Hyperemesis Gravidarum

Last Updated: June 4, 2023

Hyperemesis gravidarum is nausea and vomiting that occurs during pregnancy and can lead to dehydration, weight loss, and electrolyte imbalances. Hyperemesis gravidarum is different from morning sickness, which is mild nausea and vomiting during early pregnancy.

Hyperemesis Gravidarum falls under thePregnancy & Childrencategory.

What is hyperemesis gravidarum?

Hyperemesis gravidarum is a severe form of nausea and vomiting in pregnancy. It generally begins in the first trimester of pregnancy, at around 6 to 8 weeks of gestation, and resolves for most people by 20 weeks of gestation, although it can persist until delivery.[1] Hyperemesis gravidarum is different from morning sickness, which is a common form of nausea and vomiting during pregnancy that is mild to moderate in nature and occurs in about 80% of pregnancies. Conversely, hyperemesis gravidarum affects about 1% to 3% of pregnancies.[2]

Hyperemesis gravidarum is a leading cause of hospitalization during pregnancy and can result in dehydration, weight loss, electrolyte imbalances, and nutritional deficiencies.[3] It can also negatively affect psychosocial well-being, provoking feelings of depression and anxiety.[4] In very serious cases, it can adversely affect the fetus and is associated with preterm birth, low birth weight babies, and small for gestational age babies.[5]

What are the main signs and symptoms of hyperemesis gravidarum?

The main signs and symptoms are severe nausea, frequent vomiting, increased salivation, and a loss of appetite, with few to no symptom-free days; symptoms usually begin around 6 weeks of gestation. This can lead to weight loss, electrolyte imbalances, nutritional deficiencies, and symptoms of dehydration such as dizziness, headache, lightheadedness, lethargy, decreased urination, and heart palpitations.[6] Frequent vomiting can cause damage to the esophagus, and in very serious cases, prolonged nutritional deficiencies and electrolyte imbalances, which can cause neurological and cardiovascular damage or even maternal and fetal death; however, these grave outcomes are increasingly rare with access to medical treatments.[7] Although most symptoms resolve around 20 weeks of gestation, some people have nausea and vomiting until the third trimester or even until delivery.[8][9]

Hyperemesis gravidarum can also have psychosocial impacts, such as reduced quality of life, depression, anxiety, inability to work or perform daily activities, job loss, fear of future pregnancies, and even considering or actually terminating the current pregnancy.[10][11][12] These negative effects on mental health can persist into the post-partum period, sometimes causing post-traumatic stress disorder.[13]

How is hyperemesis gravidarum diagnosed?

There is no universal definition for hyperemesis gravidarum. It is usually diagnosed based on a combination of signs and symptoms that are not due to other causes and begin early in pregnancy, including persistent and severe nausea and vomiting, dehydration, weight loss (≥5% of pre-pregnancy weight), inability to eat and drink normally, strong limitation of daily activities, and the presence of ketones in the urine.[3][14]

In order to rule out other causes and determine the severity of the condition (which informs treatment), a clinician may perform an assessment, evaluate certain signs (like weight and blood pressure), order laboratory tests (to check hydration status, electrolyte balance, liver chemistries, nutritional status, thyroid function, etc.), and complete an obstetric ultrasound to check the health of the fetus.[15]

What are some of the main medical treatments for hyperemesis gravidarum?

Medical treatments for hyperemesis gravidarum focus on symptom management and prevention of complications. This usually involves rehydration (e.g., intravenous fluids), nutritional support, and anti-nausea medications. Depending on the severity of the condition, hospitalization may be required.[15]

There are a variety of medications used to control nausea and vomiting, and some people require a combination of medications to better manage their symptoms. Some common medications for hyperemesis gravidarum include promethazine (a dopamine and serotonin antagonist and antihistamine), ondansetron (a serotonin antagonist), and metoclopramide (a dopamine and serotonin antagonist that can increase lower esophageal sphincter tone and gastric emptying). Corticosteroid medications, like prednisone, are sometimes used, but their safety in pregnancy has been questioned. Although doxylamine/vitamin b6 is a first-line medication for morning sickness, it has not been studied in hyperemesis gravidarum.[1][3]

If there are signs and symptoms of dehydration, intravenous fluids are often required to rehydrate the body and correct vitamin deficiencies and electrolyte imbalances. Tube feeding may be required for nutritional support in people with hyperemesis gravidarum who are unable to maintain weight with oral food intake.[3][16]

Have any supplements been studied for hyperemesis gravidarum?

