Nausea and vomiting during pregnancy

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Chapter 24 NAUSEA AND VOMITING DURING PREGNANCY

Nausea and vomiting of pregnancy, also known as morning sickness, is very common, affecting 70% to 85% of pregnant women. It can range in severity from mild nausea to hyperemesis gravidarum. The cause of nausea and vomiting of pregnancy is not known. Risk factors include molar gestation, multiple gestation, family history, or a history of hyperemesis gravidarum in prior pregnancies. Recognition and treatment of milder symptoms can prevent progression of symptoms and hospitalization.

Nausea and vomiting of pregnancy usually starts before 9 weeks of pregnancy and usually ends by the 20th week. If symptoms begin after 9 weeks, if the vomiting is severe, or if other symptoms are present, then other causes of nausea and vomiting should be investigated.

Key Historical Features

✓ Gravity and parity

✓ Onset of symptoms

✓ Frequency and severity

✓ History of nausea and vomiting with other pregnancies

✓ Presence of diarrhea

✓ Abdominal pain

✓ Significant weight loss associated with vomiting

✓ Fever and chills, which may indicate infection such as cholecystitis, pyelonephritis, or appendicitis

✓ Palpitations, heat intolerance, or anxiety, which may indicate hyperthyroidism

✓ Medical history, especially history of thyroid disease, liver disease, gallbladder disease, pancreatitis, gastroesophageal reflux disease, migraines, or diabetes

✓ Medications

✓ Family history

• A family history of diabetes mellitus, thyroid disease, or migraines, which can increase the risk for these diseases

• Similar symptoms in other family members, in which case an infectious cause should be considered, such as acute gastroenteritis

✓ Social history

• Alcohol abuse, which can cause pancreatitis

• Tobacco use

✓ Review of systems, especially the following:

• Gastrointestinal symptoms

— Vomiting that begins after the 9th week of pregnancy, which is usually not part of clinical nausea and vomiting of pregnancy

— Diarrhea, which may indicate gastroenteritis or hyperthyroidism

— Abdominal pain, which may indicate an intra-abdominal process such as cholecystitis, pancreatitis, appendicitis, or bowel obstruction

• Genitourinary symptoms

— Dysuria, which may indicate a urinary tract infection

— Hematuria, which may indicate nephrolithiasis or a urinary tract infection

• Neurologic symptoms

— Headaches, which may be suggestive of a migraine, meningitis, or brain tumor

Key Physical Findings

✓ Vital signs

• Hypotension, which can be indicative of severe dehydration or sepsis

• Hypertension, which can be indicative of preeclampsia

✓ General assessment of health and well-being

✓ Neurologic examination to evaluate for a central nervous system disorder

✓ Head and neck examination

• Facial edema may be suggestive of preeclampsia

• Dry mucous membranes, which indicate dehydration

• Photophobia, which may indicate a central nervous system process

• Neck stiffness, which may indicate meningitis

• A goiter, which indicates thyroid disease

✓ Cardiovascular examination for tachycardia, which may indicate dehydration, infection, or hyperthyroidism

✓ Gastrointestinal examination

• Abdominal tenderness, which may indicate an intra-abdominal process, such as cholecystitis, pancreatitis, appendicitis, or bowel obstruction

• An enlarged liver, which indicates liver disease

✓ Back examination for costovertebral angle tenderness, which is suggestive of pyelonephritis

✓ Extremity examination for edema, suggestive of preeclampsia

✓ Skin examination

• Jaundice, suggestive of liver or biliary tract disease

• Poor skin turgor, suggestive of dehydration

Suggested Work-Up

Pregnancy test	To confirm pregnancy if not already done
Urinalysis	For ketonuria and a high specific gravity, which indicate dehydration
	For pyuria, which indicates possible urinary tract infection
	For glucosuria, which indicates hyperglycemia and possible diabetes
	For proteinuria, which may indicate preeclampsia

Additional Work-Up

Further workup should be guided by the patient’s symptoms and the physical examination. If the timing, persistence, and severity of symptoms are not suggestive of typical nausea and vomiting of pregnancy, a further work up is necessary:

Serum glucose measurement	If diabetes mellitus is suspected
Complete blood cell count	To evaluate for infection such as cholecystitis or pyelonephritis
Blood urea nitrogen (BUN) and creatinine measurement	To evaluate for dehydration or renal disease
Serum electrolyte measurements	For hypokalemia or hyponatremia in cases of severe vomiting
	To evaluate for the development of acidosis in patients with severe dehydration
Liver enzyme measurements	If hepatitis is suspected
Bilirubin measurement	If gallbladder or liver disease is suspected
Amylase or lipase measurement	If pancreatitis is suspected
Thyroid-stimulating hormone (TSH)	If thyroid disease is suspected
Abdominal ultrasonography	If liver, gallbladder, or pancreatic disease is suspected
Obstetric ultrasonography	If multiple fetuses or molar disease is suspected
Esophagogastroduodenoscopy	If peptic ulcer disease is suspected

FURTHER READING

American College of Obstetrics and Gynecology. ACOG (American College of Obstetrics and Gynecology) Practice Bulletin: nausea and vomiting of pregnancy. Obstet Gynecol. 2004;103:803-814.

Goodwin TM. Hyperemesis gravidarum. Clin Obstet Gynecol. 1998;41:597-605.

Koch KL, Frissora CL. Nausea and vomiting during pregnancy. Gastroenterol Clin. 2003;32:201-234.

Kuşcu NK, Koyuncu F. Hyperemesis gravidarum: current concepts and management. Postgrad Med J. 2002;78(916):76-79.

Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. 2003;68:121-128.

^* Adapted from Goodwin TM. Hyperemesis Gravidarum. Clinical Obstetrics and Gynecology 1998; 41: 597-605, Table 1.

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