eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Hyperemesis Gravidarum

Author: Susan Renee Wilcox, MD, Critical Care Fellow, Department of Anesthesia and Critical Care, Massachusetts General Hospital
Contributor Information and Disclosures

Updated: Jan 13, 2010

Introduction

Background

Nausea and vomiting are common in pregnancy, occurring in 70-85% of all gravid women.1 Hyperemesis gravidarum is a severe and intractable form of nausea and vomiting in pregnancy. It is a diagnosis of exclusion and may result in weight loss; nutritional deficiencies; and abnormalities in fluids, electrolyte levels, and acid-base balance. The peak incidence is at 8-12 weeks of pregnancy, and symptoms usually resolve by week 20 in all but 10% of patients. Uncomplicated nausea and vomiting of pregnancy is generally associated with a lower rate of miscarriage, but hyperemesis gravidarum may affect the health and well-being of both the pregnant woman and the fetus.

Pathophysiology

The etiology of nausea and vomiting of pregnancy is unknown. Many have postulated that nausea and vomiting are protective in pregnancy to reduce exposures to potentially teratogenic materials. Some theories hold that elevated human chorionic gonadotropin (hCG) or estradiol levels could be causative, due to correlations in numerous studies between levels and symptoms, but this has not been demonstrated conclusively. Psychological theories of the etiology are falling out of favor, and the American College of Obstetrics and Gynecology warns that attributing vomiting to psychological disorders has likely impeded progress in understanding the true etiology of hyperemesis gravidarum.

Frequency

United States

Hyperemesis gravidarum occurs in 0.5-2% of pregnancies, with the variation in incidence arising from different diagnostic criteria and ethnic variations.2 Studies have found an admission rate of 0.8% for hyperemesis gravidarum3 and an average of 1.3 hospital admissions per hyperemesis patient, with an average hospital stay of 2.6-4 days.

Mortality/Morbidity

With mild-to-moderate vomiting, the patient and the fetus are unlikely to experience any increased morbidity or mortality. Before the advent of intravenous hydration, hyperemesis was a major cause of maternal death. Currently, mortality is exceedingly rare, but maternal morbidities may include Wernicke encephalopathy from vitamin B-1 deficiency, Mallory-Weiss tears, esophageal rupture, pneumothorax, and acute tubular necrosis. Hyperemesis is the second leading cause of hospitalization in pregnancy, second only to preterm labor. Additionally, many women experience significant psychosocial morbidity, occasionally interfering with assumption of the maternal role and rarely leading to termination of the pregnancy.

Race

Hyperemesis patients are more likely to be nonwhite.

Age

Patients younger than 30 years are more likely to experience hyperemesis.

Clinical

History

  • Nausea and vomiting occur in early pregnancy and are nonresponsive to simple measures, such as reassurance and dietary changes.
  • Fever and abdominal pain are not characteristic of hyperemesis gravidarum.
  • If vomiting begins after 9 weeks' gestation, other causes should be investigated.

Physical

Findings at physical examination may include the following:

  • Weight loss
  • Dehydration
    • Decreased skin turgor
    • Postural changes in blood pressure (BP) and pulse
  • Abdominal tenderness, fever, and goiter likely indicate another process.

Causes

  • The cause of severe nausea and vomiting in pregnancy has not been identified. Hyperemesis may have a genetic component, as sisters and daughters of women with hyperemesis have a higher incidence.
  • Hyperemesis is also associated with hyperemesis in prior pregnancy, female gestation, multiple gestation, triploidy, trisomy 21, current or prior molar pregnancy, and hydrops fetalis.
  • Women with history of motion sickness, migraine headaches, psychiatric illness, pregestational diabetes, being underweight pregestation,4 hyperthyroidism, pyridoxine deficiency, and gastrointestinal disorders are also at an increased risk.
  • Some studies have suggested that Helicobacter pylori infection may play a role in hyperemesis,5 but the data are inconclusive.
  • Cigarette smoking and maternal age older than 30 years appear to be protective.

More on Pregnancy, Hyperemesis Gravidarum

Overview: Pregnancy, Hyperemesis Gravidarum
Differential Diagnoses & Workup: Pregnancy, Hyperemesis Gravidarum
Treatment & Medication: Pregnancy, Hyperemesis Gravidarum
Follow-up: Pregnancy, Hyperemesis Gravidarum
References
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Further Reading

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Keywords

morning sickness, morning sickness symptoms, morning sickness treatment, morning sickness causes, hyperemesis gravidarum, nausea and vomiting in pregnancy, pernicious vomiting in pregnancy, uncontrollable vomiting in pregnancy, severe nausea and vomiting in pregnancy, miscarriage

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Contributor Information and Disclosures

Author

Susan Renee Wilcox, MD, Critical Care Fellow, Department of Anesthesia and Critical Care, Massachusetts General Hospital
Susan Renee Wilcox, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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