hiperemesis gravidea.pdf

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Hyperemesis gravidarum, or pernicious vomit-

ing of pregnancy, is a complication of preg-nancy that affects various areas of the womans

health, including homeostasis, electrolytes, andkidney function, and may have adverse fetal con-sequences. Nausea and vomiting are common inpregnancy, affecting up to 70% to 85% of pregnantwomen.1 Hyperemesis affects between 0.3% and2.3% of all pregnancies.2 The condition is definedas uncontrolled vomiting requiring hospitalization,severe dehydration, muscle wasting, electrolyteimbalance, ketonuria, and weight loss of more than

5% of body weight.3 Most of these patients also have

hyponatremia, hypokalemia, and a low serum urea

level.4 Ptyalism is also a typical symptom of hyper-emesis.5 The symptoms of this disorder usually peakat 9 weeks of gestation and subside by approximately20 weeks of gestation.6 Approximately 1% to 5% ofpatients with hyperemesis must be hospitalized.7Women who experienced hyperemesis in their firstpregnancy have a high risk for recurrence.6,8,9

The differential diagnosis of hyperemesis gravi-darum (Table 1) includes urinary tract infection,uremia, thyrotoxicosis, diabetic ketoacidosis, Addisondisease, hypercalcemia, gastritis, peptic ulcer dis-

ease, pancreatitis, bowel obstruction, hepatitis,

Treatment of Hyperemesis Gravidarum

Lindsey J. Wegrzyniak, DO,1 John T. Repke, MD,2 Serdar H. Ural, MD21Philadelphia College of Osteopathic Medicine, Philadelphia, PA; 2The Pennsylvania State University College ofMedicine, Department of Obstetrics and Gynecology, Hershey, PA

Hyperemesis gravidarum, or pernicious vomiting of pregnancy, is a complication of preg-

nancy that affects various areas of the womans health, including homeostasis, electro-

lytes, and kidney function, and may have adverse fetal consequences. Recent research

now provides additional guidelines for protection against and relief from hyperemesis

gravidarum. Alterations to maternal diet and lifestyle can have protective effects.

Medicinal methods of prevention and treatment include nutritional supplements and

alternative methods, such as hypnosis and acupuncture, as well as pharmacotherapy.

[Rev Obstet Gynecol. 2012;5(2):78-84 doi: 10.3909/riog0176 ]

2012 Medreviews, LLC

Key words

Hyperemesis gravidarum Nausea Vomiting Pregnancy

78 Vol. 5 No. 2 2012 Reviews in Obstetrics & Gynecology

TreaTmenT review


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battling hyperemesis have a vari-ety of different obstacles to over-come before becoming healthy. Theinfants of mothers with hyperemesismay be born prematurely, be small

for gestational age, have significantlylower birth weights,15 or have 5-min-ute Apgar scores of, 7.8

In a meta-analysis completedby Veenendaal and colleagues,16

pregnant women with hypereme-sis gravidarum were more likely todeliver babies who were born smallfor gestational age (odds ratio[OR] 1.28; 95% confidence interval[CI], 1.02-1.60). Hyperemesis wasalso found to be associated with

delivery before 37 weeks of gesta-tion when compared with subjectswithout hyperemesis (OR 1.32; 95%CI, 1.04-1.68).16 There may be anassociation between hyperemesisand testicular cancer, which maybe due to hormonal imbalance. Ithas been reported that the increaseof in-utero estradiol in womenwith hyperemesis gravidarum mayprevent the infants testes fromdescending.16

Although hyperemesis has cleardetrimental effects, there are areasof study that show limitations inthe ways in which infants can beaffected. When comparing infantsborn at an early gestational age tothose who were not, there was nosignificant difference in Apgarscores, congenital anomalies, orperinatal death.16 In this study,there were no significant findings

in long-term outcomes between

drug-induced vomiting, centralnervous system (CNS) disease, and

vestibular disease.

4,10

It may alsocause Mallory-Weiss tears andesophageal rupture.6,11 If not ap-propriately treated, it may causesevere adverse effects, includingneurologic disturbances, such asWernicke encephalopathy, centralpontine myelinolysis, and evenmaternal death.

