching and vomiting for hours on end along with the severe feeling of nausea in between.

Many women who fear dying feel guilty that they may be the cause of the death of their unborn child if they do not force themselves to eat, even though they know they will inevitably vomit after consuming food. The complex physiological changes which cause such severe symptoms can be very challenging to treat and as each woman is likely to respond in a different way to the next due to the multifactorial causes of the illness, no single medication can be prescribed. Finding the appropriate treatment for the individual can present a real challenge although it is known to decrease the severity and duration and prevent many further complications arising. Bed rest and IV hydration have been found to be two of the most effective treatments by the HER Foundation Survey for HG. However, this does not mean that these two treatments alone are a complete remedy, just that they are universally beneficial to women with HG. Fluids given in IV form which contain necessary vitamins can be administered at home in certain countries at a minimal cost and presenting little risk . IV home care is often included in insurance policies which provide the mother with continuous fluids instead of the cycle of hydration to vomiting to dehydration. This cycle can often make HG worse and create a delay in the recovery process. Home IV fluids can prevent the feeling many women experience of making a journey to the emergency room for IV fluids only to start vomiting and have to return a few days later for a top up of fluids. Providing there is no infection a regular IV can be left in for up to a week at a time. Many doctors are unaware of the idea of stopping the dehydration cycle to avoid exacerbation of HG. A mother who exhibits signs of dehydration or production of ketones should receive IV fluids, preferably with IV vitamins. Few drugs are considered completely safe during pregnancy, however the risks involved in taking these medications must be balanced against the potential complications known to arise because of prolonged starvation and dehydration. Both present risks for the mother and child but focusing on treating the individual symptoms and lessening the incredible misery of HG has to be a top priority. It should be remembered that individuals respond to medication in various ways. There is no single remedy or "cure" for the nausea and vomiting which is guaranteed to work for all women. Treatment should be focused on the main triggers of vomiting/nausea such as motion sensitivity. Medications that directly target the vomiting center in the brain (serotonin antagonists) are likely to be most effective when there are a number of triggers. If a woman is constantly vomiting, medications taken orally are unlikely to work for obvious reasons. It is important to try IV administration of a particular medication as well as the oral version as it will sometimes work in one or other of these ways. You should consult your physician before taking treatments if you are a smoker, have any history of medication reactions, or have pre-existing medical conditions such as diabetes or heart disease.

Treatment for Hyperemesis gravidarum is not cheap. It is estimated that two hundred million dollars is spent every year to treat Hyperemesis gravidarum. Because there is little information regarding this disease, it often is not treated properly and is diagnosed as hormonal changes. This leaves the woman who suffers from weak, tired and helpless. The loss of financial income is also a great risk because women often lose their employment due to excessive absences. It is critically important that Hyperemesis gravidarum be treated in its early stages to prevent all of the unnecessary hardships that it can cause.

Hyperemesis Gravidarum Nausea is the most common gastrointestinal symptom of pregnancy and it occurs in 8085% of all pregnancies during the first trimester. 52% of women have associated vomiting. The symptoms are normal features of pregnancy, are self-limiting, and usually subside by 16-20 week gestation. 'Morning sickness' is the term usually given to nausea and vomiting in pregnancy but only 11-18% of woman have symptoms confined to the mornings.1,2 Hyperemesis gravidarum occurs when vomiting becomes intractable in early pregnancy and causes fluid and electrolyte imbalances and nutritional deficiency. The woman usually needs to be admitted to hospital. The clinical features that define it are:3 • • • • •

Persistent nausea and vomiting Dehydration Ketonuria Electrolyte imbalance Weight loss > 5% of pre-pregnancy weight

Pathophysiology The exact cause is not known but raised levels of human chorionic gonadotrophin (HCG), thyroxine and oestrogen have been implicated. Hyperemesis gravidarum is more common in pregnancies associated with higher levels of HCG (molar pregnancies, multiple pregnancies).4,5 Psychological factors have also been implicated.5,6 Epidemiology Hyperemesis gravidarum occurs in 3.5/1000 deliveries.

Risk factors Hyperemesis gravidarum is more common in: • • • • • • • • •

Trophoblastic disease Multiple pregnancies Those who have had hyperemesis gravidarum in a previous pregnancy7 Those with a family history of hyperemesis gravidarum Nulliparity Female fetus8,9 Maternal obesity Age < 30 years10 Non-smokers10

Clinical features

Symptoms • • • • • • •

Nausea Vomiting Ptyalism (excessive salivation) Spitting Fatigue Anorexia Weight loss

Signs • • • • • • •

Dehydration Muscle wasting Ketosis Weight loss > 5% of pre-pregnancy weight Postural hypotension Tachycardia Collapse

Differential diagnosis3 There are other causes of nausea and vomiting in pregnancy. Ask about associated abdominal pain, diarrhoea and assess for fever. Causes include: • • •