The vomiting associated with hyperemesis gravidarum can result in the depletion of important vitamins, including thiamine (vitamin B1) and vitamin K, which can lead to further neurological and cardiovascular complications.[7] Repletion of these vitamins will generally be included in standard medical care, but supplementation may also be recommended to maintain adequate levels.

As in all pregnancies, supplementation with a prenatal vitamin is recommended to ensure baseline vitamin and mineral requirements are being met. Certain vitamins and minerals can also be administered intramuscularly or intravenously if nausea and vomiting prevent oral intake.

Pyridoxine (vitamin B6) and ginger are effective for treating mild to moderate nausea and vomiting in pregnancy, but they have not been found to be effective for the severe nausea and vomiting of hyperemesis gravidarum.[1][17]

How could diet affect hyperemesis gravidarum?

Maintaining adequate food intake during hyperemesis gravidarum can be challenging. To improve tolerance, eating small, frequent meals may be helpful. Foods that are bland and high in protein or carbohydrates tend to be better tolerated, while foods with a strong odor or high-fat foods may worsen symptoms. Ultimately, any foods and beverages that are pregnancy-safe and tolerated should be consumed.[6]

Are there any other treatments for hyperemesis gravidarum?

Low-quality evidence suggests that acupuncture and acupressure may help to reduce nausea and the need for medications.[1][6] In particular, the PC6 or NeiGuan point is the most thoroughly studied for nausea and vomiting and is located on the underside of the wrist, approximately 3 cm above the wrist crease between two tendons.[18] Pressure can be applied manually or by utilizing a wristband device. There is also data suggesting that hypnotherapymay be a helpful adjunctive treatment for certain people,[19][20] as can psychotherapy.[17]

What causes hyperemesis gravidarum?

The causes of hyperemesis gravidarum are poorly understood and likely multifactorial. Genetics appear to play an important role, as risk increases substantially if a sister or mother experienced hyperemesis gravidarum during pregnancy.[21] In fact, a genome-wide association study found that two genes, GDF15 and IGFBP7, are associated with hyperemesis gravidarum. These genes are involved in the formation of the placenta and appetite regulation.[22] Hormonal changes during pregnancy, particularly increased human chorionic gonadotropin but also changes in progesterone, estrogen, and thyroid hormones, have been found to be associated with an increased risk of hyperemesis gravidarum in some research. It is speculated that people with hyperemesis gravidarum may have higher than normal levels of these hormones; however, the data are inconsistent, and clear associations between levels of these hormones and risk of hyperemesis gravidarum are lacking.[3][15][23]

Examine Database: Hyperemesis Gravidarum
What works and what doesn't?