Studies have focused on thereasons some pregnant mothersdevelop hyperemesis; however, thecause has not yet been clearly iden-tified. The pathogenesis is not fullyunderstood, but may be attrib-uted to hormones, gastrointestinal(GI) dysfunction, thyrotoxicosis,serotonin, hepatic abnormalities,autonomic nervous dysfunction,nutritional deficiencies, asthma,8allergies,12Helicobacter pylori infec-tion,13 or psychosomatic causes.8,14

This condition does not just affect

the mother. Babies born to mothers

women with and without hyper-emesis.16 Neurological maturity wasalso not affected by age 1 year.

Hyperemesis has a tremendousdetrimental effect on the weight of

newborns, which is a focus of recentresearch. When comparing womenwith hyperemesis having , 7 kgof weight gain during pregnancywith women who gained $ 7 kg,

the risk of a small for gestational ageinfant was increased (OR 1.5; 95%CI, 1.0-2.2).16 Also, babies of womenwith , 7 kg of weight gain had anincreased risk of having a 5-minuteApgar score of, 7 (OR 5.0; 95% CI,2.6-9.6) compared with babies from

the control group.16

The authors con-cluded that hyperemesis itself is not arisk factor for adverse outcomes, butthese outcomes are the consequenceof the low weight gain associatedwith hyperemesis. With minimalweight gain, adverse outcomes forthe newborns have been noted.16

If a mother does have significantweight loss during pregnancy, itcan create further complications.In a retrospective analysis, patientswho had. 5% weight loss and weremalnourished have experiencedadverse pregnancy outcomes.16These results include low birthweight, antepartum hemorrhage,preterm delivery, and an associa-tion with fetal anomalies. Thereare reports of congenital malfor-mations such as undescended tes-ticles, hip dysplasia, and Downsyndrome.16 Studies also have

shown an increased incidence of

ThyrotoxicosisDiabetic ketoacidosis

Addison diseaseHypercalcemiaGastritisGastroparesisPeptic ulcer diseasePancreatitisAppendicitisAcute fatty liver of pregnancyBowel obstructionHepatitisKidney stone

Urinary tract infectionUremiaDrug-induced vomitingMigrainesCentral nervous system diseaseVestibular disease

TABLe 1

Differential Diagnosis ofVomiting During Pregnancy

The infants of mothers with hyperemesis may be born prematurely,be small for gestational age, have signicantly lower birthweights, or have 5-minute Apgar scores of 7.

When comparing women with hyperemesis having 7 kg ofweight gain during pregnancy with women who gained 7 kg,the risk of a small for gestational age infant was increased.

Vol. 5 No. 2 2012 Reviews in Obstetrics & Gynecology 79



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thiamine may be diluted in 100 mLof normal saline and infused for30 minutes to 1 hour weekly.4

AntiemeticsSeveral common drugs are used

as antiemetics to control nauseaand vomiting during pregnancy.They should not be used before12 to 14 weeks of gestation due topossible detrimental effects to thedeveloping fetus.4 However, thereare data showing lack of teratoge-nicity with the use of dopamineantagonists, phenothiazines, andhistamine receptor blockers.4

In their 2004 guidelines on vom-

iting in pregnancy, the AmericanCongress of Obstetricians andGynecologists recommended thatthe first-line antiemetic medica-tions be IV dimenhydrinate, meto-clopramide, or promethazine.1 In adouble-blind study conducted byTan and colleagues,2 promethazineand metoclopramide were found tohave similar therapeutic effects forthe treatment of hyperemesis

(P5

.47), but there were feweradverse effects with metoclo-pramide.2 Medications includedpromethazine, 25 mg, or metoclo-pramide, 10 mg, every 8 hours for24 hours. Metoclopramide causedsignificantly less frequent drowsi-ness (P5 .001), dizziness (P, .001),and dystonia (P5 .02) when com-pared with promethazine.2

In a study by Nageotte and col-leagues,17 patients using a combina-tion treatment of droperidol anddiphenhydramine had significantlyshorter hospital stays for hyper-emesis, fewer days hospitalized forhyperemesis during pregnancy,

and fewer readmissions for hyper-emesis compared with those who

were not treated with droperidol

food and fluids more often canhelp prevent mild cases of nauseaand vomiting from worsening.The meals should contain morecarbohydrate than fat and acid.6Protein-rich meals also decreasesymptoms. Lighter snacks, includ-

ing nuts, dairy products, andbeans, are often endorsed. Drinksthat contain electrolytes and othersupplements are advised. If certainfoods or food preparations triggernausea, they should be avoided.

