Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting during pregnancy that is much more serious than typical morning sickness. It affects 0.5-2% of pregnant women and can cause significant dehydration, weight loss, and nutritional deficiencies that may require hospitalization and intensive medical management to protect both mother and baby.

Medical Disclaimer: This information is for educational purposes only and should not replace professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of any medical condition.

Understanding Hyperemesis Gravidarum

Unlike typical morning sickness that affects up to 80% of pregnant women, hyperemesis gravidarum is a severe condition characterized by persistent nausea and vomiting that can lead to more than 5% weight loss, dehydration, and electrolyte imbalances. The condition typically begins in the first trimester and may persist throughout pregnancy.

HG vs. Morning Sickness

Feature Morning Sickness Hyperemesis Gravidarum
Prevalence 70-80% of pregnancies 0.5-2% of pregnancies
Duration Usually subsides by 12-14 weeks May persist throughout pregnancy
Weight loss Little to no weight loss >5% pre-pregnancy weight
Dehydration Rare Common and severe
Hospitalization Not required Often necessary

Symptoms and Signs

HG symptoms are severe and can significantly impact daily functioning and quality of life:

Primary Symptoms

Gastrointestinal Symptoms

Systemic Symptoms

Signs of Dehydration

  • Dry mouth and decreased saliva
  • Dark yellow urine or decreased urination
  • Dry skin with poor elasticity
  • Sunken eyes
  • Low blood pressure
  • Elevated heart rate

Complications and Warning Signs

  • Severe pregnancy complications
  • Electrolyte imbalances (low sodium, potassium)
  • Ketosis from starvation
  • Liver dysfunction
  • Neurological symptoms (confusion, memory problems)
  • Depression and anxiety

Causes and Risk Factors

The exact cause of hyperemesis gravidarum is not fully understood, but several factors are believed to contribute:

Hormonal Factors

  • Human chorionic gonadotropin (hCG): Elevated levels correlate with HG severity
  • Estrogen: High levels may contribute to nausea and vomiting
  • Progesterone: May slow gastric emptying
  • Thyroid hormones: Hyperthyroidism often accompanies HG

Genetic Factors

  • Family history of HG increases risk
  • Genetic variations in hormone receptors
  • Inherited susceptibility to motion sickness
  • Ethnic predisposition (higher in some populations)

Risk Factors

  • Multiple pregnancy: Twins, triplets increase risk
  • Previous HG: 15-80% recurrence rate
  • Female fetus: Slightly higher risk
  • First pregnancy: More common in primigravidas
  • Young maternal age: Higher risk in younger women
  • Molar pregnancy: Associated with very high hCG levels

Medical Conditions

  • Thyroid disorders (hyperthyroidism)
  • Gastrointestinal disorders
  • Psychiatric conditions (depression, anxiety)
  • Diabetes
  • History of eating disorders

Diagnosis

HG diagnosis is primarily clinical, based on symptoms and exclusion of other conditions:

Diagnostic Criteria

  • Persistent nausea and vomiting
  • Weight loss >5% of pre-pregnancy weight
  • Dehydration
  • Electrolyte imbalances
  • Ketonuria (ketones in urine)
  • Inability to maintain nutrition and hydration

Laboratory Tests

  • Electrolytes: Sodium, potassium, chloride levels
  • Kidney function: Blood urea nitrogen, creatinine
  • Liver function: ALT, AST, bilirubin
  • Thyroid function: TSH, free T4
  • Urinalysis: Specific gravity, ketones, protein
  • Complete blood count: Check for hemoconcentration

Imaging and Other Tests

  • Pelvic ultrasound to confirm pregnancy and rule out molar pregnancy
  • Upper GI series if other conditions suspected
  • Abdominal ultrasound if gallbladder disease suspected

Differential Diagnosis

  • Gastroenteritis
  • Food poisoning
  • Peptic ulcer disease
  • Gallbladder disease
  • Pancreatitis
  • Appendicitis
  • Urinary tract infection
  • Hyperthyroidism

Treatment and Management

Treatment goals include controlling nausea and vomiting, correcting dehydration and nutritional deficiencies, and preventing complications:

Initial Management

  • IV fluid therapy: Normal saline or lactated Ringer's solution
  • Electrolyte replacement: Potassium, magnesium, phosphorus
  • Thiamine (Vitamin B1): To prevent Wernicke encephalopathy
  • Nothing by mouth initially: Rest the GI tract

Anti-nausea Medications

  • First-line:
    • Pyridoxine (Vitamin B6) + Doxylamine
    • Ondansetron (Zofran)
    • Metoclopramide (Reglan)
  • Second-line:
    • Promethazine (Phenergan)
    • Prochlorperazine (Compazine)
    • Diphenhydramine (Benadryl)
  • Third-line:
    • Corticosteroids (methylprednisolone)
    • Chlorpromazine

Nutritional Support

  • Oral refeeding: Small, frequent, bland meals
  • Enteral nutrition: Nasogastric or jejunostomy tube feeding
  • Parenteral nutrition: Total parenteral nutrition (TPN) for severe cases
  • Vitamin supplementation: Especially B vitamins and folate

Alternative Therapies

  • Ginger: Natural anti-nausea properties
  • Acupuncture/Acupressure: P6 (Nei Guan) point stimulation
  • Aromatherapy: Peppermint or lemon scents
  • Hypnosis: May help reduce symptoms

Hospitalization Criteria

  • Severe dehydration
  • Electrolyte imbalances
  • Weight loss >5% of pre-pregnancy weight
  • Ketonuria
  • Inability to tolerate oral intake
  • Failed outpatient management

Complications

Maternal Complications

  • Nutritional deficiencies: Thiamine, folate, B12 deficiency
  • Wernicke encephalopathy: Rare but serious neurological complication
  • Mallory-Weiss tear: Esophageal tear from severe vomiting
  • Pneumothorax: From forceful vomiting
  • Dental problems: Enamel erosion from stomach acid
  • Depression and anxiety: Psychological impact
  • PTSD: Post-traumatic stress from severe illness

Fetal Complications

  • Small for gestational age (SGA)
  • Low birth weight
  • Preterm birth
  • Intrauterine growth restriction (IUGR)

Long-term Effects

  • Fear of future pregnancies
  • Impact on family planning decisions
  • Chronic digestive issues
  • Dental problems requiring ongoing care

Prognosis and Outlook

Typical Course

  • Symptoms usually begin 4-6 weeks of pregnancy
  • Peak severity around 9-13 weeks
  • Most cases improve by 20 weeks
  • Some women have symptoms throughout pregnancy
  • Symptoms resolve after delivery

Factors Affecting Prognosis

  • Early recognition and treatment
  • Severity of initial presentation
  • Response to medications
  • Support system availability
  • Previous pregnancy history

Future Pregnancies

  • Recurrence rate: 15-80%
  • May be less severe in subsequent pregnancies
  • Preconception counseling recommended
  • Early intervention strategies can be planned