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Hyperemesis Gravidarum by Jacquelyn Rudis

Definition

Hyperemesis gravidarum (HG) is an uncommon condition characterized by frequent, persistent, and severe vomiting and nausea during pregnancy. As a result, you may be unable to take in a sufficient amount of food and fluids. It can cause a weight loss of more than 5% of your pre-pregnancy body weight. This can also cause dehydration and vitamin and mineral deficiencies. Treatment may require hospitalization.

HG is a more severe form of nausea and vomiting of pregnancy (NVP), also called morning sickness. Morning sickness affects anywhere between 50% to 90% of pregnant women. HG is estimated to occur in 0.5%-2% of pregnancies.

Causes

There are many theories about the causes of HG, but none have been confirmed. HG is a complex disease that is likely caused by many factors. Some of these include:

Vitamin B deficiency
Human chorionic gonadotropin (hyperemesis most severe during period of highest HCG levels)
Hyperthyroidism (may be a result of high chorionic gonadotropin levels)
Endocrine imbalances (high levels of estrogen)
A multiple pregnancy (twins or more)
Brain nausea-control-center sensitivity to pregnancy changes

The Brain May Be Cause of Nausea

Risk Factors

Some researchers have found that the following factors increase your chance of developing HG. If you have any of these risk factors, tell your doctor:

History of HG in previous pregnancies
Molar pregnancy (an abnormal mass made up of placental tissue; may or may not contain some fetal tissue)
Mother or sister with HG
A multiple pregnancy
Young maternal age
No previous completed pregnancies
First-time pregnancy
Obesity

Symptoms

The following list of symptoms are general and may be caused by other, less serious health conditions. However, if you experience any one of them, call your physician to discuss your condition. Symptoms may include:

Severe and persistent vomiting, beginning 4 to 6 weeks after conception, peaking 9-13 weeks, and usually improving and ending 14-20 weeks
Progressive weight loss of greater than 5% of original, pre-pregnancy body weight
Dehydration, which may show the following signs:
- Ketones in urine
- Increased hematocrit (% of red blood cells in blood)
- Increased pulse rate
- Decreased blood pressure
Rapid heartbeat (tachycardia)
Excessive salivation (ptyalism)
Distinctive breath odor (ketonic odor)

Diagnosis

Your doctor will ask about your symptoms and medical history. A physical exam will be done. Tests may include the following:

Weight measurement—to determine if you have lost weight
Blood electrolytes—to identify disturbances in salts and other minerals in the blood due to extreme vomiting
Ketones—to determine if you are dehydrated
Overall condition—ability to perform daily activities; psychological state of mind

Treatment

Treating HG symptoms early in pregnancy can make you less sick in the long run and can decrease recovery time. Because HG is caused by many factors that vary among women, it is difficult to find a treatment that works for everyone. Talk with your doctor about the best treatment plan for you. Treatment options include the following:

Diet

Try to eat frequent, small meals, bland or dry foods, high-protein choices.

Anti-nausea Medications

Reducing nausea, and thus allowing eating and drinking, will hasten recovery. Due to the risk of stating that a drug is safe for use during pregnancy, very few pharmaceutical manufacturers will say that their drugs are intended for a pregnancy condition like HG (examples: promethazine or prochlorperazine). However, doctors often recommend that women with HG take certain anti-nausea medicines, balancing the potential benefits and risks. Talk to your doctor about the right medicines for you.

A common and safe remedy is to take supplemental vitamin B6 (pyridoxine), to a maximum of 100 mg/day. The American Congress of Obstetricians and Gynecologists recommends that first-line treatment of nausea and vomiting of pregnancy should start with pyridoxine with or without doxylamine. Pyridoxine has been found to be effective in significantly reducing severe vomiting.

IV Hydration and Anti-nausea Medications

In urgent visit situations, HG can be managed by IV fluids and vitamins. This can sometimes be done without hospitalization. Very rarely, some people require IV fluids throughout the entire pregnancy.

Nutrition by Vein

If you are unable to tolerate food by mouth, you may need to receive nutrition by vein. This is called parenteral nutrition. A special kind of catheter is placed in a large vein and liquid nutrition is given. This can sometimes be done without hospitalization.

Alternative Therapy

Acupressure may help to reduce nausea. Acupressure is when pressure is applied to acupuncture points.

Termination of Pregnancy

In extreme cases, induced abortion may be considered.

If you are diagnosed with HG, follow your doctor's instructions.

Prevention

Many of the conditions that lead to HG are not preventable. It is unknown why some women without those conditions develop HG. You can try to reduce your nausea during pregnancy by:

Avoiding smells, foods, or other things that stimulate nausea
Eating frequent small meals
Not allowing yourself to get too hungry or too full

RESOURCES:

The American Congress of Obstetricians and Gynecologists http://www.acog.org
Hyperemesis Education and Research Foundation http://www.helpher.org
National Organization for Rare Diseases http://www.rarediseases.org

CANADIAN RESOURCES:

The Canadian Women's Health Network http://www.cwhn.ca/en
The Society of Obstetricians and Gynaecologists of Canada (SOGC) http://www.sogc.org/index_e.asp

References:

ACOG issues guidance on the treatment of morning sickness during pregnancy. American College of Obstetrics and Gynecology website. Available at: http://www.acog.org/About_ACOG/News_Room/News_Releases/2004/ACOG_Issues_Guidance_on_Treatment_of_Morning_Sickness_During_Pregnancy. Accessed August 20, 2011.
Acupuncture. EBSCO Natural and Alternative Treatments website. Available at: http://www.ebscohost.com/healthLibrary. Updated January 2009. Accessed January 19, 2009.
Beers MH, Berkow R, eds. The Merck Manual of Diagnosis and Therapy. 17th ed. Whitehouse Station, NJ: Merck Research Laboratories; 1999.
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National Organization for Rare Diseases website. Available at: http://www.rarediseases.org
Nausea and vomiting in pregnancy. EBSCO DynaMed website. Available at: https://dynamed.ebscohost.com. Updated October 2010. Accessed October 25, 2010.
Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. 2003;68:121-128. American Family Physician website. Available at: http://www.aafp.org/afp/20030701/121.html. Accessed August 12, 2005.
Sadock BJ, Sadock VA, eds. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 9th ed. Philadelphia, PA: Lippincott, Williams and Wilkins; 2003.
Wise MG, Rundell JR, eds. The American Psychiatric Publishing Textbook of Consultation-Liaison Psychiatry: Psychiatry in the Medically Ill. 2nd ed. Washington, DC: American Psychiatric Publishing, Inc.; 2002.

Last reviewed September 2012 by Andrea Chisholm

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