LifestyleWomen who are affected by thisillness should avoid stress and tryto get as much rest as possible. Ifemotional support is needed, thepatient can see a psychologistto help address the debilitatingsymptoms. Supportive counsel-ing or crisis intervention may benecessary.6

Intravenous FluidsIntravenous (IV) fluids shouldbe provided to replenish the lost

intravascular volume. Rehydrationalong with replacement of elec-trolytes is very important in thetreatment of hyperemesis. Normalsaline or Hartmann solution aresuitable solutions; potassiumchloride can be added as needed.While replacing electrolytes, thephysician must consider the risksof rapid infusion in order to pre-vent such conditions as centra l

pontine myelinolysis.4

ThiamineThiamine should be a routine sup-plement in patients with protracted

vomiting. Pregnant women shouldingest a total of 1.5 mg/d. If this

cannot be taken orally, 100 mg of

CNS malformation. Researchersagree that the vomiting is mostlikely not teratogenic, but theuntreated electrolyte disturbances,malnutrition, and maternal weightloss may be harmful.10 Babies mayexperience severe effects as a result

of the complications of maternalhyperemesis.

The effects of hyperemesis gravi-darum are quite widespread. Inaddition to feeling ill, women withthis condition report other sourcesof distress, including time lostfrom work and decreased qualityof life.6 In a study of 147 patients,82.8% were restricted in theireveryday activities. They reported

being limited not only due to thenausea and vomiting, but also fromthe psychological affliction thatwas caused by feeling ill for weeksto months.6 Women have alsoreported feeling treated differentlysocially as well as in the workplace.Hyperemesis can result in finan-cial hardship for these patients,their places of employment, andthe health care system,6 showing

that the effects of the disease arenot limited to pregnant womenalone.

Recent research now providesadditional guidelines for pro-tection against and relief fromhyperemesis gravidarum. Thesetreatment methods include a rangeof options, from routine changes tomedications and various differenttherapies. Alterations to maternaldiet and lifestyle can have protec-tive effects. Medicinal methods ofprevention and treatment includenutritional supplements as well asalternative methods, such as hyp-nosis and acupuncture.

DietModification of the amount andsize of meals consumed through-out the day may help relieve symp-

toms. Having smaller amounts of

Thiamine should be a routine supplement in patients withprotracted vomiting.


Treatment of Hyperemesis Gravidarum continued


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responses and consequent nauseafeedback.

In a double-blind, randomized,crossover trial, 1 g of ginger wasadministered daily for 4 days. Thepreference among the patients toreceive ginger versus placebo was

significant.12 Concurrently, therelief of nausea and vomiting foundwith the use of ginger comparedwith placebo was significantlygreater. In a study by Vutyavanichand associates,20 1 g of ginger wasgiven to women with hypereme-sis for 4 days, and two measur-ing scales were implemented toquantify patients nausea.20 Theimprovement in the nausea scores

of patients receiving ginger was sig-nificantly greater than that of theplacebo group. Also, after 4 days oftreatment, there was a significantdecrease in vomiting in the ginger-treated group versus the placebo-treated group.20 However, differentcollections of ginger may differ dueto their growing climates, condi-tions, and harvesting times.20 Therehave been no teratogenic effects of

ginger in this or other studies.12

Nasogastric EnteralFeedingIn one study of seven patients withhyperemesis, the placement of aDobhoff tube improved symp-toms of nausea and vomiting in24 hours, and symptoms continuedto improve with enteral feedings.The mean hospitalization afterfeedings began was 4.6 days, withthe longest being 8 days. On dis-charge, one woman did not requireenteral feedings, and the other sixcontinued feedings in the outpa-tient setting. The average durationof feedings was 43 days, rangingfrom 5 to 174 days. One patient wascontent with the enteral feedingsand continued them for 174 days;however, the second longest dura-

tion was only 49 days.21

between 15 and 45 mg/d helpedpatients resume eating, reversemuscle wasting, and regain lostweight from prepregnancy weight.After discharge, maintenancedoses of$ 15 mg/d were used from6 to 20 weeks.5 There is no clear evi-

dence of steroid teratogenicity.5,15 Itis advised that steroids only be usedafter all other causes of vomitinghave been excluded, vomiting hascontinued for more than 4 weeksand is associated with dehydration,and the risks and benefits of thetreatment have been explained.5

In a randomized, double-blind,controlled study comparing steroidsand promethazine for the treat-

ment of hyperemesis, steroids werefound to be more effective.19 Oralmethylprednisolone, 16 mg, wasadministered three times daily, andpromethazine, 25 mg, was adminis-tered three times daily. No womenwere readmitted to the hospitalwho were treated with methylpred-nisolone, but five patients from thepromethazine group were readmit-ted to the hospital for hyperemesis

within 2 weeks of discharge. Neitherdrug displayed adverse effects.

