What is Hyperemesis Gravidarum?
Hyperemesis gravidarum is a condition that causes extreme vomiting during pregnancy. This severe sickness can lead to weight loss and dehydration, resulting in an excessive amount of ketones in urine or blood, conditions known as ketonuria and ketonemia, respectively. While there isn’t an agreement on the specific elements needed to diagnose this condition, it’s usually understood to represent the worst cases of nausea and vomiting during pregnancy. This happens in about 2% of all pregnancies in the United States. It can greatly affect the day-to-day life of the women experiencing it, as well as their families. Unfortunately, it can also be quite difficult to treat.
What Causes Hyperemesis Gravidarum?
The exact cause of severe morning sickness during pregnancy, known as hyperemesis gravidarum, is not entirely understood, but there are a few theories (this gets quite technical, so we won’t go into detail). However, certain elements can increase someone’s chances of experiencing severe morning sickness during pregnancy. For instance, if a woman is carrying twins, or a molar pregnancy which doesn’t develop into a normal baby but is a bunch of tissue in the womb, she has a higher risk of severe morning sickness.
Also, women who have had experiences of nausea and vomiting outside of pregnancy, possibly due to using medications that contain estrogen, feeling sick when moving, or having a history of severe headaches called migraines, are more likely to have nausea and vomiting during pregnancy. Some research also indicates that if a woman’s mother or sister had severe morning sickness when they were pregnant, she may be more likely to have it as well.
Ironically, certain factors can reduce a woman’s likelihood of having severe morning sickness. For example, taking multivitamins before the sixth week of pregnancy or smoking cigarettes (although we are not advocating smoking – it is harmful to both the mother and the child in numerous ways).
Risk Factors and Frequency for Hyperemesis Gravidarum
Many women, up to ninety percent, may feel sick or nauseous during their pregnancy. It’s worth noting that about 27 to 30 percent of women feel only nausea, while between 28 to 52 percent of women may experience vomiting throughout their pregnancy. Hyperemesis gravidarum, a severe form of morning sickness, affects a smaller percentage of pregnant women, ranging from 0.3 to 3 percent. It appears to be more common in western countries.
- Up to 90% of women might feel sick during pregnancy.
- 27 to 30% of women experience only nausea.
- Vomiting may occur in 28 to 52% of all pregnancies.
- Hyperemesis gravidarum, a serious form of morning sickness, affects 0.3 to 3% of pregnancies.
- Hyperemesis gravidarum is more prevalent in western countries.
Signs and Symptoms of Hyperemesis Gravidarum
For women experiencing severe morning sickness, often referred to as hyperemesis gravidarum, a thorough health background check is important. This includes knowing whether the woman is pregnant, how far along she is in her pregnancy, any complications from previous pregnancies, how often she feels nauseous or vomits, treatments tried to alleviate symptoms, and how effective these treatments were. Symptoms of this condition generally start around the 5th or 6th week of pregnancy.
During a medical check-up, several things should be assessed. It’s important to listen for the baby’s heartbeats, depending on how far the pregnancy has progressed. Doctors also look for signs of dehydration, such as checking the blood pressure, heart rate, how dry the mouth is, how quickly the skin returns to its normal color after being pinched, and the elasticity of the skin. Recording the patient’s weight is also essential for comparing with past and future weigh-ins. If necessary, the doctor may perform an abdominal and pelvic exam to determine if there’s any tenderness when touched.
- Pregnancy status
- Estimated gestational age (how far along the pregnancy is)
- Complication history from past pregnancies
- Frequency and severity of nausea and vomiting
- Previous treatments for symptoms, and their effectiveness
- Fetal heart rate (depending on gestational age)
- Examination of fluid status, including blood pressure check, heart rate, dryness of mouth, skin color return speed after being pinched, skin elasticity
- Patient’s weight
- Possible abdominal and pelvic exam to look for tenderness
Testing for Hyperemesis Gravidarum
Hyperemesis gravidarum (HG) is a term typically used to describe severe nausea and vomiting during pregnancy. It is a diagnosis made based on symptoms and physical health examination. The main indicators include vomiting that leads to serious dehydration (as indicated by a urine test that shows an increased presence of ketones, or changes in your body’s electrolyte balance) and significant weight loss (usually, this implies losing at least five percent of your individual weight before pregnancy). The condition is diagnosed when these symptoms are present during pregnancy, and there isn’t another underlying illness causing the vomiting. If a pregnant woman also has significant belly or pelvic pain, or vaginal bleeding, her doctor would look into other potential issues causing these symptoms.
To assess the severity of the condition, a number of tests can be performed. Urine tests can show ketones, which are substances made when your body breaks down fat for energy, as well as the concentration of your urine. Blood tests can show how balanced your body’s electrolytes are, as well as your complete blood count. The levels of hemoglobin or hematocrit, the part of your blood that carries oxygen, may rise due to a concentration of blood when you’re dehydrated. Severe dehydration might lead to a decrease in kidney function, indicated by an increase in the levels of creatinine, a waste product that your kidneys filter out, and blood urea nitrogen, a waste product your liver produces. Low intake of fluids through prolonged vomiting might alter the levels of potassium, calcium, magnesium, sodium, and bicarbonate in your body. Other tests for checking thyroid function, lipase (an enzyme that helps your body absorb fats), and liver function might also be required.
Your doctor might also opt for imaging studies to rule out other conditions causing the symptoms. An obstetrical ultrasound, for example, can confirm whether there’s more than one baby, a pregnancy occurring outside the uterus (ectopic pregnancy), and gestational trophoblastic disease, which involves unusual growths inside the uterus. The kind of tests considered would depend on the patient’s health history and previous obstetrical evaluations. In some cases, magnetic resonance imaging (MRI) might be necessary to check for other conditions such as appendicitis.
