Managing Hyperemesis Gravidarum: A Multimodal Challenge

JK Jueckstock; R Kaestner; I Mylonas

Disclosures

BMC Fam Pract. 2010;11(54) 

In This Article

Abstract and Introduction

Abstract

Up to 90% of pregnant women experience nausea and vomiting. When prolonged or severe, this is known as hyperemesis gravidarum (HG), which can, in individual cases, be life threatening. In this article the aetiology, diagnosis and treatment strategies will be presented based on a selective literature review. Treatment strategies range from outpatient dietary advice and antiemetic drugs to hospitalization and intravenous (IV) fluid replacement in persistent or severe cases. Alternative methods, such as acupuncture, are not yet evidence based but sometimes have a therapeutic effect.
In most cases, the condition is self limiting and subsides by around 20 weeks gestation. More severe forms require medical intervention once other organic causes of nausea and vomiting have been excluded. In addition, a psychosomatic approach is often helpful.
In view of its potential complexity, general practitioners and obstetricians should be well informed about HG and therapy should be multimodal.

Introduction

About 50% - 90% of all pregnancies are accompanied by nausea and vomiting.[1] According to a study of more than 360 pregnant women, only 2% experienced only nausea in the morning whereas, in 80%, complaints persisted throughout the day. The condition is usually self-limiting and peaks at around 9 weeks gestation. At 20 weeks symptoms typically cease. However, in up to 20% of cases, nausea and vomiting may continue until delivery.[1]

This condition is known as nausea and vomiting during pregnancy (NVP) or emesis gravidarum and is of no pathological significance as long as the affected women do not feel unwell or restricted in their daily life.[2] There are, however, different grades in the scope of NVP, which range from occasional morning-sickness to excessive vomiting that persists throughout the day. The most severe grade of NVP often leads to hyperemesis gravidarum (HG; see below), but it can be difficult to differentiate between the two conditions.

A prospective study of more than 9000 pregnant women showed that NVP occurred significantly more often in primigravidas and in women who were less educated, younger, non-smokers and overweight or obese. The incidence of NVP was also higher in women with a history of nausea and vomiting in a previous pregnancy.[3]

In order to exclude differential diagnoses the following crucial parameters should be investigated: Onset of nausea and vomiting (nearly all of the cases begin before 9 weeks of gestation), attendant symptoms, underlying chronic disorders or, in rare cases, hereditary diseases (see Figures 1 and 2).[4]

Figure 1.

Differential diagnosis of nausea and vomiting.

Figure 2.

Differential diagnosis of nausea and vomiting in respect to abdominal symptoms.

A small percentage of pregnant women experience a severe form of nausea and vomiting that is termed HG (synonym: excessive vomiting during pregnancy). This disorder has an estimated incidence of 0.5% - 2% of all live births.[5] A standard definition of HG is the occurrence of more than three episodes of vomiting per day with ketonuria and more than 3 kg or 5% weight loss. However, the diagnosis is usually made clinically following the exclusion of other causes.[6,7]

HG can, in individual cases, be life threatening and treatment must be initiated immediately. Clinical findings include dehydration, acidosis due to inadequate nutrition, alkalosis due to loss of hydrochloride and hypokalaemia. There are two degrees of severity: (i) grade 1, nausea and vomiting without metabolic imbalance; and (ii) grade 2, pronounced feelings of sickness with metabolic imbalance.[2]

In this article the aetiology, diagnosis, clinical presentation and treatment options will be outlined on the basis of a selective literature review.

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