GingerThe GI symptoms of motion sick-ness and hyperemesis are simi-lar; therefore, the root of ginger,Zingiber officinale, has been stud-ied to treat hyperemesis. The effec-tiveness of ginger is thought to bedependent on its aromatic, carmi-native, and absorbent characteris-tics. It is thought to act on the GItract to increase motility, and itsabsorbent property may decreasestimuli to the chemoreceptor zone

in the medulla that sends stimulito the emetic center of the brain

stem. Ginger may also block the GI

or diphenhydramine as a primarytherapy.17 Droperidol was dosed ini-tially at 1.0 to 2.5 mg, depending onseverity of symptoms, and admin-istered over 15 minutes. A con-tinuous infusion was then startedat 1.0 mg/h. If the symptoms per-

sisted, the amount was increased to1.25 mg/h, and increases from thatpoint were made in 0.25-mg incre-ments every 4 hours. Droperidol isstructurally related to haloperidol;it did not cause abnormal fetal orneonatal outcomes, and there wereno maternal adverse outcomes,including hypotension.17

Ondansetron is a 5-HT3

antag-onist that acts on the CNS and

peripheral nervous system. Theprimary location of action is in theCNS, but it also increases gastricemptying. It is very effective forpatients who experience the emeticeffects of chemotherapy.18 It alsoaids patients with postoperativenausea and vomiting. A study onondansetron found it to decreasevomiting after the first dose anddecrease nausea subsequently.18 The

patient studied was able to tolerate alight diet after 2 days of treatment,and she was discharged 14 daysafter being admitted on 4 mg ofondansetron three times daily.

SteroidsThe mechanism of action of steroidsis assumed to be a direct effect on thevomiting center of the brain. Becausesuch high doses are required, it isimprobable that there is a lack ofpituitary adrenal reserve in thisillness.

One study showed vomit-ing ceased in all patients within

3 hours after administration ofthe first dose of IV hydrocorti-

sone. Maintenance doses ranging

One study showed vomiting ceased in all patients within 3 hoursafter administration of the rst dose of IV hydrocortisone.




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should begin at 30 to 45 mL/hand increase in increments of20 mL/h/d.3

Fat emulsions have been shownto induce contractions of theuterine muscle at a high infusionrate.3,22 This may happen at any

point in the pregnancy. Placentalinfarctions and placental fat depos-its are also a risk with fat emulsioninfusions, possibly resulting in pla-cental insufficiency.3,22 Fat emul-sions should not exceed 3 g/kg/d,or more than 60% of the total calo-ries, to avoid a fat overload.22 TPNshould be discontinued once thewoman is able to tolerate enteralfeedings.22 Infections are also a risk

of TPN, and vigilant observationmust be practiced.4 More severerisks when using TPN include sep-sis and cardiac complications dueto electrolyte imbalances.1

AcupunctureIn addition to standard treat-ment, acupuncture to PC6, whichis the point 5 cm proximal to the

wrist crease on the palmar sideof the forearm, could quicken theresolution of hyperemesis. In aplacebo-controlled, randomized,single-blind, crossover study, acu-puncture treatments were givenfor 30 minutes three times a daybecause, in previous studies, an8-hour treatment effect had beenshown. Women in the active acu-puncture group versus the placebogroup had a significantly quickerdecrease in the amount of nau-sea they experienced.14 There wasalso a significant difference in theamount of vomiting between thetwo test groups. The active acu-puncture group had significantlyfewer patients vomiting. There wasno significant difference in foodintake between the two groups, andno side effects were observed.

