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HomeObstetrics & GynecologyHyperemesis Gravidarum

Hyperemesis Gravidarum

Practice Essentials

Hyperemesis gravidarum is the most severe form of nausea and vomiting in pregnancy, characterized by persistent nausea and vomiting associated with ketosis and weight loss (>5% of prepregnancy weight). This condition may cause volume depletion, electrolytes and acid-base imbalances, nutritional deficiencies, and even death. Severe hyperemesis requiring hospital admission occurs in 0.3-2% of pregnancies.

Signs and symptoms

The defining symptoms of hyperemesis gravidarum are gastrointestinal in nature and include nausea and vomiting. Other common symptoms include ptyalism (excessive salivation), fatigue, weakness, and dizziness.

Patients may also experience the following:

Sleep disturbance

Hyperolfaction

Dysgeusia

Decreased gustatory discernment

Depression

Anxiety

Irritability

Mood changes

Decreased concentration

See Clinical Presentation for more detail.

Diagnosis

Physical examination in women with suspected hyperemesis gravidarum is usually unremarkable. Findings may be more helpful if the patient has unusual complaints suggestive of other disorders (eg, bleeding, abdominal pain).

Examination includes the following:

Vital signs, including standing and lying blood pressure and pulse

Volume status (eg, mucous membrane condition, skin turgor, neck veins, mental status)

General appearance (eg, nutrition, weight)

Thyroid evaluation

Abdominal evaluation

Cardiac evaluation

Neurologic evaluation

Laboratory tests

Initial laboratory studies used in the evaluation of women with hyperemesis gravidarum should include the following:

Urinalysis for ketones and specific gravity

Serum levels of electrolytes and ketones

Liver enzymes and bilirubin levels

Amylase/lipase levels

Thyroid stimulating hormone, free thyroxine levels

Urine culture

Calcium level

Hematocrit level

Hepatitis panel

Imaging studies

The following imaging studies may be used to assess women with hyperemesis gravidarum:

Obstetric ultrasonography: Usually warranted to evaluate for multiple gestations or trophoblastic disease

Upper abdominal ultrasonography: If clinically indicated, to evaluate the pancreas and/or biliary tree

Abdominal computed tomography scanning or magnetic resonance imaging: If appendicitis is suspected as a cause of nausea and vomiting in pregnancy

Additional imaging studies may be warranted if the patient’s clinical presentation is atypical (eg, nausea and/or vomiting beginning after 9-10 wk of gestation, nausea and/or vomiting persisting after 20-22 wk, acute severe exacerbation) or if another disorder is suggested based on the history or physical examination findings.

Procedures

In patients with abdominal pain or upper gastrointestinal bleeding, upper gastrointestinal endoscopy appears to be safe in pregnancy, although careful monitoring is suggested.

See Workup for more detail.

Management

Initial management in pregnant women with hyperemesis gravidarum should be conservative and may include reassurance, dietary recommendations, and support. Alternative therapies may include acupressure and hypnosis.

Pharmacotherapy

The only FDA-approved drug for treating nausea and vomiting in pregnancy is doxylamine/pyridoxine. However, antihistamines, antiemetics of the phenothiazine class, and promotility agents (eg, metoclopramide) have also been used to manage nausea and vomiting during pregnancy. In cases refractory to standard therapy, ondansetron and steroids may be considered.

The following medications may be used in women with hyperemesis gravidarum:

Vitamins (eg, pyridoxine)

Herbal medications (eg, ginger)

Antiemetics (eg, doxylamine-pyridoxine, prochlorperazine, promethazine, chlorpromazine, trimethobenzamide, metoclopramide, ondansetron)

corticosteroids (eg, methylprednisolone)

Antihistamines (eg, meclizine, diphenhydramine)

Surgery

In some refractory severe cases of hyperemesis gravidarum, if maternal survival is threatened, or if hyperemesis gravidarum is causing severe physical and psychological burden, termination of the pregnancy should be considered.

See Treatment and Medication for more detail.

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