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:
Decreased gustatory discernment
See Clinical Presentation for more detail.
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)
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
Thyroid stimulating hormone, free thyroxine levels
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.
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.
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.
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)
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.