Managing Nausea and Vomiting of Pregnancy: Symptoms, Risk Factors, and Clinical Presentation

Nausea and vomiting of pregnancy DR.NOOSIN-ESHRAGHI IUMS-AKBARABADI HOSPITAL

Nausea with or without vomiting is so common in early pregnancy that mild symptoms may be considered part of the normal physiology of pregnancy in the first trimester especially when persistent severe Time Nausea with or without vomiting is so common in early pregnancy that mild symptoms may be considered part of the normal physiology of pregnancy in the first trimester. However, these symptoms can significantly impact the quality of life of both the pregnant person and their family, especially when persistent and/or severe [1]. Although "morning sickness" is commonly used to describe nausea and vomiting of pregnancy, symptoms can occur at any time of the day or night..

"morning sickness" is commonly used to describe nausea and vomiting of pregnancy, symptoms can occur at any time of the day or night

Hyperemesis gravidarum severe end of the symptom spectrum : weight loss exceeding 5 percent of pre-pregnancy body weight) Severe symptoms can negatively impact daily functioning cause anxiety and depression interfere with work performance lead some patients to consider termination of pregnancy or avoiding a future pregnancy

INCIDENCE Some degree of nausea with or without vomiting occurs in up to 90 percent of pregnancies In a prospective study including almost 800 patients followed from conception, 57 percent reported nausea and 27 percent reported both nausea and vomiting

Risk factors Nonpregnant people : nausea and vomiting related to estrogen-based medications motion sickness migraines multiple gestation symptoms in a prior pregnancy hydatidiform molar pregnancy

CLINICAL PRESENTATION Symptoms typically start at 5 to 6 weeks of gestation peak at approximately 9 weeks usually subside by 16 to 20 weeks However, symptoms may continue until the third trimester in 15 to 20 percent of patients and until delivery in 5 percent

DIAGNOSIS Nausea and vomiting of pregnancy : The diagnosis of nausea and vomiting of pregnancy is based on the presence of nausea and/or vomiting that appears to be related to pregnancy rather than another etiology Patients with the common mild form of nausea and vomiting of pregnancy maintain normal vital signs and have normal physical and laboratory examinations and pregnancy course

Hyperemesis gravidarum : Hyperemesis gravidarum is considered the severe end of the spectrum of nausea and vomiting of pregnancy

persistent vomiting accompanied by weight loss exceeding 5 percent of prepregnancy body weight and ketonuria vomiting that occurs more than three times per day with weight loss greater than 3 kg Symptoms start in early pregnancy, before a gestational age of 16 weeks Nausea and/or vomiting is severe The patient is unable to eat and/or drink normally Daily activities are strongly limited

Laboratory tests Serum electrolytes Urine ketones and specific gravity

Blood urea nitrogen Creatinine Complete blood count Liver chemistries Amylase/lipase Phosphorus, magnesium, and calcium levels Thyroid function tests

Imaging If not obstetric ultrasound examination is performed : fetal cardiac activity ,multiple gestation,gestational trophoblastic disease Ultrasound examination of the liver is indicated if liver disease is suspected Additional imaging is needed if appendicitis is suspected

Spectrum of findings and interpretation Electrolyte and acid-base derangements : hypokalemia and hypochloremic metabolic alkalosis (from vomiting gastric secretions) Ketosis can occur if caloric intake is minimal

increase in hematocrit: indicating hemoconcentration due to plasma volume depletion The degree of hemoconcentration may be masked by the physiologic decline in hematocrit that normally occurs in pregnancy, although this is maximal in the second trimester Lymphocyte count tends to be higher in patients with hyperemesi

elevated blood urea nitrogen and urine specific gravity The serum creatinine concentration will increase

Abnormal liver chemistries : approximately 50 percent of patients who are hospitalized with hyperemesis The most striking abnormality is an increase in serum aminotransferases. Alanine aminotransferase (ALT) is typically elevated to a greater degree than aspartate aminotransferase (AST) Hyperbilirubinemia may occur but rarely exceeds 4 mg/d

The degree of abnormality in liver chemistries correlates with the severity of vomiting; the highest elevations are seen in patients with the most severe or protracted vomiting. Abnormal liver chemistries resolve promptly upon resolution of vomiting.

Serum amylase and lipase : elevated in 10 to 15 percent of patients and may increase as much as fivefold

Gestational transient or physiologic hyperthyroidism: can be seen in 3 to 11 percent of patients in early pregnancy This is likely due to high serum concentrations of human chorionic gonadotropin, which has TSH receptor stimulating activity In hyperemesis gravidarum have abnormally high serum T4 levels and low TSH levels

Hypomagnesemia and hypocalcemia

DIFFERENTIAL DIAGNOSIS Nausea and vomiting that first develops after 10 weeks of gestation is not likely due to nausea and vomiting of pregnancy Abdominal pain, fever, headache, abnormal neurologic findings, diarrhea, constipation, leukocytosis, goiter, cyclicity, or hypertension

Preeclampsia, HELLP syndrome : (hemolysis, elevated liver enzymes, low platelets), and acute fatty liver of pregnancy are also causes of pregnancy-related nausea and vomiting, but onset is in the latter half of pregnancy (usually the third trimester) hypertension is usually present, and thrombocytopenia is common

Hyperparathyroidism in pregnancy is uncommon, but should be considered, as hypercalcemia may contribute to vomiting

Treatment goals Reduce severity of symptoms and improve quality of life Correct hypovolemia, ketonuria and electrolyte abnormalities, if present Prevent serious complications of persistent vomiting Minimize the potential fetal effects of maternal pharmacotherapy

Nausea: conservative measures (eg, dietary changes, trigger avoidance, ginger supplements,) If these measures are inadequate: pyridoxine doxylamine-pyridoxine

Vomiting but normal electrolyte levels and acid-base balance : Patients who are vomiting most food and liquids should be clinically evaluated to assess their volume and metabolic status and exclude other diagnoses that could account for their symptoms

Management of hospitalized patients Fluid replacement and thiamine : Patients with hypovolemia require fluid replacement with up to 2 liters of isotonic crystalloid fluids

Ondansetron: For patients who are hospitalized because of hypovolemia, we suggest intravenous ondansetron

Diet : A short period of gut rest is useful during fluid replacement, followed by reintroduction of oral intake with liquids, low-fat foods