Hyperemesis gravidarum

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Hyperemesis gravidarum, with metabolic derangement

Classification and external resources ICD-10 ICD-9 O21.1 643.1

Hyperemesis gravidarum (HG) is a severe form of morning sickness, with "unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids."[1] Hyperemesis is considered a rare complication of pregnancy but, because nausea and vomiting during pregnancy exist on a continuum, there is often not a good diagnosis between common morning sickness and hyperemesis. Estimates of the percentage of pregnant women afflicted range from 0.3% to 2.0%.[2]

Contents
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1 Etymology 2 Causes 3 Symptoms 4 Complications o 4.1 For the pregnant woman o 4.2 For the fetus 5 Diagnosis 6 Treatment o 6.1 IV hydration o 6.2 Medications o 6.3 Nutritional support o 6.4 Support 7 References

[edit] Etymology
Hyperemesis gravidarum is from the Greek hyper-, meaning excessive, and emesis, meaning vomiting, as well as the Latin gravida, meaning pregnant. Therefore, hyperemesis gravidarum means "excessive vomiting in pregnancy."

[edit] Causes

The cause of HG is unknown. The leading theories state that it is an adverse reaction to the hormonal changes of pregnancy. In particular, HG may be due to raised levels of beta HCG (human chorionic gonadotrophin)[3] as it is more common in multiple pregnancies and in gestational trophoblastic disease. This theory would also explain why hyperemesis gravidarum is most frequently encountered in first trimester (often around 8 12 weeks of gestation), as HCG levels are highest at that time and decline afterward. It is thought that estrogen produces nausea and regurgitation of stomach acids in some women. [4] There is also evidence that leptin may play a role in HG.[5] A recent study gives "preliminary evidence" that there may be a genetic component.[6] Symptoms of morning sickness, and HG, can be aggravated by the following factors: hunger, fatigue, prenatal vitamins (especially those containing iron), odors, and diet.[7]

[edit] Symptoms
When HG is severe and/or inadequately treated, it may result in:

Loss of 5% or more of pre-pregnancy body weight Dehydration, causing ketosis, and constipation Nutritional deficiencies Metabolic imbalances 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 Subconjunctival hemorrhage (broken blood vessels in the eyes) Difficulty with daily activities Hallucinations

Some women with HG lose as much as 30% 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 hyperolfaction. Ptyalism, or hypersalivation, is another symptom experienced by some 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 they give birth to their baby, and sometimes even after giving birth. An overview of the significant differences between morning sickness and HG can be found at Hyperemesis or Morning Sickness: Overview.

[edit] Complications
[edit] 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. On rare occasions a woman can die from hyperemesis; Charlotte Bront is a presumed victim of the disease.[8]

[edit] For the fetus

Infants of women with severe hyperemesis that 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 that have a pregnancy weight gain of more than 7 kg appear similar as infants from uncomplicated pregnancies.[9] No long-term follow-up studies have been conducted on children of hyperemetic women.

[edit] Diagnosis
Women experiencing hyperemesis gravidarum often are dehydrated and lose 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.[10] Fever, abdominal pain, or late onset of nausea and vomiting usually indicate another condition, such as appendicitis, gallbladder disorders, gastritis, hepatitis, or infection.[10]

[edit] Treatment
Because of the potential for severe dehydration and other complications, HG is in general treated as a medical emergency. Treatment of HG may include antiemetic medications 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. In some instances, women with HG may be able to avoid hospitalization by eating a special diet of clear liquids and bland food rich in carbohydrates,[11] and eating before rising in the morning; while these may be of some assistance, they are unlikely to resolve the disorder on their own. Hypnosis has relieved symptoms in some cases, though the majority of women do not respond to this measure.[12] Wristbands used for motion sickness and seasickness have been shown by one study to be effective in treating some cases of HG, but not others; these are worn around the wrist at a traditional acupuncture point, 3 finger-widths from the joint, and are available at many pharmacies.[13] There is evidence that ginger may be effective in treating pregnancy-related nausea; however, in general this is ineffective in cases of HG.

[edit] IV hydration
IV hydration often includes supplementation of electrolytes as 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.[14] 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). Home treatment is often less expensive than long-term and/or repeated hospital stays.

[edit] Medications
While no medication is considered completely risk-free for use during pregnancy, there are several that are commonly used to treat HG and are believed to be safe. The standard treatment in most of the world is Bendectin (also sold under the trademark name Diclectin), a combination of doxylamine succinate and vitamin B6. However, due to a series of birth-defect lawsuits in the United States against its maker, Merrill Dow, Bendectin 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 Bendectin does not cause birth defects.) Its component ingredients are available over-thecounter (doxylamine succinate is the active ingredient in many sleep medications), and some doctors will recommend this treatment to their patients. Antiemetic drugs, 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. Zofran is also available in ODT (oral disintegrating tablet), which can be easier for women who have trouble swallowing due to the nausea. Promethazine (Phenergan) has been shown to be safe, at least in rats and may be used during pregnancy with minimal/no side-effects. Metoclopramide is 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, corticosteroids, and antihistamines. Other medications that are frequently prescribed for HG are Compazine, Tigan, Phenergan, and Reglan. These can be given orally or intravenously, or administered as a rectal suppository. They are considered safe for use during pregnancy.[15] Anecdotal evidence suggests that the use of marijuana, or of the pharamaceutical extract Marinol, can relieve the symptoms of HG, in a similar way to treating nausea in people with Cancer and AIDS. However, due to the criminalisation of cannabis, there have been no clinical trials into its effectivess or risks to the fetus.[16] However, use of marijuana has been shown to increase the risk for central nervous system growth impairment, low birth weight and size of infants, and preterm deliveries, all of which are associated with poor infant outcomes. [17] [18]

[edit] 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).