Pregnancy-related: e.g. pre-eclampsia, acute fatty liver of pregnancy Gastrointestinal: e.g. gastroenteritis, appendicitis, cholecystitis, peptic ulcer disease, intestinal obstruction, pancreatitis, hepatitis Genito-urinary: e.g. urinary tract infection, renal calculi, degenerating uterine fibroid, ovarian cyst torsion

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Ear, nose and throat: e.g. labyrinthitis Endocrine: e.g. hypercalcaemia, diabetic ketoacidosis, thyrotoxicosis Neurological: e.g. migraine, tumours Psychological: e.g. eating disorders Drug toxicity or intolerance: e.g. iron

Investigations • • • •

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Urinalysis: Look for ketonuria and increased urine specific gravity. Send MSU to exclude UTI. Full blood count: Haematocrit is usually raised. Urea, electrolytes and creatinine: May show hyponatraemia, hypokalaemia, low serum urea, raised serum creatinine. Liver function tests: May show raised serum aminotransferases and total bilirubin and mildly raised amylase. Abnormalities should resolve once symptoms improve. Thyroid function tests: May show high free T4 ± low TSH. High free T3 is less common. The woman is clinically euthyroid. Abnormalities should resolve once symptoms improve. Ultrasound scan: To exclude multiple pregnancy and hydatidiform mole.

Management Other causes of nausea and vomiting should be excluded. Ketonuria should be managed with drug treatment. If raised ketones levels persist despite drug treatment, and/or the woman is unwell, she should be admitted to hospital.

Management of nausea and vomiting symptoms NICE guidelines were published in 2003 on routine antenatal care and included advice on the management of common symptoms of pregnancy including nausea and vomiting.11These recommendations are currently being updated and the update is due to be issued in March 2008. General supportive measures • • • •

Drink and eat little and often. Meals high in carbohydrate and lower in fat are better. Cold meals reduce smell-related nausea. Avoid caffeine and alcohol as these can enhance dehydration.

NICE recommended non-drug treatment 1. Ginger: Two randomised controlled trials (RCT) have shown beneficial effects of ginger in reducing the severity of nausea and vomiting. The first used ginger 250mg four times daily and the second used 1 tablespoon of ginger syrup in 4-8

fluid ounces of water four times daily.12,13 A systematic review also reported on woman hospitalised for hyperemesis and ginger was shown to significantly reduce the degree of nausea and number of attacks of vomiting. There was no evidence of adverse effects on pregnancy outcome.14,15 2. P6 acupressure: A number of systematic reviews have shown that P6 Neiguan point acupressure (located on the volar aspect of the forearm 3 fingerbreadths proximal to the wrist) improved nausea and vomiting symptoms.14,15,16 Other RCTs have shown symptom improvement with the use of acupressure wristbands. Again, no adverse effects on pregnancy were shown. NICE recommended drug treatment 1. Antihistamines (promethazine, prochlorperazine, metoclopramide): A metaanalysis showed a significant reduction in nausea in the treated group, although an increase in drowsiness was reported.14 Another review showed no significant increased risk of teratogenicity. A lack of safety data means that metoclopramide should not be used as first-line treatment.17 2. Phenothiazines: Again a systematic review found that phenothiazines reduced nausea and vomiting symptoms with no evidence of teratogenicity.18 Other drugs not recommended by NICE • •

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Pyridoxine (vitamin B6): NICE states that this is not currently recommended for use due to concerns about possible toxicity at high doses. Cyanocobalamin (vitamin B12): This was also shown to produce significant reduction in nausea and vomiting in two RCTs.18 However, when the research for the NICE guidelines was performed, no specific data about its safety were found. Corticosteroids: Short courses of intravenous pulsed hydrocortisone have been shown in one study to be an effective treatment for intractable hyperemesis gravidarum.19 However, another study showed that they did not reduce the need for rehospitalization for hyperemesis gravidarum later in the pregnancy.20 They do not form part of the NICE 2003 recommendations for the management of nausea and vomiting in pregnancy.

Treatment in hospital If raised ketones levels persist despite drug treatment, and/or the woman is unwell, she should be admitted to hospital. •

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Parenteral fluid and electrolyte replacement: Normal saline or Hartmann's solution should be used as dextrose containing fluids that are rich in carbohydrate may precipitate Wernicke's encephalopathy. Potassium chloride may be added to the bags as needed. Urea, electrolytes and creatinine should be measured daily. Vitamin supplementation: Thiamine should be given routinely, orally or intravenously, to prevent Wernicke's encephalopathy.

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Management of nausea and vomiting symptoms: This should include the general supportive measures and NICE recommended drug treatment as detailed above. The intravenous or rectal route of drug administration may be needed initially. Parenteral nutrition: This should be commenced if the woman continues to lose weight.

