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Contents
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• 1 Etymology
• 2 Cause
• 3 Symptoms
• 4 Complications
o 4.1 For the pregnant woman
o 4.2 For the fetus
• 5 Diagnosis
• 6 Treatment
o 6.1 IV hydration
o 6.2 Medications
o 6.3 Nutritional support
o 6.4 Support
• 7 References
Etymology
Hyperemesis gravidarum is from the Greek hyper-, meaning excessive, and emesis,
meaning vomiting, as well as the Latin gravida, meaning pregnant. Therefore,
hyperemesis gravidarum means "excessive vomiting in pregnancy."
Cause
The cause of HG is unknown. The leading theories speculate that it is an adverse reaction
to the hormonal changes of pregnancy. In particular Hyperemesis may be due to raised
levels of beta HCG (human chorionic gonadotrophin)[3] as it is more common in multiple
pregnancies and in gestational trophoblastic disease. This theory would also explain why
hyperemesis gravidarum is most frequently encountered in first trimester (often around 8
– 12 weeks of gestation), as HCG levels are highest at that time and decline afterwards.
Additional theories point to high levels of estrogen and progesterone[citation needed], which
may also be to blame for hypersalivation; decreased gastric motility (slowed emptying of
the stomach and intestines); immune response to fragments of chorionic villi that enter
the maternal bloodstream; or immune response to the "foreign" fetus.[citation needed] There is
also evidence that leptin may play a role in HG.[4] Historically, HG was blamed upon a
psychological condition of the pregnant women. Medical professionals believed it was a
reaction to an unwanted pregnancy or some other emotional or psychological problem.
[citation needed]
This theory has been disproved, but unfortunately some medical professionals
espouse this view and fail to give patients the care they need.[citation needed] A recent study
gives "preliminary evidence" that there may be a genetic component.[5]
Symptoms
When HG is severe and/or inadequately treated, it may result in:
Some women with HG lose as much as 20% of their body weight. Many sufferers of HG
are extremely sensitive to odors in their environment; certain smells may exacerbate
symptoms. This is known as hyperolfaction. Ptyalism, or hypersalivation, is another
symptom experienced by some women suffering from HG.
Complications
For the pregnant woman
Infants of women with severe hyperemesis who gain less than 7 kg (15.4 lb) during
pregnancy tend to be of lower birth weight, small for gestational age, and born before 37
weeks gestation, in contrast, infants of women with hyperemesis who have a pregnancy
weight gain of more than 7 kg appear similar as infants from uncomplicated pregnancies.
[7]
No long-term follow-up studies have been conducted on children of hyperemetic
women.
Diagnosis
Women who are experiencing hyperemesis gravidarum often are dehydrated and losing
weight despite efforts to eat. The nausea and vomiting begins in the first or second month
of pregnancy. It is extreme and is not helped by normal measures.[8]
Fever, abdominal pain, or late onset of nausea and vomiting usually indicate another
condition, such as appendicitis, gallbladder disorders, gastritis, hepatitis, or infection.[8]
Treatment
Because of the potential for severe dehydration and other complications, HG is generally
treated as a medical emergency. Treatment of HG may include antiemetic medications
and intravenous rehydration. If medication and IV hydration are insufficient, nutritional
support may be required.
Medications
While no medication is considered completely risk-free for use during pregnancy, there
are several which are commonly used to treat HG and are believed to be safe.
The standard treatment in most of the world is Benedictin (also sold under the trademark
name Diclectin), a combination of doxylamine succinate and vitamin B6. However, due
to a series of birth-defect lawsuits in the United States against its maker, Merrill Dow,
Benedictin is not currently on the market in the U.S. (None of the lawsuits were
successful, and numerous independent studies and the Food and Drug Administration
(FDA) have concluded that Benedictin does not cause birth defects.) Its component
ingredients are available over-the-counter (doxylamine succinate is the active ingredient
in many sleep medications), and some doctors will recommend this treatment to their
patients.
Antiemetic drugs, especially ondansetron (Zofran), are effective in many women. The
major drawback of ondansetron has been its cost. In severe cases of HG, the Zofran pump
may be more effective than tablets. Zofran is also available in ODT (oral disintegrating
tablet) which can be easier for women who have trouble swallowing due to the nausea.
Promethazine (Phenergan) has been shown to be safe, at least in rats and may be used
during pregnancy with minimal/no side effects. Metoclopramide is sometimes used in
conjunction with antiemetic drugs; however, it has a somewhat higher incidence of side
effects. Other medications less commonly used to treat HG include Marinol,
corticosteroids and antihistamines.