[edit] Support
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.

[edit] References
1. ^ Hyperemesis Education & Research Foundation Understanding Hyperemesis: Overview 2. ^ Eliakim, R., Abulafia, O., & Sherer, D. M. (2000). "Hyperemesis gravidarum: A current review". American Journal of Perinatology 17 (4): 207218. doi:10.1055/s2000-9424. PMID 11041443. 3. ^ Hershman JM (June 2004). "Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid". Best Pract. Res. Clin. Endocrinol. Metab. 18 (2): 24965. doi:10.1016/j.beem.2004.03.010. PMID 15157839. http://linkinghub.elsevier.com/retrieve/pii/S1521690X0400020X. 4. ^ Carlson, Karen J., MD; Eisenstat, Stephanie J., MD; Ziporyn, Terra, PhD (2004). The New Harvard Guide to Women's Health. Harvard University Press. pp. 3923. ISBN 0674013433.

Hyperemesis gravidarum
Nausea - persistent - in pregnancy; Vomiting - persistent - in pregnancy Last reviewed: June 5, 2010. Hyperemesis gravidarum is extreme, persistent nausea and vomiting during pregnancy that may lead to dehydration.

Causes, incidence, and risk factors

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.

Symptoms

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

Signs 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.

Treatment
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, ginger ale, or other sparkling waters may be helpful. Vitamin B6 (no more than 100 mg 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.

Expectations (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.

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.

Calling your health care provider

Call your health care provider if you are pregnant and have severe nausea and vomiting.

References
1. Hepatic and gastrointestinal diseases. In: Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: Normal and Problem Pregnancies. 5th ed. New York, NY: Churchill Livingstone; 2007:Chap.43. 2. Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2003;(4):CD000145.

Hyperemesis Gravidarum
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Hyperemesis gravidarum is a condition characterized by severe nausea, vomiting, weight loss, and electrolyte disturbance. Mild cases are treated with dietary changes, rest and antacids. More severe cases often require a stay in the hospital so that the mother can receive fluid and nutrition through an intravenous line (IV). DO NOT take any medications to solve this problem without first consulting your health care provider.

Why is this happening to me?

The majority of pregnant women experience some type of morning sickness (70 - 80%). Recent studies show that at least 60,000 cases of extreme morning sickness called hyperemesis gravidarum (HG) are reported by those who treated in a hospital but the

numbers are expected to be much higher than this since many women are treated at home or by out patient care with their health care provider. It is believed that this severe nausea is caused by a rise in hormone levels; however, the absolute cause is still unknown. They symptoms of HG usually appear between 4-6 weeks of pregnancy and may peak between 913 weeks. Most women receive some relief between weeks 14-20, although up to 20% of women may require care for hyperemesis throughout the rest of their pregnancy. There is no known prevention of Hyperemesis gravidarum but you can take comfort in knowing that there are ways to manage it.

Distinguishing between morning sickness and hyperemesis gravidarum:

Morning Sickness: Nausea sometimes accompanied by vomiting Nausea that subsides at 12 weeks or soon after Vomiting that does not cause severe dehydration Vomiting that allows you to keep some food down Hyperemesis Gravidarum: Nausea accompanied by severe vomiting Nausea that does not subside Vomiting that causes severe dehydration Vomiting that does not allow you to keep any food down

Signs and symptoms of hyperemesis gravidarum:

Severe nausea and vomiting Food aversions Weight loss of 5% or more of pre-pregnancy weight Decrease in urination Dehydration Headaches Confusion Fainting Jaundice Extreme fatigue Low blood pressure Rapid heart rate Loss of skin elasticity Secondary anxiety/depression

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What are the treatments for hyperemesis gravidarum?

In some cases hyperemesis gravidarum is so severe that hospitalization may be required. Hospital treatment may include some or all of the following:

Intravenous fluids (IV) to restore hydration, electrolytes, vitamins, and nutrients Tube feeding: o Nasogastric restores nutrients through a tube passing through the nose and to the stomach o Percutaneous endoscopic gastrostomy restores nutrients through a tube passing through the abdomen and to the stomach; requires a surgical procedure Medications metoclopramide, antihistamines, and antireflux medications*

Other treatments may include:

Bed Rest This may provide comfort, but be cautious and aware of the effects of muscle and weight loss due to too much bed rest. Acupressure The pressure point to reduce nausea is located at the middle of the inner wrist, three finger lengths away from the crease of the wrist, and between the two tendons. Locate and press firmly, one wrist at a time for three minutes. Sea bands also help with acupressure and can be found at your local drug store. Herbs ginger or peppermint Homeopathic remedies are a non-toxic system of medicines. Do not try to self medicate with homeopathic methods; have a doctor prescribe the proper remedy and dose. Hypnosis

* When it comes to medications, it is very important that you weigh the risks and the benefits. Some drugs may have adverse effects on you or the development of your baby. Discuss the risks and side effects of each drug with your health care provider.