Acupuntura

T
 HEME
Nausea and
vomiting

Hyperemesis gravidarum
Assessment and management
BACKGROUND
Nausea and vomiting are common symptoms in early pregnancy. In most women the condition is mild and self limiting.
A small percentage of women experience severe nausea and vomiting. This is known as hyperemesis gravidarum.
Outcomes have improved with intravenous rehydration therapy. Consequencesinclude decreased quality of life, time off
work and secondary depression.

Penny Sheehan
MBBS, FRANZCOG, GDEB,
is an obstetrician and Head,
Maternity Care Program, and
Clinical Research Fellow, Royal
Women’s Hospital, Melbourne,
Victoria. penny.sheehan@rwh.
org.au

OBJECTIVE
This article outlines the aetiology, outcomes, history and examination of women with hyperemesis gravidarum.Treatment
modalities are discussed together with evidence regarding use.

DISCUSSION
It is important to exclude other causes of nausea and vomiting such as urinary tract infection and thyrotoxicosis.
Assessment of severity by checking for ketones is important as severity determines management. Management will include
rehydration (intravenous or oral). Evidence is lacking regarding dietary andlifestyle recommendations but some women find
them useful. Pyridoxine and metoclopramide (category A) are first line in treatment of hyperemesis gravidarum followed
by prochlorperazine (category C), prednisolone (category A), promethazine (category C) and ondansetron (category B1).
Benefit has been reported with the use of ginger. Evidence is mixed regarding acupressure and acupuncture.Nausea and vomiting affects up to 85% of pregnant
w omen. 1 A lthough popularly known as ‘morning
sickness’ one study demonstrated that less than 2%
of women experienced nausea only in the morning
and 80% reported nausea throughout the day.2 The
condition is usually mild and self limiting, peaking
at around 9 weeks gestation and usually resolving,
frequently quite abruptly, before 14 weeksgestation.
In the same study however, 13% of women reported
nausea lasting beyond 20 weeks gestation.

Hyperemesis gravidarum
A small percentage of women experience a severe
form of nausea and vomiting known as hyperemesis
gravidarum. Estimates of the incidence of hyperemesis
v ary from 0.3–1.5% of all live births. 3 D iagnosis is
s ubjective, but the condition is usually described asintractable vomiting leading to fluid, electrolyte and acid
base imbalance, nutritional deficiency and weight loss.

Outcome and complications
Before the introduction of intravenous (IV) rehydration,
the mortality from hyperemesis was considerable, the

698 Reprinted from Australian Family Physician Vol. 36, No. 9, September 2007

most well known case probably being that of Charlotte
B rontewho died in 1855 from severe nausea and
vomiting 4 months into her pregnancy. 4 C ases have
been reported in the literature with advanced vitamin
a nd met abolite disturbances such as Wernicke
encephalopathy, coagulopathy and peripheral neuropathy.
Although vomiting is the most obvious concerning
symptom, persistent, debilitating nausea can severely
a dversely affect the woman’s quality oflife. In
s tudies, 35% of women with paid employment lost
t ime from work through nausea and 26% lost time
from housework.1
N ausea and vomiting in early pregnancy are
consistently associated with lower rates of miscarriage.5
There are no other associations with pregnancy outcomes.
Psychosocial morbidity for the mother is common enough
h owever, as up to 60% of women with hyperemesisgravidarum develop secondary depression.6

Aetiology
The aetiology is unknown. The endocrine factor most
c ommonly invoked is human chorionic gonadotropin
hormone (HCG) on the basis of the observed temporal

association, that incidence of hyperemesis is highest at
the time that HCG production reaches its peak. In addition,
hyperemesis is said to have a higher incidence in those
conditions...