High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals

Objective

The goal of this study was to determine the prevalence of severe nausea and vomiting of pregnancy/hyperemesis gravidarum among relatives of affected individuals.

Study design

Family history data were obtained on 1224 self-reported cases of hyperemesis gravidarum. Cases completed an online survey administered by the Hyperemesis Education and Research Foundation between 2003 and 2006.

Results

Approximately 28% of cases reported their mother had severe nausea and vomiting or hyperemesis gravidarum while pregnant with them. Of the 721 sisters with a pregnancy history, 137 (19%) had hyperemesis gravidarum. Among the most severe cases, those requiring total parenteral nutrition or nasogastric feeding tube, the proportion of affected sisters was even higher, 49/198 (25%). Nine percent of cases reported having at least two affected relatives including sister(s), mother, grandmother, daughters, aunt(s), and cousin(s).

Conclusion

There is a high prevalence of severe nausea and vomiting of pregnancy/hyperemesis gravidarum among relatives of hyperemesis gravidarum cases in this study population. Because the incidence of hyperemesis gravidarum is most commonly reported to be 0.5%, this study provides strong but preliminary evidence for a genetic component to extreme nausea and vomiting of pregnancy.     

Mirtazapine use in resistant hyperemesis gravidarum: report of three cases and review of the literature

{\it Background}: Hyperemesis gravidarum is a serious health problem for the fetus and the mother. Effective treatment regimens are obscure in patients with severe symptoms. Our aim was to use mirtazapine in hyperemesis gravidarum patients who failed to respond to conventional anti-emetic drugs. Cases: Three pregnant women who had severe hyperemesis gravidarum. All patients had dehydration, ketonuria, hypokalemia, and weight loss. All failed to respond to conventional anti-emesis treatment regimens, such as metoclopramide and promethazine. Al patients had mirtazapine 30 mg/day within the intravenous fluid support approximately for 1 week. All responded to mirtazapine within 24 h and were able to resume diet within a few days after the initiation of treatment. None of these pregnant women had any disturbing symptoms of emesis throughout the pregnancy and had healthy newborns. Conclusion: Mirtazapine seems to be an effective treatment modality in patients with severe hyperemesis gravidarum who do not respond to conventional anti-emesis treatment regimens. Larger-scaled studies should be performed to show the effectiveness of mirtazapine in pregnant women with severe hyperemesis gravidarum who may request pregnancy termination. Mirtazapine and severe hyperemesis gravidarum. Mirtazapine is an effective treatment regimen in severe hyperemesis gravidarum     

Treatment of intractable hyperemesis gravidarum by ondansetron

Hyperemesis gravidarum is a disabling condition. It is not uncommon that patients request termination of pregnancy because of intolerable symptoms and psychological stress. We report a case in which termination of pregnancy was avoided by the use of ondansetron to treat the hyperemesis gravidarum.     

Hyperemesis gravidarum. A comparison of single and multiple admissions

Recurrent hyperemesis gravidarum is a frustrating and poorly studied complication of early pregnancy. Between 1979 and 1987, 140 women with emesis severe enough to require parenteral fluid and electrolyte replacement were admitted to the Medical University of South Carolina Hospital, Charleston, on 220 occasions. Thirty-nine of the 140 women were admitted on multiple occasions. A comparison of clinical characteristics of women with single and multiple admissions revealed no significant differences except that women admitted repeatedly for hyperemesis gravidarum were more likely to be nulliparous (P less than .05). Ptyalism (59% vs. 9%) and persistent vomiting for greater than 24 hours after admission (69% vs. 23%) were significantly more common among women who were admitted repeatedly (P less than .05). Despite published reports that hyperemesis gravidarum has no impact on ultimate perinatal outcome, this study indicated that women admitted repeatedly have a more severe nutritional disturbance, associated with significantly reduced maternal weight gain and neonatal birth weight. These risks argue for more aggressive antenatal treatment and increased fetal surveillance in pregnancies complicated by recurrent hyperemesis gravidarum.     