There are a few possible mecha-

nisms of action for the reduction of

were defined by indirect calorim-etry, and the appropriate numberof calories was calculated for eachpatient. The group of hyperemesispatients compared with the twocontrol groups of healthy pregnantwomen and healthy women who

were not pregnant had significantlydifferent substrate utilization. Thehyperemesis patients used fat,consistent with a catabolic state.The hyperemesis group also had amean respiratory quotient that was, 1.00, an indication of a catabolicstate. After treatment with TPN,the respiratory quotient of eachhyperemesis patient was . 1.00,showing a shift to utilization of car-

bohydrate and protein, indicatingan anabolic state and improvementin nutritional status. The pre- andposttreatment mean respiratoryquotients of the hyperemesis group

were significantly different. The

birth weights of the infants sur-passed the average birth weights fortheir respective gestational ages.3

Complications of the TPN cathe-ter include pneumothorax, punc-ture of nearby artery, or airembolism.22 There are also riskswhen using TPN due to the infu-sion of such a large amount of glu-cose. The consequences are similarto a woman with diabetes duringpregnancy. Hyperglycemia maycause fetal anomalies and compli-cations. Elevations in the mothersglucose may increase the risk ofhaving a macrosomic baby.3,12 Aninfusion with a high amount of glu-cose may compromise respiration ifcarbon dioxide is overproduced.22

Hypertonic dextrose infusionsshould be started slowly at 40 mL/hor 1 L/d, then increased.3 If admin-istering solutions containing 25%

or more of dextrose, the infusion

This treatment has potentialcomplications, such as pneumotho-rax aspiration, infection, venousthrombosis, intrahepatic cholesta-sis, and fatty infiltration of theplacenta. In order to minimize thepossibility of aspiration, the feeding

tube was placed past the pylorus.This technique, however, exposesthe patient to radiation to checkthe position of the tube. Despite itsexpense, it is considerably cheapercompared with total parenteralnutrition (TPN). This type of feed-ing is most useful in patients whosenausea and vomiting are associatedwith the consumption of food.21

Total Parenteral NutritionTPN is a nutrient source that maybe used in pregnant women whosuffer from severe hyperemesis or

when there is a lack of absorption

of adequate nutrients.22

The severenutritional deprivation caused byhyperemesis is preferably treatedwith enteral hyperalimentation,but if the patient cannot toleratethis and vomits after feeding, therisk of aspiration increases. TPNhas been used in other conditionsto sustain pregnancies, such as jeju-noileal bypass, diabetes, and Crohndisease.3,22 TPN is a nonproteincalorie source, usually glucose orlipid emulsions, that provides uti-lizable nitrogen, electrolytes, traceelements, water, and fat-solublevitamins. This source of caloriesprevents ketosis, which developsfrom fatty acid metabolism andmay have adverse effects on thefetus.

In order to study the nutri-tional effects of hyperemesis, thebasal metabolic expenditure and

adjusted metabolic expenditure

TPN is a nutrient source that may be used in pregnant women whosuffer from severe hyperemesis or when there is a lack of absorptionof adequate nutrients.




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the suggestion.7 It is, however, nec-essary to dispel any myths or doubtthe patients have about hypnotictreatment. No teratogenic effectswere noted.7 It is also proposed thatexpanding this treatment to womenwith morning sickness would pre-

vent the nausea and vomiting fromworsening or progressing to hyper-emesis gravidarum.

ConclusionsNausea and vomiting are positivepredictors of a favorable pregnancyoutcome, but excessive vomitingmay have negative effects on themother and baby, including low

birth weight, antepartum hemor-rhage, preterm delivery, and fail-ure of infant testes to descend. Inorder to alleviate this nausea andvomiting, the simplest changes areto eat more frequent, smaller mealsand avoid foods or odors that trig-ger vomiting. Another lifestylealteration is to decrease stress andget more rest throughout the day.Thiamine should be supplemented

Hypnosis works through a dis-sociation of content, when theindividuals attention is focusedon a certain task causing the restof the information surround-ing him or her to be temporarilyunreachable. An example of this

is the unnoticed hum of a com-puter motor.7 Hypnosis also actsthrough dissociation of context,in which this narrowing of atten-tion briefly suspends higher-orderprocesses.7

