Hyperemesis Gravidarum in Emergency Medicine
Hyperemesis gravidarum is a severe and intractable form of nausea and vomiting in pregnancy, affecting 0.8-2.3% of pregnant women. [2, 3] It is a diagnosis of exclusion and may result in weight loss; nutritional deficiencies; and abnormalities in fluids, electrolyte levels, and acid-base balance. The peak incidence is at 8-12 weeks of pregnancy, and symptoms usually resolve by week 20 in all but 10% of patients. Uncomplicated nausea and vomiting of pregnancy is generally associated with a lower rate of miscarriage, but hyperemesis gravidarum may affect the health and well-being of both the pregnant woman and the fetus.
The etiology of nausea and vomiting of pregnancy is unknown. Many have postulated that nausea and vomiting are protective in pregnancy to reduce exposures to potentially teratogenic materials. Some theories hold that elevated human chorionic gonadotropin (hCG) or estradiol levels could be causative, due to correlations in numerous studies between levels and symptoms, but this has not been demonstrated conclusively. Psychological theories of the etiology are falling out of favor, and the American College of Obstetrics and Gynecology warns that attributing vomiting to psychological disorders has likely impeded progress in understanding the true etiology of hyperemesis gravidarum. 
The cause of severe nausea and vomiting in pregnancy has not been identified. Hyperemesis may have a genetic component, as sisters and daughters of women with hyperemesis have a higher incidence.
Hyperemesis is also associated with hyperemesis in prior pregnancy, female gestation, multiple gestation, triploidy, trisomy 21, current or prior molar pregnancy, and hydrops fetalis.
Women with history of motion sickness, migraine headaches, psychiatric illness, pregestational diabetes, being underweight pregestation,  hyperthyroidism, pyridoxine deficiency, and gastrointestinal disorders are also at an increased risk.
Some studies have suggested that Helicobacter pylori infection may play a role in hyperemesis,  but the data are inconclusive.
Cigarette smoking and maternal age older than 30 years appear to be protective.
Hyperemesis gravidarum occurs in 0.5-2% of pregnancies, with the variation in incidence arising from different diagnostic criteria and ethnic variations.  Studies have found an admission rate of 0.8% for hyperemesis gravidarum  and an average of 1.3 hospital admissions per hyperemesis patient, with an average hospital stay of 2.6-4 days.
Hyperemesis patients are more likely to be nonwhite.
Patients younger than 30 years are more likely to experience hyperemesis.
One study has demonstrated that adverse fetal outcomes are mostly limited to poor maternal weight gain.  Women who gained less than 7 kg in pregnancy were more likely to have fetal complications, but those with hyperemesis and greater than 7 kg weight gain had no increased risk. This research indicates that treating hyperemesis gravidarum such that the patient is able to gain weight portends a better prognosis.
With mild-to-moderate vomiting, the patient and the fetus are unlikely to experience any increased morbidity or mortality. Before the advent of intravenous hydration, hyperemesis was a major cause of maternal death. Currently, mortality is exceedingly rare, but maternal morbidities may include Wernicke encephalopathy from vitamin B-1 deficiency, Mallory-Weiss tears, esophageal rupture, pneumothorax, and acute tubular necrosis. Hyperemesis is the second leading cause of hospitalization in pregnancy, second only to preterm labor. Additionally, many women experience significant psychosocial morbidity, occasionally interfering with assumption of the maternal role and rarely leading to termination of the pregnancy.
Complications of vomiting rarely occur; however, Mallory-Weiss tears and esophageal perforations have been reported.
Women with hyperemesis and poor weight gain have lower average birth weights and are more likely to have a small for gestational age infant and may be at higher risk for preterm birth.
In severe cases, without thiamine supplementation, Wernicke encephalopathy may occur (ie, diplopia, nystagmus, disorientation, confusion, coma).
If treatment is unsuccessful, complications of prolonged dehydration and starvation may occur.
Bottomley C, Bourne T. Management strategies for hyperemesis. Best Pract Res Clin Obstet Gynaecol. 2009 Aug. 23(4):549-64. [Medline].