A randomized, placebo-controlled trial of corticosteroids for hyperemesis due to pregnancy

OBJECTIVE: Hyperemesis gravidarum, a severe form of nausea and vomiting due to pregnancy for which there is no proven pharmacological treatment, is the third leading cause for hospitalization during pregnancy. Corticosteroids are commonly used for the treatment of nausea and vomiting due to cancer chemotherapy-induced emesis and might prove useful in hyperemesis gravidarum. METHODS: A randomized, double-blind, placebo-controlled trial was conducted in 126 women who previously had not responded to outpatient therapy for hyperemesis gravidarum during the first half of pregnancy. Intravenous methylprednisolone (125 mg) was followed by an oral prednisone taper (40 mg for 1 day, 20 mg for 3 days, 10 mg for 3 days, 5 mg for 7 days) versus an identical-appearing placebo regimen. All women also received promethazine 25 mg and metoclopramide 10 mg intravenously every 6 hours for 24 hours, followed by the same regimen administered orally as needed until discharge. The primary study outcome was the number of women requiring rehospitalization for hyperemesis gravidarum. RESULTS: A total of 110 women delivered at our hospital and had pregnancy outcomes available for analysis; 56 were randomized to corticosteroids and 54 were administered placebo. Nineteen women in each study group required rehospitalization (34% versus 35%, P =.89, for corticosteroids versus placebo, respectively). CONCLUSION: The addition of parenteral and oral corticosteroids to the treatment of women with hyperemesis gravidarum did not reduce the need for rehospitalization later in pregnancy.     

Mirtazapine (Remergil) for treatment resistant hyperemesis gravidarum: rescue of a twin pregnancy

Case report We present the case of a 25-year-old woman with treatment resistant hyperemesis gravidarum in the 15th week with a 13 kg loss of body weight. When the patient asked for termination of the pregnancy because of the unbearable symptoms, treatment with intravenous mirtazapine (Remergil) was started.Results Nausea and vomiting disappeared within hours, pregnancy termination was no longer desired. The patient was discharged two weeks later in good health and at 36 weeks gestation a cesarean section was performed. Post partum evaluation as well as 6-month post-partum revealed no dysmorphology or laboratory abnormalities in the children.     

Droperidol and diphenhydramine in the management of hyperemesis gravidarum

OBJECTIVE: Hyperemesis gravidarum is a common pregnancy complication requiring hospitalization. Continuous droperidol infusion and bolus intravenous diphenhydramine were instituted as treatment. We compared the number and length of hospitalizations for hyperemesis gravidarum, readmissions for this diagnosis, and pregnancy outcome in patients receiving this treatment protocol with a historic group of patients receiving other forms of parenteral therapy for hyperemesis gravidarum. STUDY DESIGN: All patients hospitalized with a diagnosis of hyperemesis gravidarum between January 1992 and January 1994 were offered the droperidol-diphenhydramine protocol. These patients were compared with patients admitted between January 1990 and January 1992 with a diagnosis of hyperemesis gravidarum but who were not treated with droperidol at any time or with diphenhydramine as primary therapy for the control of severe nausea and vomiting. Data regarding the number and length of hospitalizations and readmissions for hyperemesis gravidarum were compared, as were maternal and perinatal outcomes. RESULTS: Patients treated with the droperidol-diphenhydramine protocol had significantly shorter hospitalizations (3.1 ± 1.9 vs 3.8 ± 2.4 days, p = 0028), fewer days per pregnancy hospitalized for hyperemesis (3.5 ± 2.3 days vs 4.8 ± 4.3 days, p = 0018), and fewer readmissions with this diagnosis (15.0% vs 31.5%, p = 0015). There were no significant differences in maternal or perinatal outcomes. CONCLUSION: Droperidol and diphenhydramine infusion is a beneficial, cost-effective therapy for the treatment of hyperemesis gravidarum. (Am J Obstet Gynecol 1996;174:1801-6.)     