Complications •

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Wernicke's encephalopathy: This is due to thiamine deficiency. Clinical features include diplopia, nystagmus, ophthalmoplegia, ataxia and confusion. It can lead to irreversible Korsakoff's syndrome which can cause permanent neurological disability usually presenting as an inability to form new memories. Abnormal liver function tests are common and may play a role in its pathogenesis by decreasing the conversion of thiamine to its active metabolite. Other vitamin deficiencies: Vitamin B12 and vitamin B6 deficiency can cause anaemia, peripheral neuropathy and subacute combined degeneration of the spinal cord. Mallory-Weiss tears and oesophageal rupture. Hyperthyroxinaemia. Hyponatraemia: This can lead to lethargy, confusion, convulsions and respiratory arrest. Central pontine myelinolysis occurs if severe hyponatraemia is corrected too rapidly. This can cause progressive quadriparesis and bulbar palsy and can be fatal. Depression: This can occur in up to 60% of women. In the worst cases it may lead to women wanting to terminate their pregnancy.21,4,5

Prognosis Babies born to women who have had hyperemesis gravidarum have a higher incidence of low birth weight.22 One study showed that adverse infant outcomes associated with hyperemesis were more likely to occur in women with poor weight gain during pregnancy. It showed that infants born to a mother with hyperemesis and pregnancy weight gain of < 7 kgs were more likely to have a low birth weight, be small for gestational age, be born before 37 weeks gestation and have a 5-minute Apgar score of < 7. Those with a pregnancy weight gain of > 7 kgs had no significant difference in pregnancy outcome than those without hyperemesis.23 Prevention All women with nausea and vomiting in pregnancy should be reassured of its (usually) benign and normal nature. Self-help measures, dietary modifications and non-drug treatment should be initiated early. Any woman with ketonuria should be commenced on

drug treatment with anti-emetics. Hopefully these measures will help to reduce the number of admissions to hospital of women with hyperemesis gravidarum.

Hyperemesis Gravidarum •

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Overview o Alternative Names o Causes o Symptoms o Exams and Tests o Treatment o Outlook (Prognosis) o Possible Complications o When to Contact a Medical Professional o References News & Features

Related Topics • • • •

Dehydration Morning Sickness HCG in Urine Hydatidiform Mole

Hyperemesis gravidarum is extreme, persistent nausea and vomiting during pregnancy that may lead to dehydration. News & Features • • • •

The Claim: Morning Sickness Means a Girl Is More Likely Nausea? There’s No Need to Suffer in Silence PERSONAL HEALTH; Reasons, and Remedies, for Morning Sickness PERSONAL HEALTH; What Could Be Good About Morning Sickness? Plenty

Reference from A.D.A.M.

Back to TopAlternative Names Nausea - persistent - in pregnancy; Vomiting - persistent - in pregnancy

Back to TopCauses Nearly all women have some nausea or vomiting, or "morning sickness " -- particularly during the first 3 months of pregnancy. The cause of nausea and vomiting during pregnancy is believed to be rapidly rising blood levels of a hormone called HCG (human chorionic gonadotropin), which is released by the placenta. Extreme nausea and vomiting during pregnancy can happen if you are pregnant with twins (or more) or if you have a hydatidiform mole.

Back to TopSymptoms • •

Severe, persistent nausea during pregnancy, often leads to weight loss Lightheadedness or fainting

Back to TopExams and Tests The doctor will perform a physical exam. Blood pressure may be low. Pulse may be high. The following laboratory tests will be done to check for signs of dehydration: • •

Hematocrit Urine ketones

Your doctor may need to run tests to rule out liver and gastrointestinal problems. A pregnancy ultrasound will be done to see if you are carrying twins or more, and to check for a hydatidiform mole.

Back to TopTreatment Small, frequent meals and eating dry foods such as crackers may help relieve uncomplicated nausea. You should drink plenty of fluids. Increase fluids during the times of the day when you feel the least nauseated. Seltzer or other sparkling waters may be helpful. Vitamin B6 (no more than 100mg daily) has been shown to decrease the nausea in early pregnancy. Medication to prevent nausea is reserved for cases where vomiting is persistent and severe enough to present potential risks to you and your unborn baby. In severe cases, you may be admitted to the hospital, where fluids will be given to you through an IV.

Back to TopOutlook (Prognosis) Nausea and vomiting usually peaks between 2 and 12 weeks of pregnancy and goes away by the second half of pregnancy. With proper identification of symptoms and careful follow up, this condition rarely presents serious complications for the infant or mother.

Back to TopPossible Complications Too much vomiting is harmful because it leads to dehydration and poor weight gain during pregnancy. Social or psychological problems may be associated with this disorder of pregnancy. If such problems exist, they need to be identified and addressed appropriately.

Back to TopWhen to Contact a Medical Professional Call your health care provider if you are pregnant and have severe nausea and vomiting.