Maltepe C. Surviving morning sickness successfully: from patient’s perception to rational management. J Popul Ther Clin Pharmacol. 2014. 21(3):e555-64. [Medline].
Vandraas KF, Vikanes AV, Stoer NC, et al. Hyperemesis gravidarum and risk of cancer in offspring, a Scandinavian registry-based nested case-control study. BMC Cancer. 2015 May 13. 15:398. [Medline].
Summers A. Emergency management of hyperemesis gravidarum. Emerg Nurse. 2012 Jul. 20(4):24-8. [Medline].
Cedergren M, Brynhildsen J, Josefsson A, et al. Hyperemesis gravidarum that requires hospitalization and the use of antiemetic drugs in relation to maternal body composition. Am J Obstet Gynecol. Apr 2008. 198:412.e1-5. [Medline].
Golberg D, Szilagyi A, Graves L. Hyperemesis gravidarum and Helicobacter pylori infection: a systematic review. Obstet Gynecol. Sept 2007. 110:695-703. [Medline].
Goodwin TM. Hyperemesis Gravidarum. Obstet Gynecol Clin N Am. Sept 2008. 35:401-417. [Medline].
Fell DB, Dodds L, Joseph KS, et al. Risk factors for hyperemesis gravidarum requiring hospital admission during pregnancy. Obstet Gynecol. 2006 Feb. 107(2 Pt 1):277-84. [Medline].
Dodds L, Fell DB, Joseph KS, et al. Outcomes of pregnancies complicated by hyperemesis gravidarum. Obstet Gynecol. 2006 Feb. 107(2 Pt 1):285-92. [Medline].
American College of Obstetricians and Gynecologists. Practice bulletin no. 153: nausea and vomiting of pregnancy. Obstet Gynecol. 2015 Sep. 126 (3):e12-24. [Medline].
Murphy A, McCarthy FP, McElroy B, et al. Day care versus inpatient management of nausea and vomiting of pregnancy: cost utility analysis of a randomised controlled trial. Eur J Obstet Gynecol Reprod Biol. 2015 Dec 12. 197:78-82. [Medline].
Holmgren C, Aagaard-Tillery KM, Silver RM, Porter TF, Varner M. Hyperemesis in pregnancy: an evaluation of treatment strategies with maternal and neonatal outcomes. Am J Obstet Gynecol. Jan 2008. 198:56.e1-4. [Medline].
[Guideline] ACOG (American College of Obstetrics and Gynecology). ACOG (American College of Obstetrics and Gynecology) Practice Bulletin: nausea and vomiting of pregnancy. Obstet Gynecol. 2004 Apr. 103(4):803-14. [Medline]. [Full Text].
Koren G, Clark S, Hankins GD, et al. Effectiveness of delayed-release doxylamine and pyridoxine for nausea and vomiting of pregnancy: a randomized placebo controlled trial. Am J Obstet Gynecol. 2010 Dec. 203(6):571.e1-7. [Medline].
Koren G, Maltepe C. Preemptive Diclectin therapy for the management of nausea and vomiting of pregnancy and hyperemesis gravidarum (abstract). ClinicalTrials.gov. Available at http://clinicaltrials.gov/show/NCT00293644. Accessed: April 10, 2013.
Poon SL. Towards evidence-based emergency medicine: Best BETs from the Manchester Royal Infirmary. BET 2: Steroid therapy in the treatment of intractable hyperemesis gravidarum. Emerg Med J. 2011 Oct. 28(10):898-900. [Medline].
Boone SA, Shields KM. Treating pregnancy-related nausea and vomiting with ginger. Ann Pharmacother. 2005 Oct. 39(10):1710-3. [Medline].
Borrelli F, Capasso R, Aviello G, et al. Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstet Gynecol. 2005 Apr. 105(4):849-56. [Medline].
Aikins Murphy P. Alternative therapies for nausea and vomiting of pregnancy. Obstet Gynecol. 1998 Jan. 91(1):149-55. [Medline].
Bailit JL. Hyperemesis gravidarium: Epidemiologic findings from a large cohort. Am J Obstet Gynecol. 2005 Sep. 193(3 Pt 1):811-4. [Medline].