Treatment Options for Hyperemesis Gravidarum
The American College of Obstetrics and Gynecology (ACOG) provides guidelines on treating Nausea and Vomiting in Pregnancy. The first line of treatment usually includes non-medication approaches. Swapping a patient’s prenatal vitamins just for folic acid, using ginger supplements as required, and wearing acupressure wristbands are examples of these.
If the condition persists, the next step involves medications, like a combined treatment of vitamin B6 (known as pyridoxine) and doxylamine. These are both approved for use during pregnancy.
If there’s still no relief, different medications like antihistamines or drugs that work against dopamine (a brain chemical) might be tried. Examples include dimenhydrinate, diphenhydramine, prochlorperazine, or promethazine.
In cases where the patient still has severe symptoms but is not dehydrated, medications like metoclopramide, ondansetron, or promethazine could be given by mouth. If the patient is dehydrated, they may need to receive fluids directly into a vein, as well as electrolytes (body salts) replaced as needed.
For extremely severe cases that do not respond to other treatments, medications like chlorpromazine or methylprednisolone could be used, either by mouth or directly into a vein. Please remember, all these treatments should be decided and reviewed by your doctor as every pregnant woman and their situation would be unique.
What else can Hyperemesis Gravidarum be?
Hyperemesis gravidarum, a condition causing severe nausea and vomiting during pregnancy, is diagnosed by ruling out other potential conditions. It’s important to note that there are numerous other possible reasons for similar symptoms, which fall under various categories:
- Gastrointestinal Conditions like gastroenteritis, gastroparesis, hepatitis, pancreatitis, and appendicitis
- Genitourinary Conditions such as pyelonephritis, uremia, ovarian torsion, kidney stones, and degenerating uterine leiomyoma
- Metabolic Conditions including diabetic ketoacidosis, porphyria, Addison disease, Hyperthyroidism, and hyperparathyroidism
- Neurologic Disorders like pseudotumor cerebri, vestibular lesions, migraine, tumors of the central nervous system, and lymphocytic hypophysitis
- Miscellaneous Conditions such as drug toxicity or intolerance
- Psychologic Conditions
- Pregnancy-related conditions like acute fatty liver of pregnancy and preeclampsia
Evaluation methods typically begin with an ultrasound scan, which can confirm the diagnosis in most instances. Other considerations include gestational trophoblastic disease and multiple gestations as these conditions also cause severe nausea and vomiting in early pregnancy.
If nausea and vomiting starts after the first nine weeks of pregnancy, it is crucial to consider other possible diagnoses. Conditions such as preeclampsia, HELLP syndrome, and acute fatty liver of pregnancy typically occur during the later stages of pregnancy.
Remember, nausea and vomiting can also result from non-pregnancy related causes. Such causes include psychiatric disorders such as anxiety and depression, and various medical conditions including gastrointestinal and metabolic disorders, and even neurological disorder. Always remember that pregnant patients are at a higher risk of blood clotting – conditions resulting in insufficient blood supply or formation of blood clots can be more common during pregnancy.
What to expect with Hyperemesis Gravidarum
Feeling nauseous and vomiting are quite common during pregnancy. These symptoms typically start before the ninth week of the pregnancy, and for most women, they stop by the 20th week. However, around 3% of pregnant women may continue to feel sick and throw up during their third trimester, the last few months of their pregnancy. Roughly 10% of women who suffer from severe vomiting during pregnancy – a condition known as hyperemesis gravidarum – may experience this throughout their entire pregnancy.
Thankfully, having severe vomiting during one pregnancy doesn’t necessarily mean it will happen in subsequent pregnancies. Each pregnancy can be different. So, if you had hyperemesis gravidarum in one pregnancy, it’s entirely possible that you won’t have it in your next one.
Possible Complications When Diagnosed with Hyperemesis Gravidarum
Hyperemesis gravidarum is a condition that affects pregnant people, causing extreme nausea and vomiting. It’s essential to consider the health and well-being of both the person who is pregnant and the baby (or babies) when discussing possible complications of hyperemesis gravidarum.
In serious cases, the pregnant person can experience severe dehydration, vitamin deficiencies, and malnutrition if not properly treated. Major complications can include a condition called Wernicke encephalopathy, which happens due to a vitamin B-1 deficiency, and can be fatal or lead to lasting disability if not treated in time. There are also rare situations where forceful and frequent vomiting has resulted in physical injuries such as esophageal rupture or a collapsed lung (pneumothorax). Additionally, electrolyte abnormalities such as low potassium levels can lead to severe health consequences and even death. Pregnant people with hyperemesis gravidarum may also experience higher rates of depression and anxiety.
Potential Complications for Pregnant People:
- Vitamin deficiencies
- Dehydration
- Malnutrition
- Wernicke encephalopathy
- Physical injuries like esophageal rupture and pneumothorax
- Electrolyte abnormalities like low potassium levels
- Increased likelihood of experiencing depression and anxiety
Concerning the baby, research studies have shown mixed results concerning the risk of low birth weight and premature birth in cases of severe nausea and vomiting during pregnancy. However, research generally agrees that there seems to be no increased likelihood of perinatal or neonatal death, or any increase in congenital defects in babies born to those who had hyperemesis gravidarum during their pregnancy.
Potential Complications for Babies:
- Potential risk of low birth weight
- Potential risk of premature birth
Preventing Hyperemesis Gravidarum
Taking a multivitamin that includes folic acid every day at least one month before conceiving can be very beneficial. This practice not only lessens the chances of birth defects like spina bifida (which are problems related to the baby’s spinal cord and brain), but it can also help reduce how often and how severe morning sickness symptoms are during pregnancy.