Unlock the full potential of Examine

Get started

Don't miss out on the latest research

Update History
References
  1. ^Boelig RC, Barton SJ, Saccone G, Kelly AJ, Edwards SJ, Berghella VInterventions for treating hyperemesis gravidarum: a Cochrane systematic review and meta-analysis.J Matern Fetal Neonatal Med.(2018-Sep)
  2. ^Matthews A, Haas DM, O'Mathúna DP, Dowswell TInterventions for nausea and vomiting in early pregnancyCochrane Database Syst Rev.(2015 Sep 8)
  3. ^London V, Grube S, Sherer DM, Abulafia OHyperemesis Gravidarum: A Review of Recent LiteraturePharmacology.(2017)
  4. ^Poursharif B, Korst LM, Fejzo MS, MacGibbon KW, Romero R, Goodwin TMThe psychosocial burden of hyperemesis gravidarum.J Perinatol.(2008-Mar)
  5. ^Veenendaal MV, van Abeelen AF, Painter RC, van der Post JA, Roseboom TJConsequences of hyperemesis gravidarum for offspring: a systematic review and meta-analysis.BJOG.(2011-Oct)
  6. ^Austin K, Wilson K, Saha SHyperemesis Gravidarum.Nutr Clin Pract.(2019-Apr)
  7. ^Popa SL, Barsan M, Caziuc A, Pop C, Muresan L, Popa LC, Perju-Dumbrava LLife-threatening complications of hyperemesis gravidarum.Exp Ther Med.(2021-Jun)
  8. ^Goodwin TMHyperemesis gravidarum.Obstet Gynecol Clin North Am.(2008-Sep)
  9. ^Nurmi M, Rautava P, Gissler M, Vahlberg T, Polo-Kantola PReadmissions due to hyperemesis gravidarum: a nation-wide Finnish register study.Arch Gynecol Obstet.(2022-Nov)
  10. ^Heitmann K, Nordeng H, Havnen GC, Solheimsnes A, Holst LThe burden of nausea and vomiting during pregnancy: severe impacts on quality of life, daily life functioning and willingness to become pregnant again - results from a cross-sectional studyBMC Pregnancy Childbirth.(2017 Feb 28)
  11. ^Poursharif B, Korst LM, Macgibbon KW, Fejzo MS, Romero R, Goodwin TMElective pregnancy termination in a large cohort of women with hyperemesis gravidarum.Contraception.(2007-Dec)
  12. ^Nijsten K, Dean C, van der Minnen LM, Bais JMJ, Ris-Stalpers C, van Eekelen R, Bremer HA, van der Ham DP, Heidema WM, Huisjes A, Kleiverda G, Kuppens SM, van Laar JOEH, Langenveld J, van der Made F, Papatsonis D, Pelinck MJ, Pernet PJ, van Rheenen-Flach L, Rijnders RJ, Scheepers HCJ, Vogelvang T, Mol BW, Roseboom TJ, Koot MH, Grooten IJ, Painter RCRecurrence, postponing pregnancy, and termination rates after hyperemesis gravidarum: Follow up of the MOTHER study.Acta Obstet Gynecol Scand.(2021-Sep)
  13. ^Nijsten K, van der Minnen LM, Dean C, Bais JMJ, Ris-Stalpers C, van Eekelen R, Bremer HA, van der Ham DP, Heidema WM, Huisjes A, Kleiverda G, Kuppens SM, van Laar JOEH, Langenveld J, van der Made F, Papatsonis D, Pelinck MJ, Pernet PJ, van Rheenen-Flach L, Rijnders RJ, Scheepers HCJ, Vogelvang T, Mol BW, Olff M, Roseboom TJ, Koot MH, Grooten IJ, Painter RCDepression, anxiety, and post-traumatic stress disorder symptoms after hyperemesis gravidarum: a prospective cohort study.J Matern Fetal Neonatal Med.(2022-Dec)
  14. ^L A W Jansen, M H Koot, J Van't Hooft, C R Dean, P M M Bossuyt, W Ganzevoort, N Gauw, B Y Van der Goes, J Rodenburg, T J Roseboom, R C Painter, I J GrootenThe windsor definition for hyperemesis gravidarum: A multistakeholder international consensus definitionEur J Obstet Gynecol Reprod Biol.(2021 Nov)
  15. ^Marlena S Fejzo, Jone Trovik, Iris J Grooten, Kannan Sridharan, Tessa J Roseboom, Åse Vikanes, Rebecca C Painter, Patrick M MullinNausea and vomiting of pregnancy and hyperemesis gravidarumNat Rev Dis Primers.(2019 Sep 12)
  16. ^ACOG Practice Bulletin No. 189 Summary: Nausea And Vomiting Of Pregnancy.Obstet Gynecol.(2018-Jan)
  17. ^McParlin C, O'Donnell A, Robson SC, Beyer F, Moloney E, Bryant A, Bradley J, Muirhead CR, Nelson-Piercy C, Newbury-Birch D, Norman J, Shaw C, Simpson E, Swallow B, Yates L, Vale LTreatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review.JAMA.(2016-Oct-04)
  18. ^Van den Heuvel E, Goossens M, Vanderhaegen H, Sun HX, Buntinx FEffect of acustimulation on nausea and vomiting and on hyperemesis in pregnancy: a systematic review of Western and Chinese literature.BMC Complement Altern Med.(2016-Jan-13)