Bashiri A, Neumann L, Maymon E. Hyperemesis gravidarum: epidemiologic features, complications and outcome. Eur J Obstet Gynecol Reprod Biol. 1995 Dec. 63(2):135-8. [Medline].
Carmichael SL, Shaw GM. Maternal corticosteroid use and risk of selected congenital anomalies. Am J Med Genet. 1999 Sep 17. 86(3):242-4. [Medline].
Chan NN. Thyroid function in hyperemesis gravidarum. Lancet. 1999 Jun 26. 353(9171):2243. [Medline].
Child TJ. Management of hyperemesis in pregnant women. Lancet. 1999 Jan 23. 353(9149):325. [Medline].
Chiossi G, Neri I, Cavazzuti M. Hyperemesis gravidarum complicated by Wernicke encephalopathy: background, case report, and review of the literature. Obstet Gynecol Surv. 2006 Apr. 61(4):255-68. [Medline].
Czeizel AE, Dudas I, Fritz G. The effect of periconceptional multivitamin-mineral supplementation on vertigo, nausea and vomiting in the first trimester of pregnancy. Arch Gynecol Obstet. 1992. 251(4):181-5. [Medline].
Czeizel AE, Vargha P. A case-control study of congenital abnormality and dimenhydrinate usage during pregnancy. Arch Gynecol Obstet. 2005 Feb. 271(2):113-8. [Medline].
Davis M. Nausea and vomiting of pregnancy: an evidence-based review. J Perinat Neonatal Nurs. 2004 Oct-Dec. 18(4):312-28. [Medline].
Dickson MJ. Management of hyperemesis in pregnant women. Lancet. 1999 Jan 23. 353(9149):325. [Medline].
Einarson A, Maltepe C, Navioz Y, Kennedy D, Tan MP, Koren G. The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study. BJOG. 2004 Sep. 111(9):940-3. [Medline].
Fischer-Rasmussen W, Kjaer SK, Dahl C. Ginger treatment of hyperemesis gravidarum. Eur J Obstet Gynecol Reprod Biol. 1991 Jan 4. 38(1):19-24. [Medline].
Frigo P, Lang C, Reisenberger K. Hyperemesis gravidarum associated with Helicobacter pylori seropositivity. Obstet Gynecol. 1998 Apr. 91(4):615-7. [Medline].
Fukada Y, Ohta S, Mizuno K. Rhabdomyolysis secondary to hyperemesis gravidarum. Acta Obstet Gynecol Scand. 1999 Jan. 78(1):71. [Medline].
Hod M, Orvieto R, Kaplan B. Hyperemesis gravidarum. A review. J Reprod Med. 1994 Aug. 39(8):605-12. [Medline].
Hoo JJ. Acupressure for hyperemesis gravidarum. Am J Obstet Gynecol. 1997 Jun. 176(6):1395-7. [Medline].
Jacoby EB, Porter KB. Helicobacter pylori infection and persistent hyperemesis gravidarum. Am J Perinatol. 1999. 16:85-8. [Medline].
Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2003. CD000145. [Medline].
Kocak I, Akcan Y, Ustun C, et al. Helicobacter pylori seropositivity in patients with hyperemesis gravidarum. Int J Gynaecol Obstet. 1999 Sep. 66(3):251-4. [Medline].
Koren G, Maltepe C. Pre-emptive therapy for severe nausea and vomiting of pregnancy and hyperemesis gravidarum. J Obstet Gynaecol. 2004 Aug. 24(5):530-3. [Medline].
Kousen M. Treatment of nausea and vomiting in pregnancy. Am Fam Physician. 1993 Nov 15. 48(7):1279-84. [Medline].
Lee RH, Pan VL, Wing DA. The prevalence of Helicobacter pylori in the Hispanic population affected by hyperemesis gravidarum. Am J Obstet Gynecol. 2005 Sep. 193(3 Pt 2):1024-7. [Medline].
Meighan M, Wood AF. The impact of hyperemesis gravidarum on maternal role assumption. J Obstet Gynecol Neonatal Nurs. 2005 Mar-Apr. 34(2):172-9. [Medline].