In the case examples of hypnosistreating hyperemesis performedby Simon and Schwartz,7 the treat-ment was found to be effective intwo ways. The first component is a

deep relaxation that acts to decreasesympathetic nervous systemarousal.7 This decreases the sym-pathetic hyperaroused state. Thesecond component is the responseto hypnotic suggestion of symptomremoval. This response to sugges-tion is independent of the sympa-thetic or parasympathetic systemsand is often independent of theirconscious awareness or memory of

hyperemesis from acupuncture. Itseems to inhibit nociceptive trans-mission and autonomic reflexes.It also seems to decrease pain inthe system from the periaqueduc-tal gray, which partially worksthrough endorphinergic mecha-

nisms. Because one potential causeof hyperemesis is reduced gastricemptying, and acupuncture hasan effect on the GI tract, anotherpossible mechanism of action isthrough somatovisceral reflexes.14

HypnosisHypnosis is used to control physio-logic changes that are thought to be

involuntary. Hypnotized patientshave, however, been able to controlsympathetic tone, vasoconstriction,and vasodilation, heart rate, andmuscle tone.7 It has been comparedwith biofeedback because patientsare trained to voluntarily controlthese mechanisms. Biofeedbackuses an external method of feed-back whereas hypnosis uses aninternal control from the patient.

Agent Dosage Efficacy Safety

Metoclopramide 10 mg every 8 h for 24 h Reduces nausea andvomiting

Less drowsiness, dizziness,dystoniaNo known malformations

Promethazine 25 mg every 8 h for 24 h Reduces nausea andvomiting

No known malformations

Diphenhydramine 12.5-25 mg every 4-6 h Reduces nausea andvomiting

No increased risk ofmalformationsCauses drowsiness

Droperidol anddiphenhydramine

1.0-2.5 mg over 15 min, then1.0 mg/h50 mg over 30 min every 6 h

Reduces nausea andvomiting

No abnormal outcomes

Ondansetron 4 mg every 8 h Reduces nausea andvomiting after first dose

Methylprednisolone 16 mg every 8 h No known malformationsGinger 1 mg for 4 d Reduces nausea and

vomitingNo known malformations

TABLe 2

Summary of Treatment Agents




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6. Jueckstock JK, Kaestner R, Mylonas I. Managing

hyperemesis gravidarum: a multimodal challenge.

BMC Med. 2010;8:46.

7. Simon EP, Schwartz J. Medical hypnosis for hypereme-

sis gravidarum. Birth. 1999;26:248-254.

8. Sonkusare S. Hyperemesis gravidarum: a review.Med

Journal Malaysia. 2008;63:272-276.

9. Tan PC, Jacob R, Quek KF, Omar SZ. Pregnancy out-

come in hyperemesis gravidarum and the effect of

laboratory clinical indicators of hyperemesis severity.

J Obstet Gynaecol Res. 2007;33:457-464.

10. Tsang IS, Katz VL, Wells SD. Maternal and fetal out-comes in hyperemesis gravidarum. Int J Gynaecol

Obstet. 1996;55:231-235.

11. Kucu NK, Koyuncu F. Hyperemesis gravidarum:

current concepts and management. Postgrad Med J.

2002;78:76-79.

12. Fischer-Rasmussen W, Kjaer SK, Dahl C, Asping U.

Ginger treatment of hyperemesis gravidarum. Eur J

Obstet Gynecol Reprod Biol. 1991;38:19-24.

13. Eliakim R, Abulafia O, Sherer DM. Hyperemesis gravi-

darum: a current review.Am J Perinatol. 2000;17:207-218.

14. Carlsson CP, Axemo P, Bodin A, et al. Manual acu-

puncture reduces hyperemesis gravidarum: a placebo-

controlled, randomized, single-blind, crossover study.

J Pain Symptoms Manage. 2000;20:273-279.

15. Nelson-Piercy C, Fayers P, de Swiet M. Randomised,

double-blind, placebo-controlled trial of corticoste-

roids for the treatment of hyperemesis gravidarum.BJOG. 2001;108:9-15.

16. Veenendaal MV, van Abeelen AF, Painter RC, et al.

Consequences of hyperemesis gravidarum for off-

spring: a systematic review and meta-analysis. BJOG.

2011;118:1302-1313.

17. Nageotte MP, Briggs GG, Towers CV, Asrat T. Droperidol

and diphenhydramine in the management of hypereme-

sis gravidarum.A J Obstet Gynecol. 1996;174:1801-1805.

18. Tincello DG, Johnstone MJ. Treatment of hyperemesis

gravidarum with the 5-HT3

antagonist ondansetron

(Zofran). Postgrad Med J. 1996;72:688-689.

