Hyperemesis Gravidarum

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Chapter 212 Hyperemesis Gravidarum

INTRODUCTION

Description: Hyperemesis gravidarum is exaggerated nausea and vomiting of early pregnancy sufficient to produce dehydration, metabolic disturbances, and weight loss. Alkalosis (from HCl loss) and hypokalemia are common.

Prevalence: Seventy percent to 85% of women experience nausea; 50% have emesis in the first trimester; hyperemesis occurs in 0.5% to 2% of pregnancies.

Predominant age: Reproductive.

Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Unknown.

Risk Factors: Multiple gestation, hydatidiform mole, ambivalence about pregnancy (debated).

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Nausea and vomiting leading to weight loss, dehydration, ketone formation, and electrolyte disturbances

• Symptoms generally begin between the fourth and eighth week, lasting until 16 weeks or longer

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Small, frequent feedings with bland foods (crackers, toast, etc.). (Early intervention is more likely to be effective and will reduce the likelihood of further complications, including hospitalization.)

Specific Measures: Vitamin B6, antiemetics, or intravenous hydration. Gradual reintroduction of diet as symptoms are controlled. Techniques such as acupuncture, acupressure, steroid use, or ginger therapy have not been proven to be effective.

Diet: Spicy or greasy foods should be avoided, and some advocate eating a protein snack at bedtime.

Activity: No restriction.

Patient Education: American College of Obstetricians and Gynecologists Patient Education Booklet AP001 (Nutrition During Pregnancy), AP126 (Morning Sickness).

Drug(s) of Choice

Vitamin B6 (pyridoxine) 50 to 100 mg PO daily (may be divided and taken twice a day) with doxylamine succinate (Unisom) 12.5 to 25 mg PO daily.

Promethazine (Phenergan) 25 mg PO or rectally every 4 to 6 hours.

Metoclopramide (Reglan) 10 mg PO four times a day.

Meclizine (Antivert) 12.5 to 25 mg PO four times a day.

Contraindications: See individual agents.

Precautions: Promethazine (Phenergan) is a class C agent (risk of teratogenesis in animals but unknown risk in humans). Metoclopramide (Reglan) and meclizine (Antivert) are class B agents (no known human risk).

FOLLOW-UP

Patient Monitoring: Normal health maintenance, monitoring of fetal growth.

Prevention/Avoidance: None.

Possible Complications: Maternal dehydration and metabolic compromise. Rupture or tears of the esophagus and pneumothorax have been reported as a result of vomiting.

Expected Outcome: Generally good, although relapses in severe cases are common (25% to 30%).

MISCELLANEOUS

Pregnancy Considerations: If nutrition is maintained, no effect on pregnancy. May recur with subsequent pregnancies.

ICD-9-CM Codes: 643, 643.0 (mild), 643.1 (with metabolic disturbance).

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Knight B, Mudge C, Openshaw S, et al. Effect of acupuncture on nausea of pregnancy: a randomized, controlled trial. Obstet Gynecol. 2001;97:184.

Nelson-Piercy C, Fayers P, de Swiet M. Randomised, double-blind, placebo-controlled trial of corticosteroids for the treatment of hyperemesis gravidarum. BJOG. 2001;108:9.

Rosen T, de Veciana M, Miller HS, et al. A randomized controlled trial of nerve stimulation for relief of nausea and vomiting in pregnancy. Obstet Gynecol. 2003;102:129.

Yost NP, McIntire DD, Wians FHJr, et al. A randomized, placebo-controlled trial of corticosteroids for hyperemesis due to pregnancy. Obstet Gynecol. 2003;102:1250.

Bondok RS, El Sharnouby NM, Eid HE, Abd Elmaksoud AM. Pulsed steroid therapy is an effective treatment for intractable hyperemesis gravidarum. Crit Care Med. 2006;34:2781.

Borrelli F, Capasso R, Aviello G, et al. Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstet Gynecol. 2005;105:849.

Deuchar N. Nausea and vomiting in pregnancy: a review of the problem with particular regard to psychological and social aspects. Br J Obstet Gynaecol. 1995;102:6.

van Stuijvenberg ME, Schabort I, Labadarios D, Nel JT. The nutritional status and treatment of patients with hyperemesis gravidarum. Am J Obstet Gynecol. 1995;172:1585.

American College of Obstetricians and Gynecologists. Nausea and vomiting of pregnancy. ACOG Practice Bulletin 52. Obstet Gynecol. 2004;103:803.

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