Anecdotal evidence suggests that the use of marijuana, or of the pharamaceutical extract
Marinol can relieve the symptoms of HG, in a similar way to treating nausea in people
with Cancer and AIDS. However, due to the criminalisation of cannabis, there have been
no clinical trials into its effectivess or risks to the foetus.[10]
Nutritional support
Women who do not respond to IV rehydration and medication may require nutritional
support. Patients might receive parenteral nutrition (intravenous feeding via a PICC line)
or enteral nutrition (via a nasogastric tube or a nasojejunum tube).
Support
It is important that women get early and aggressive care during pregnancy. This can help
limit the complications of HG. Also, because depression can be a secondary condition of
HG, emotional support, and sometimes even counseling, can be of benefit. It is important,
however, that women not be stigmatized by the suggestion that the disease is being
caused by psychological issues..
Pregnancy Pregnancy
Ectopic pregnancy (Abdominal pregnancy, Cervical pregnancy,
with
Ovarian pregnancy, Interstitial pregnancy) · Hydatidiform
abortive
mole · Miscarriage
outcome
Oedema,
proteinuria
Gestational hypertension (Pre-eclampsia, Eclampsia, HELLP
and
syndrome) · Gestational diabetes
hypertensive
disorders
• Nausea and vomiting can occur at any time of the day and may be constant.1
• The causes of nausea and vomiting in early pregnancy are unknown.
• Most women do not require treatment. However persistent vomiting and severe
nausea can progress to hyperemesis gravidarum.
• Hyperemesis gravidarum refers to intractable vomiting leading to fluid and
electrolyte disturbance, marked ketonuria, nutritional deficiency and weight loss.2
• Nausea in later pregnancy may be due to reflux oesophagitis and respond to
antacids.
Epidemiology
• Nausea affects about 70% and vomiting about 60% of pregnant women.
• Nausea and vomiting in pregnancy is more common in:
o Primigravidae
o Multiple pregnancy
o History of previous hyperemesis
• It is less common with increasing maternal age.
• It tends to be a disease of Western society and is less common in developing
countries, especially in rural communities.
Presentation
• Symptoms usually start between 4 and 7 weeks gestation and resolve by 16 weeks
in about 90% of women.
• Check for signs of dehydration and any possible underlying cause.
• Pre-eclampsia can cause vomiting so blood pressure may be raised.
Differential diagnosis
• Hydatidiform mole
• Pre-eclampsia
• Gastrointestinal cause, e.g. infection, gastritis, cholecystitis, appendicitis,
obstruction, peptic ulceration, hepatitis, pancreatitis, fatty liver of pregnancy
• Urinary tract infection
• Twisted ovarian cyst
• Ear, nose and throat disease (e.g. labyrinthitis, Meniere's disease, motion
sickness)
• Drug side effects
• Raised intracranial pressure
• Metabolic, e.g. diabetes, hypercalcaemia, Addison's disease, hyperparathyroidism
• Psychological (e.g. bulimia nervosa)
Investigations
Management
Most cases are mild and do not require treatment. Nausea and vomiting in pregnancy
usually resolves spontaneously within 16 to 20 weeks and is not associated with a poor
pregnancy outcome. However persistent vomiting and severe nausea can progress to
hyperemesis if the woman is unable to maintain adequate hydration; fluid and electrolyte
balance as well as nutritional status are jeopardised.3 The following interventions appear
to be effective in reducing symptoms:4
Management options
• Advice:
o There is no research-based evidence on the effectiveness of dietary
treatment.5
o Advise to rest; eat small, frequent meals that are high in carbohydrate and
low in fat.
o Avoid any foods or smells that trigger symptoms.
• Ginger: three RCTs and one randomised crossover trial found that ginger reduced
nausea and vomiting in early pregnancy. One further RCT found that ginger
reduced nausea and dry retching, but had no effect on episodes of vomiting.5
• Drug treatment should only be given when symptoms are persistent, severe and
prevent daily activities. Prochlorperazine, cyclizine and metoclopramide are often
used. Due to concerns about fetal safety, there have been relatively few studies on
the efficacy and safety of anti-emetics used for nausea and vomiting in
pregnancy.6
o Antihistamines (H1 antagonists): two systematic reviews found limited
evidence that antihistamines reduced nausea and vomiting with no
evidence of teratogenicity.7
o Phenothiazines: one systematic review found limited evidence that
phenothiazines reduced the proportion of women with nausea and
vomiting. However, the results were not conclusive. The review found no
evidence of teratogenicity.5
o Pyridoxine (vitamin B6): two systematic reviews found limited evidence
that pyridoxine reduced nausea but found no evidence of an effect on
vomiting.5
• Acupressure: one systematic review of small RCTs found limited evidence that
P6 acupressure reduced self reported morning sickness compared with sham
acupressure or no intervention. Three subsequent RCTs and two randomised
crossover trials found that P6 acupressure reduced the duration, but not
necessarily the intensity, of nausea and vomiting.5
• Acupuncture: one RCT found that acupuncture reduced nausea and retching
compared with no acupuncture, with no evidence of adverse effects. However, an
improvement was also found with sham acupuncture compared with no treatment.