Hyperemesis gravidarum: a current review

Hyperemesis gravidarum or pernicious vomiting of pregnancy affects between 0.3% and 2% of all pregnant patients. The objective of this paper is to review current literature pertaining to epidemiology, etiology, symptomatology, complications, treatment, and perinatal outcome of patients with hyperemesis gravidarum. We performed a MEDLINE search of the English literature from 1966 through January 2000 utilizing the keywords: hyperemesis gravidarum, nausea and vomiting, and pregnancy. Current data pertaining to epidemiology, etiology, clinical manifestations, differential diagnosis, complications, various treatment modalities, subsequent perinatal outcome and recent developments are presented. Review of the literature supports that hyperemesis gravidarum is a multifactorial disease in which pregnancy-induced hormonal changes associated with concurrent gastrointestinal dysmotility and possible Helicobacter pylori infection function as contributing factors. Therapeutic key elements are mainly supportive in conjunction with antiemetic medication. It appears perinatal outcome is unaffected.     

Diaphragmatic tear in pregnancy induced by intractable vomiting: a case report and review of the literature

Objective: Nausea and vomiting of pregnancy, the most common medical condition of pregnancy, affects up to 80% of all pregnancies to some extent, and hyperemesis gravidarum does less than 1% of pregnant women. When hyperemesis gravidarum induces diaphragmatic tear, diagnosis can be missed because of nonspecific presentation with abdominal pain, nausea and vomiting. Methods: We reported a pregnant case suffering from intractable vomiting at the beginning of the second trimester (the 13th week of gestation) with delayed diagnosis of diaphragmatic tearing. Results: The patient was misdiagnosed initially, which delayed the surgical intervention and unnecessary abortion. Conclusion: It is worthwhile considering the maternal diaphragmatic cause as an unusual one of refractory vomiting accompanied by clinically significant progressive epigastric pain, distension and respiratory embarrassment.     

Helicobacter pylori and severe nausea and vomiting during pregnancy

Helicobacter pylori is a bacterial infection of the stomach, which may aggravate nausea and vomiting in pregnancy. Studies have found conflicting evidence of the role of H. pylori in severe nausea and vomiting in pregnancy and hyperemesis gravidarum. Several women suffering from weight loss and experiencing continued nausea and vomiting were tested for H. pylori antibody during their pregnancy. This article reviews the outcomes of women with both positive and negative H. pylori tests, the treatment of H. pylori, and its controversial role in managing severe nausea and vomiting in pregnancy.     

Helicobacter pylori infection and persistent hyperemesis gravidarum.

Hyperemesis gravidarum is the most severe spectrum of gastrointestinal complaints in pregnant women. Our purpose is to describe an association of Helicobacter pylori with hyperemesis gravidarum. Three pregnant women are described with the working diagnoses of hyperemesis gravidarum unresponsive to standard therapy. The medical management used to treat Helicobacter pylori in these women are elaborated. The persistence of the symptomatology and/or hematemesis resulted in Helicobacter pylori testing of these women. A 2-week course of antibiotics and a proton pump inhibitor or H2 receptor antagonist resulted in resolution of the hyperemesis. A discussion of the incidence, diagnosis, and management of Helicobacter pylori in pregnancy is described. When the symptoms of hyperemesis gravidarum are persistent into the second trimester, active peptic ulcer disease from Helicobacter pylori should be included in the differential diagnoses.     

Pneumomediastinum following esophageal rupture associated with hyperemesis gravidarum

A patient was diagnosed with pneumomediastinum caused by an esophageal rupture during hyperemesis gravidarum. The woman, at 15 weeks' gestation, presented with hyperemesis gravidarum complicated by an episode of chest pain and disturbance of consciousness. Radiological examination revealed pneumomediastinum and subcutaneous emphysema. They are normally caused by either pulmonary or esophageal rupture. The esophageal etiology was suspected as more likely because of the severe vomiting accompanied with it. Although the clinical feature was quite complicated and esophageal rupture is generally a life-threatening disease, we chose conservative therapy which resulted in rapid recovery. The final diagnosis was confirmed by endoscopic examination performed after recovery. Pneumomediastinum during pregnancy is rare but it could be lethal. Careful and considerate assessments including surgical treatment should be necessary.     

Intramuscular ACTH or placebo in the treatment of hyperemesis gravidarum.

Thirty-two women with hyperemesis gravidarum were treated with intramuscular ACTH (0.5 mg) or placebo for 4 days in a randomized double-blind trial. The two treatments were equally effective in relieving hyperemesis, although the function of the adrenal cortex was stimulated only during the ACTH therapy. The administration of ACTH thus appears useless for the treatment of severe vomiting in early pregnancy.     

