- Hyperemesis gravidarum
Name = Hyperemesis gravidarum
DiseasesDB = 6227
ICD10 = ICD10|O|21|0|o|20, ICD10|O|21|1|o|20
ICD9 = ICD9|643.0, ICD9|643.1
eMedicineSubj = med
eMedicineTopic = 1075
eMedicine_mult = eMedicine2|emerg|479 | MeshID = D006939
Hyperemesis gravidarum (from Greek "hyper" and "emesis" and Latin "gravida"; meaning "excessive vomiting of pregnant women") is a severe form of
morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids." [Hyperemesis Education & Research Foundation [http://www.helpher.org/hyperemesis-gravidarum/ Understanding Hyperemesis: Overview] ] Hyperemesis is considered a rare complication of pregnancybut, because nauseaand vomitingduring pregnancy exist on a continuum, there is often not a good diagnosis between common morning sicknessand hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2%.
The cause of HG is unknown. The leading theories speculate that it is an adverse reaction to the hormonal changes of pregnancy. In particular Hyperemesis may be due to raised levels of beta HCG (Human Chorionic Gonadotrophin) as it is more common in multiple pregnancies and in
gestational trophoblastic disease.
Additional theories point to high levels of estrogen and progesterone,fact|date=December 2007 which may also be to blame for hypersalivation; decreased gastric motility (slowed emptying of the stomach and intestines); immune response to fragments of chorionic villi that enter the maternal bloodstream; or immune response to the "foreign" fetus.Fact|date=February 2007
Historically, HG was blamed upon a psychological condition of the pregnant women. Medical professionals believed it was a reaction to an unwanted pregnancy or some other emotional or psychological problem.fact|date=December 2007 This theory has been disproved, but unfortunately some medical professionals espouse this view and fail to give patients the care they need.fact|date=December 2007
When HG is severe and/or inadequately treated, it may result in:
*loss of 5% or more of pre-pregnancy body weight
*difficulty with daily activities
*altered sense of taste
*sensitivity of the brain to motion
*food leaving the stomach more slowly
*rapidly changing hormone levels during pregnancy
*stomach contents moving back up from the stomach
*physical and emotional stress of pregnancy on the body
Some women with HG lose as much as 20% of their body weight. Many sufferers of HG are extremely sensitive to odors in their environment; certain smells may exacerbate symptoms. This is known as hyper
olfaction. Ptyalism, or hypersalivation, is another symptom experienced by some, but not all, women suffering from HG.
As compared to morning sickness, HG tends to begin somewhat earlier in the pregnancy and last significantly longer. 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 delivery. A chart comparing morning sickness to HG can be found [http://www.helpher.org/mothers/hyperemesis-or-morning-sickness/index.php here] .
For the pregnant woman
If inadequately treated, HG can cause
renal failure, central pontine myelinolysis, coagulopathy, atrophy, Mallory-Weiss syndrome, hypoglycemia, jaundice, malnutrition, Wernicke's encephalopathy, pneumomediastinum, rhabdomyolysis, deconditioning, splenic avulsion and vasospasms of cerebral arteries. Depression is a common secondary complication of HG. Charlotte Brontëis believed to have died from HG.
The serious, and sometimes fatal complications of HG are almost always avoided with aggressive treatment.
For the fetus
No long-term follow-up studies have been conducted on children of hyperemetic women. Children born to hyperemetic women appear to have no greater risk of complications or birth defects than the general population. However, recent research in fetal programming indicates that prolonged stress, dehydration and malnutrition during pregnancy can put the fetus at risk for chronic disease, such as diabetes or heart disease, later in life, or neurobehaviorial issues from birth. This underscores the importance of aggressive treatment of the condition.
Women who are experiencing hyperemesis gravidarum often are dehydrated and losing weight despite efforts to eat. The nausea and vomiting begins in the first or second month of pregnancy. It is extreme and is not helped by normal measures.cite web |url=http://www.emedicine.com/EMERG/topic479_2.htm |title=eMedicine - Pregnancy, Hyperemesis Gravidarum - Diagnosis and Differentials : Article by Susan Renee Wilcox, MD |accessdate=2008-02-02 |format= |work=]
Fever, abdominal pain, or a late onset of nausea and vomiting usually indicate another condition, such as
appendicitis, gall bladder problems, gastritis, hepatitis, or infection.
Because a self-report of this condition can be used to conceal an
eating disorder, the presence of conditions such as bulimia nervosaand purging disordermust be appropriately evaluated.cite journal |author=Franko DL, Spurrell EB |title=Detection and management of eating disorders during pregnancy |journal= Obstet Gynecol|volume=95 |issue=6 Pt 1 |pages=942–6 |year=2000 |pmid=10831998 |doi= |url=http://www.greenjournal.org/cgi/pmidlookup?view=long&pmid=10831998] One way to do this is to ask the pregnant woman to eat in a closely observed environment.
Because of the potential for severe dehydration and other complications, HG is generally treated as a medical emergency. Treatment of HG may include
antiemeticmedications and intravenous rehydration. If medication and IV hydration are insufficient nutritional support may be required.