  19. ^Ozgunay SE, Dincgez B, Karasu D, Ozgen G, Taymur I, Eminoglu S, Ceylan IAdjuvant Hypnotherapy for Hyperemesis Gravidarum: A Randomized Pilot Study.Int J Clin Exp Hypn.(2022)
  20. ^Torem MSHypnotherapeutic techniques in the treatment of hyperemesis gravidarum.Am J Clin Hypn.(1994-Jul)
  21. ^Fejzo MS, Ingles SA, Wilson M, Wang W, MacGibbon K, Romero R, Goodwin TMHigh prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals.Eur J Obstet Gynecol Reprod Biol.(2008-Nov)
  22. ^Fejzo MS, Sazonova OV, Sathirapongsasuti JF, Hallgrímsdóttir IB, Vacic V, MacGibbon KW, Schoenberg FP, Mancuso N, Slamon DJ, Mullin PM,Placenta and appetite genes GDF15 and IGFBP7 are associated with hyperemesis gravidarum.Nat Commun.(2018-Mar-21)
  23. ^Liu C, Zhao G, Qiao D, Wang L, He Y, Zhao M, Fan Y, Jiang EEmerging Progress in Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum: Challenges and Opportunities.Front Med (Lausanne).(2021)
  24. ^Dean CR, Bruin CM, O'Hara ME, Roseboom TJ, Leeflang MM, Spijker R, Painter RCThe chance of recurrence of hyperemesis gravidarum: A systematic review.Eur J Obstet Gynecol Reprod Biol X.(2020-Jan)
  25. ^Ng QX, Venkatanarayanan N, De Deyn MLZQ, Ho CYX, Mo Y, Yeo WSA meta-analysis of the association between Helicobacter pylori (H. pylori) infection and hyperemesis gravidarum.Helicobacter.(2018-Feb)
  26. ^Jansen LAW, Nijsten K, Limpens J, van Eekelen R, Koot MH, Grooten IJ, Roseboom TJ, Painter RCPerinatal outcomes of infants born to mothers with hyperemesis gravidarum: A systematic review and meta-analysis.Eur J Obstet Gynecol Reprod Biol.(2023-May)
  27. ^Morisaki N, Nagata C, Morokuma S, Nakahara K, Kato K, Sanefuji M, Shibata E, Tsuji M, Shimono M, Kawamoto T, Ohga S, Kusuhara K,Lack of catch-up in weight gain may intermediate between pregnancies with hyperemesis gravidarum and reduced fetal growth: the Japan Environment and Children's Study.BMC Pregnancy Childbirth.(2022-Mar-12)
  28. ^Dodds L, Fell DB, Joseph KS, Allen VM, Butler BOutcomes of pregnancies complicated by hyperemesis gravidarum.Obstet Gynecol.(2006-Feb)
  29. ^Nijsten K, Jansen LAW, Limpens J, Finken MJJ, Koot MH, Grooten IJ, Roseboom TJ, Painter RCLong-term health outcomes of children born to mothers with hyperemesis gravidarum: a systematic review and meta-analysis.Am J Obstet Gynecol.(2022-Sep)
  30. ^Koren G, Maltepe CPre-emptive therapy for severe nausea and vomiting of pregnancy and hyperemesis gravidarum.J Obstet Gynaecol.(2004-Aug)
  31. ^Cao X, Sun M, Yang Q, Wang Q, Hou L, Wang J, Wu Y, Ge LRisk of abnormal pregnancy outcomes after using ondansetron during pregnancy: A systematic review and meta-analysis.Front Pharmacol.(2022)
  32. ^Pasternak B, Svanström H, Mølgaard-Nielsen D, Melbye M, Hviid AMetoclopramide in pregnancy and risk of major congenital malformations and fetal death.JAMA.(2013-Oct-16)
  33. ^Dormuth CR, Winquist B, Fisher A, Wu F, Reynier P, Suissa S, Dahl M, Ma Z, Lu X, Zhang J, Raymond CB, Filion KB, Platt RW, Moriello C, Paterson JM,Comparison of Pregnancy Outcomes of Patients Treated With Ondansetron vs Alternative Antiemetic Medications in a Multinational, Population-Based Cohort.JAMA Netw Open.(2021-Apr-01)
  34. ^Fejzo MS, MacGibbon KW, Mullin PMOndansetron in pregnancy and risk of adverse fetal outcomes in the United States.Reprod Toxicol.(2016-Jul)
Examine Database References
  1. Nausea Symptoms - Fischer-Rasmussen W, Kjaer SK, Dahl C, Asping UGinger treatment of hyperemesis gravidarumEur J Obstet Gynecol Reprod Biol.(1991 Jan 4)
  2. Nausea Symptoms - Smith C, Crowther C, Willson K, Hotham N, McMillian VA randomized controlled trial of ginger to treat nausea and vomiting in pregnancyObstet Gynecol.(2004 Apr)
  3. Nausea Symptoms - Ernst E, Pittler MHEfficacy of ginger for nausea and vomiting: a systematic review of randomized clinical trialsBr J Anaesth.(2000 Mar)