Solid pseudopapillary pancreatic tumor in pregnancy. A case report

BACKGROUND: Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm, occurring predominantly in young African American women. Tumor growth, which is typically slow, may be accelerated during pregnancy secondary to the influence of progesterone. CASE: We report a rare case of an 8-cm SPT in the head of the pancreas presenting as hyperemesis gravidarum during pregnancy. In contrast to previous case reports, surgical resection of the tumor at 16 weeks' gestation, although successful, did not ameliorate the patient's abdominal pain, nausea or vomiting. With intravenous nutritional support, she delivered a healthy infant near term. CONCLUSION: SPT may present as hyperemesis gravidarum. Patients with refractory hyperemesis gravidarum should be evaluated for thyroid disease, gastroesophageal reflux, cholestasis and pancreatitis. If these more common etiologies are excluded, then one may consider SPT in the differential diagnosis, particularly in African American patients. SPT may grow during pregnancy due to progesterone responsiveness. Surgical resection during pregnancy is possible without harmful fetal effects but may not correct gastrointestinal dysfunction during pregnancy.     

Emesis gravidarum bei Magenbandpatientin

Many patients who have bariatric surgery are in fertile age, and the number of pregnancies after these operations is increasing. Therefore, pregnancy after bariatric surgery is of great clinical relevance. Moreover, a large number of pregnant women experience nausea and vomiting and some suffer from hyperemesis gravidarum, with symptoms frighteningly similar to the potential complications after bariatric surgery. We report of a 24-year-old woman with grade-III obesity who underwent laparoscopic gastric banding. A few years later, she presented to hospital because of recurrent vomiting and it was discovered she was pregnant.. The patient’s vomiting continued, but she was discharged with the diagnosis of hyperemesis gravidarum. The patient’s condition deteriorated progressively, she had to be transferred to intensive care, and the pregnancy had to be terminated. After her condition stabilized, she was assigned to our obesity center. A contrast swallow examination showed complete band slippage with a parastomal passage stop. The patient was immediately operated on laparoscopically and the gastric band was removed.     

Hyperemesis gravidarum: current aspect

An advanced state of nausea and vomiting, which are common symptoms of early pregnancy, is known as hyperemesis gravidarum and may result in dehydration, ketonuria, catabolism and require hospitalisation. Aetiological factors include increased hCG and steroids, multiple pregnancy and vitamin deficiency. Differential diagnosis of nausea and vomiting should be made and supportive treatment as well as antiemetic therapy is recommended. This review discusses aetiology and management modalities of hyperemesis gravidarum including fluid therapy, antiemetics, vitamins, psychological support and non-pharmacological measures.     

Understanding the Stigma of Hyperemesis Gravidarum: Qualitative Findings from an Action Research Study

Abstract: Background: Severe nausea and vomiting in pregnancy (hyperemesis gravidarum) can be a distressing and debilitating condition when it is uncontrolled. For all concerned, hyperemesis gravidarum can be difficult to treat satisfactorily, and women tend to be admitted to a hospital several times during early pregnancy. Our research objectives were to describe the experience of hyperemesis gravidarum from the perspective of affected women and to explore with health care professionals the barriers and facilitators to caring for women with the condition. Methods: A qualitative research design was used. A total of 18 women were interviewed, of whom 8 had two or more interviews. Seven focus groups were conducted with health care professionals. Thematic data analysis was undertaken. Results: The main themes emerging from the women’s data were the effect and burden of the symptoms of the condition and feeling unpopular with staff. From the practitioner data, the main themes were the validity (or invalidity) of hospitalization for women, skepticism of the severity of symptoms, the psychological and social dimensions of the condition, and inadequate primary care services. Conclusions: The main findings revealed that hyperemesis gravidarum is a debilitating condition and that the unhelpful attitudes of practitioners may affect whether women access timely and appropriate care. Many women appear to be unsupported by primary care services and are distressed when perceived either as “time wasters” or someone else’s responsibility. We propose that a tailored assessment and care plan for each woman is needed to help them control their symptoms, which ideally should be delivered in the community. (BIRTH 37:3 September 2010)     