19. Safari HR, Fassett MJ, Souter IC, et al. The efficacy of

methylprednisolone in the treatment of hyperemesis

gravidarum: a randomized, double-blind, controlled

study.Am J Obstet Gynecol. 1998;179:921-924.

20. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for

nausea and vomiting in pregnancy: randomized,double-masked, placebo-controlled trial. Obstet

Gynecology. 2001;97:577-582.

21. Hsu JJ, Clark-Glena R, Nelson DK, Kim CH. Nasogastric

enteral feeding in the management of hyperemesis

gravidarum. Obstet Gynecology. 1996;88:343-346.

22. Rayburn W, Wolk R, Mercer N, Roberts J. Parental

nutrition in obstetrics and gynecology. Obstet Gynecol

Surv. 1986;41:200-214.

Although the exact mechanism ofaction is unknown, there are noknown adverse effects on the baby.By entering a deeply relaxed stateand decreasing the sympatheticstate through hypnosis, womenwith hyperemesis have reported

improvement in their nausea andvomiting.

Hyperemesis gravidarum is apotentially severe condition thatcan cause detrimental changes inthe pregnant woman and her fetus.In order to decrease these effects,managing the nausea and vomitingas well as their consequences, willprevent harmful or undesired out-comes. The current medications

and treatments reviewed here willaid in proper management andrelief of this disorder.

References

1. American College of Obstetrics and Gynecology.

ACOG (American College of Obstetrics and

Gynecology) Practice Bulletin: nausea and vomiting

of pregnancy. Obstet Gynecol. 2004;103:803-814.

2. Tan PC, Khine PP, Vallikkannu N, Zawiah SZ.

Promethazine compared with metoclopramide for

hyperemesis gravidarum: a randomized controlled

trial. Obstet Gynecol. 2010;115:975-981.

3. Levine MG, Esser D. Total parental nutrition for the

treatment of severe hyperemesis gravidarum: maternal

nutritional effects and fetal outcome. Obstet Gynecol.

1988;72:102-107.

4. Nelson-Piercy C. Treatment of nausea and vomiting in

pregnancy: when should it be treated and what can be

safely taken? Drug Saf. 1998;19:155-164.

5. Taylor R. Successful management of hyperemesis

gravidarum using steroid therapy. QJM. 1996;89:

103-107.

at 1.5 mg/d in women with hyper-emesis. When these methods do nothelp, IV fluids should be adminis-tered to replace the lost fluid andelectrolytes.

The medications found toimprove hyperemesis gravidarum

symptoms without causing detri-mental effects to the fetus are listedin Table 2. Metoclopramide, whencompared with promethazine,proved to cause less drowsiness, diz-ziness, and dystonia. Steroids werefound to relieve symptoms betterthan promethazine, but are only tobe used if all other causes of vomit-ing have been excluded. Ginger wasfound to significantly improve the

nausea and vomiting of hypereme-sis. With severe hyperemesis, moreinvasive measures have been shownto improve symptoms. Nasogastricfeedings relieved symptoms anddecreased length of hospital stay.TPN shifted the patients from a cat-abolic state to an anabolic state andimproved their nutritional status.This method, however, does haverisks.

Alternative treatment withacupuncture resulted in signifi-cantly less vomiting. The use ofacupuncture plus administrationof IV fluids improved symptomsfaster than placebo plus IV fluids.

Hyperemesis gravidarum, or pernicious vomiting of pregnancy, is a complication of pregnancy that affects

various areas of the womans health, including homeostasis, electrolytes, and kidney function, and may alsohave adverse fetal consequences. The pathogenesis is not fully understood, but may be attributed to hormones,gastrointestinal dysfunction, thyrotoxicosis, serotonin, hepatic abnormalities, autonomic nervous dysfunction,nutritional deficiencies, asthma, allergies, Helicobacter pyloriinfection, or psychosomatic causes.

Hyperemesis itself is not a risk factor for adverse outcomes, but these outcomes are the consequence of the lowweight gain associated with hyperemesis. Patients who had . 5% weight loss and were malnourished haveexperienced adverse pregnancy outcomes, such as low birth weight, antepartum hemorrhage, preterm delivery,and an association with fetal anomalies.

Treatment methods include a range of options, including maternal diet and lifestyle alterations, administrationof intravenous fluids, antiemetics or steroids, and alternative therapies such as acupuncture and hypnosis.

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