Management of HG can be complicated because not all women respond to treatment. Coping strategies for uncomplicated morning sickness, which may include eating a bland diet and eating before rising in the morning, may be of some assistance but are unlikely to resolve the disorder on their own. There is evidence that
gingermay be effective in treating pregnancy-related nausea, however this is generally ineffective in cases of HG.
IV hydration often includes supplementation of
electrolytesas persistent vomiting frequently leads to a deficiency. Likewise supplementation for lost thiamine(Vitamin B1) must be considered to reduce the risk of Wernicke's encephalopathy. cite book | author=British National Formulary | authorlink=British National Formulary | title="BNF" | edition=45 | year=2003 | month=March | chapter=4.6 Drugs used in nausea and vertigo - Vomiting of pregnancy] A and B vitamins are depleted within two weeks, so extended malnutrition indicates a need for evaluation and supplementation. Additionally, mineral levels should be monitored and supplemented; of particular concern are sodiumand potassium.
After IV rehydration is completed, patients generally progress to frequent small liquid or bland meals. After rehydration, treatment focuses on managing symptoms to allow normal intake of food.
When continuing care is necessary,fact|date=May 2008 home care is available in the form of a
PICC line. Home treatment is often less expensive than long-term hospital admission.
While no medication is considered completely risk-free for use during pregnancy, there are several which are commonly used to treat HG and are believed to be safe.
The standard treatment in most of the world is Benedictin (also sold under the trademark name Diclectin), a combination of
doxylaminesuccinate and vitamin B6. However, due to a series of birth-defect lawsuits in the United States against its maker, Merrill Dow, Benedictin is not currently on the market in the U.S. (None of the lawsuits were successful, and numerous independent studies and the Food and Drug Administration(FDA) have concluded that Benedictin does not cause birth defects.) Its component ingredients are available over-the-counter (doxylamine succinate is the active ingredient in many sleep medications), and some doctors will recommend this treatment to their patients. Antiemeticdrugs, especially ondansetron(Zofran), are effective in many women. The major drawback of ondansetron has been its cost. In severe cases of HG, the Zofran pump may be more effective than tablets. Metoclopramideis sometimes used in conjunction with antiemetic drugs; however, it has a somewhat higher incidence of side effects. Other medications less commonly used to treat HG include Marinol, corticosteroidsand antihistamines.
Practice in United Kingdom
The practice in the United Kingdom, following the thalidomide tragedy, is to generally use older drugs for which there has been a greater experience of use in pregnancy. Hence the first choice drug is
promethazinewith second choice being either metoclopramideor prochlorperazine; with the administration of thiamine strongly recommended.
Women who do not respond 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 tubeor a nasojejunum tube).
Complementary and alternative medicine
Some women with HG find relief with complementary or
alternative medicine, including chiropractic, homeopathy, acupunctureand energy psychology. None of these treatments has been proven effective in randomized controlled trialsand pregnant women suffering from HG should always contact a certified physician to prevent damage to themselves and their babies.
There is anecdotal evidence for the benefits of
medical marijuana, which is more widely used to treat nausea and increase appetite during chemotherapy, but has been used for the same purpose in treating HG. [http://www.hyperemesis.org/hyperemesis-gravidarum/treatments/medications.php] [http://findarticles.com/p/articles/mi_m0838/is_124/ai_n6015580/pg_14] [http://www.haworthpress.com/store/ArticleAbstract.asp?sid=KWTA7852SBWC8G5TH4FH70TCWGJGAE4E&ID=18139] [http://www.rxmarijuana.com/shared_comments/Hyperemesis_Gravidarum.htm] [http://www.rxmarihuana.com/shared_comments/Hyperemesis_Gravidarum2.htm] The effects of cannabis on the fetus are not well understood.
It is important that women get early and aggressive care during pregnancy. This can help limit the complications of HG. Also, because depression can be a secondary condition of HG, emotional support, and sometimes even counseling, can be of benefit. It is important, however, that women not be stigmatized by the suggestion that the disease is being caused by psychological issues.
According to the Hyperemesis Education and Research Foundation (HER), hospitalization in the United States for HG may cost more than $3,300 per incident, with 1–3% of all pregnant women being hospitalized at least once for this condition. cite web
title=Help HER - » Understanding Hyperemesis | Impact of HG | Overview
publisher= HER Foundation
accessdate=2008-07-12] HG may also interfere with daily activities, employment and important relationships, with some women
divorcingor limiting their family size through pregnancy preventionand even abortion.
* [http://www.helpher.org/ Hyperemesis Education & Research Foundation] - includes a cite web |title=Survival Guide |url=http://www.helpher.org/downloads/survival-guide.pdf |format=PDF
* [http://pregnancy.about.com/cs/morningsickness/a/aa111499.htm/ Pregnancy] at
* [http://www.umm.edu/ency/article/001499.htm Hyperemesis site] at University of Maryland Medical Center
Wikimedia Foundation. 2010.