Evaluation of treatment of hyperemesis gravidarum using parenteral fluid with or without diazepam. A randomized study

OBJECTIVE: Hyperemesis gravidarum is a relatively unknown disease, and is generally self-limiting. In some women the symptoms are so severe as to threaten the health of the mother and fetus. Therapies proposed for hyperemesis gravidarum are therefore rather empirical. Medical treatment includes parenteral fluid replacement and nutrition, electrolytes, antiemetics, vitamins, sedation and psychological counseling. Diazepam and benzodiazepines have been widely studied in pregnancy but the results are contradictory. The aim of the present study was to investigate the efficacy of parenteral fluids with vitamins, with or without diazepam sedation. METHODS: Fifty women with hyperemesis gravidarum were enrolled in the study. They were treated with infusions of normal saline, glucose, vitamins and randomly with diazepam. RESULTS: The results show that the mean stay in the hospital was shorter in the diazepam group: 4.5 +/- 1.9 vs. 6 +/- 1.6 days (p < 0.05) and readmission to the hospital was 4% in the diazepam group versus 27% in other group (p < 0.05). There was a significant reduction in nausea in the diazepam group (p < 0.05). A significant reduction in vomiting was observed in both groups. No side effects or congenital neonatal malformations were found in the diazepam group. CONCLUSIONS: Intravenous administration of fluids and vitamins is the standard treatment for women hospitalized for hyperemesis gravidarum. The addition of diazepam to the treatment is effective in reducing nausea and does not have teratogenic effects. Copyright Copyright 1999 S. Karger AG, Basel     

Pregnancy outcome in hyperemesis gravidarum and the effect of laboratory clinical indicators of hyperemesis severity

OBJECTIVE: To determine pregnancy outcome in hyperemesis gravidarum and the effect of metabolic, biochemical, hematological and clinical indicators of disease severity on outcome. STUDY DESIGN: A retrospective study based on 166 women hospitalized for confirmed hyperemesis gravidarum from January 2004 to January 2005. For each woman, three controls matched for age, parity and ethnicity were obtained from our 2004 birth register. The effects of laboratory indicators of hyperemesis severity were separately analyzed within the hyperemesis gravidarum study group. Outcome measures include stillbirths, Apgar score, mode of delivery, low birthweight, preterm delivery, labor induction, pregnancy induced hypertension and gestational diabetes. Analysis was by t-test, Fisher's exact test and multivariable logistic regression analysis. RESULTS: Women with hyperemesis had similar pregnancy outcome compared to controls. In the analysis of laboratory indicators of hyperemesis severity and pregnancy outcomes, hypokalemia (adjusted odds ratio [AOR] 2.7: 95% confidence interval [CI] 1.0-6.8) was associated with emergency operative delivery, high creatinine (odds ratio 4.4: 95% CI 1.3-15) with labor induction and raised gamma glutamyltransferase (AOR 7.5: 95% CI 1.2-46) with the development of gestational diabetes. CONCLUSIONS: Hyperemesis gravidarum per se was not associated adverse pregnancy outcome. Hypokalemia, high creatinine and raised gamma glutamyltransferase in women with hyperemesis gravidarum were associated with adverse pregnancy outcome.     

Recurrence risk of hyperemesis gravidarum

Introduction: The purpose of this study is to describe the recurrence risk for hyperemesis gravidarum (HG). Methods: Women who registered on a Web site sponsored by the Hyperemesis Education and Research Foundation as having had one HG‐complicated pregnancy were contacted to follow‐up on a subsequent pregnancy. Participants completed an online survey. Results: One hundred women responded. Fifty‐seven had become pregnant again, 2 were trying to conceive, 37 were not willing to get pregnant again because of HG, and 4 did not have a second pregnancy for other reasons. Among the 57 women who responded that they had become pregnant again, 81% reported having severe nausea and vomiting in their second pregnancy. Among the women reporting recurrent HG, 98% reported losing weight and taking prescribed medication for HG, 83% reported treatment with intravenous fluids, 20% reported treatment with total parenteral nutrition or nasogastric tube feeding, and 48% reported hospitalization for HG. Discussion: This study demonstrates both a high recurrence rate of HG and a large percentage of women who change reproductive plans because of their experiences with HG.