A second smaller RCT found no significant difference in nausea between
acupuncture and sham acupuncture.5
Admission
• Women with severe symptoms should be referred for fluid, electrolyte and
vitamin replacement (usually intravenously). Nutritional support (enteral or
parenteral) is needed in women who have intractable symptoms and weight loss,
despite appropriate therapy.
• Admit for monitoring, intravenous fluids and correction of electrolyte
disturbances. if the vomiting is severe or prolonged or the woman becomes
dehydrated or ketotic.
Complications
• In severe cases, dehydration, weight loss, electrolyte disturbance (e.g. ketosis) and
nutritional deficiency can occur.
• Hyperemesis gravidarum is rarely associated with death, but may lead to serious
complications, including Wernicke's encephalopathy, central pontine myelinolysis
and spontaneous oesophageal rupture.8
Prognosis
Background
Gestational diabetes (GDM) is associated with maternal (pre-eclampsia, caesarean
section, and perineal trauma) and perinatal (macrosomia, stillbirth, shoulder dystocia,
birth injuries, hypoglycaemia, respiratory distress, stillbirth, and jaundice)
complications.1 GDM is also associated with an increased risk of later Type 2 diabetes in
both the mother and the offspring.2,3 Pregnancy is the only time to identify women with
GDM, and provides the opportunity to implement strategies to improve both pregnancy
and long-term outcomes.
The diagnosis of GDM in New Zealand (NZ) is generally made using a two-step
approach. An initial screening test involves a non-fasting 50 glucose challenge test
(GCT) at 24–28 weeks’ gestation.1 Women are subsequently referred for a diagnostic
75g oral glucose tolerance test (OGTT) if the 1-hour glucose concentration is ≥7.8
mmol/L.
Currently, GDM is diagnosed if the fasting glucose is ≥5.5 mmol/L and/or the 2-hour
glucose concentration is ≥9.0 mmol/L. These diagnostic criteria have been used since
1992 and are unique to NZ.1,4 Many other countries use lower glucose levels to diagnose
GDM.5
The current criteria for diagnosing GDM are used throughout NZ,6 but the extent of
screening for GDM varies markedly. Figure 1 shows the uptake of the 50g GCT by
District Health Boards (DHBs) in 2005, ranging from approximately 20% to 89% of
pregnancies. This is not surprising as, until the end of 2006, some organisations promoted
screening for all pregnant women,4,7 while others recommended screening women with
one or more of seven clinical risk factors.8 Similar discordance is also seen between
different global screening recommendations.6
There are several reasons for reviewing the current approach to screening for GDM.
Firstly, since the most potent nihilistic view of GDM was published in 1993,9 a great
deal has changed from both global and knowledge perspectives. The world now faces a
pandemic of diabetes and obesity,10,11 which has resulted in growing numbers of young
women with risk factors for GDM or undiagnosed Type 2 diabetes.12–14 Type 2 diabetes
in pregnancy is associated with high rates of fetal loss, congenital malformations, and
other adverse perinatal outcomes.14
Figure 1. Proportion of births where the mother had a glucose challenge test for
each District Health Board (DHB). Proportions are shown for women aged below
and above 25 years.
Polycose (Glucose Challenge) Testing as a % of Live Births by DHB
Secondly, there is good evidence that the development of Type 2 diabetes in high risk
populations can be prevented or delayed,15–17 thus providing women with GDM the
chance to actively try to delay/reduce their chance of permanent diabetes. Interventions
are potentially useful for their children, as the intrauterine and postnatal environment
influence later health risks (including obesity) for the child.18–20
Thirdly, two recent studies have made important contributions with respect to the value
of treating women with GDM during pregnancy. These are the prospective, randomised
Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS)21 and a case
control study by Langer.22 Both studies showed significant benefit from the treatment of
GDM and support other studies showing the benefits of tight glucose control during
GDM.23,24 In addition, ACHOIS laid to rest concerns that a diagnosis of GDM could be
associated with increased caesarean section rates or maternal psychological trauma. The
caesarean section rates were not increased in women treated for GDM and maternal well-
being scores were better in women treated for GDM.
With the combination of all these reasons it was timely to review the approach to
screening, diagnosis and models of care for women with GDM in NZ. The Australasian
Diabetes in Pregnancy Society (ADIPS) and the New Zealand College of Midwives
(NZCOM) worked with representatives from other relevant organisations (Appendix 1) to
develop a Technical Report to contribute to this debate. This paper describes the process
undertaken and summarises the recommendations made.