Nageotte MP, Briggs GG, Towers CV. Droperidol and diphenhydramine in the management of hyperemesis gravidarum. Am J Obstet Gynecol. 1996 Jun. 174(6):1801-5; discussion 1805-6. [Medline].
Nelson-Piercy C. Treatment of nausea and vomiting in pregnancy. When should it be treated and what can be safely taken?. Drug Saf. 1998 Aug. 19(2):155-64. [Medline].
Newman V, Fullerton JT, Anderson PO. Clinical advances in the management of severe nausea and vomiting during pregnancy. J Obstet Gynecol Neonatal Nurs. 1993 Nov-Dec. 22(6):483-90. [Medline].
Park-Wyllie L, Mazzotta P, Pastuszak A, et al. Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Teratology. 2000 Dec. 62(6):385-92. [Medline].
Petik D, Puho E, Czeizel AE. Evaluation of maternal infusion therapy during pregnancy for fetal development. Int J Med Sci. 2005 Oct. 2(4):137-42. [Medline].
Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. 2003 Jul. 68 (1):121-8. [Medline].
Robinson JN, Banerjee R, Thiet MP. Coagulopathy secondary to vitamin K deficiency in hyperemesis gravidarum. Obstet Gynecol. 1998 Oct. 92(4 Pt 2):673-5. [Medline].
Rodriguez-Pinilla E, Martinez-Frias ML. Corticosteroids during pregnancy and oral clefts: a case-control study. Teratology. 1998 Jul. 58(1):2-5. [Medline].
Russo-Stieglitz KE, Levine AB, Wagner BA. Pregnancy outcome in patients requiring parenteral nutrition. J Matern Fetal Med. 1999 Jul-Aug. 8(4):164-7. [Medline].
Safari HR, Alsulyman OM, Gherman RB. Experience with oral methylprednisolone in the treatment of refractory hyperemesis gravidarum. Am J Obstet Gynecol. 1998 May. 178(5):1054-8. [Medline].
Safari HR, Fassett MJ, Souter IC. The efficacy of methylprednisolone in the treatment of hyperemesis gravidarum: a randomized, double-blind, controlled study. Am J Obstet Gynecol. 1998 Oct. 179(4):921-4. [Medline].
Sahakian V, Rouse D, Sipes S, et al. Vitamin B6 is effective therapy for nausea and vomiting of pregnancy: a randomized, double-blind placebo-controlled study. Obstet Gynecol. 1991 Jul. 78(1):33-6. [Medline].
Selitsky T, Chandra P, Schiavello HJ. Wernicke’s encephalopathy with hyperemesis and ketoacidosis. Obstet Gynecol. 2006 Feb. 107(2 Pt 2):486-90. [Medline].
Serrano P, Velloso A, Garcia-Luna PP. Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases. Clin Nutr. 1998 Jun. 17(3):135-9. [Medline].
Sullivan CA, Johnson CA, Roach H. A pilot study of intravenous ondansetron for hyperemesis gravidarum. Am J Obstet Gynecol. 1996 May. 174(5):1565-8. [Medline].
Verberg MF, Gillott DJ, Al-Fardan N. Hyperemesis gravidarum, a literature review. Hum Reprod Update. 2005 Sep-Oct. 11(5):527-39:[Medline].
Matthews A, Haas DM, O’Mathuna DP, Dowswell T. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2015 Sep 8. 9:CD007575. [Medline].
Feras H Khan, MD Clinical Assistant Professor, Department of Emergency Medicine, University of Maryland School of Medicine; Attending Physician, Department of Emergency Medicine, Laurel Regional Hospital, University of Maryland Emergency Medicine Network Physicians; Attending Physician, Intensivist, Department of Critical Care Medicine, Mercy Medical Center
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Mark Zwanger, MD, MBA
Mark Zwanger, MD, MBA is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.
Jeter (Jay) Pritchard Taylor, III, MD Assistant Professor, Department of Surgery, University of South Carolina School of Medicine; Attending Physician, Clinical Instructor, Compliance Officer, Department of Emergency Medicine, Palmetto Richland Hospital
Jeter (Jay) Pritchard Taylor, III, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Columbia Medical Society, Society for Academic Emergency Medicine, South Carolina College of Emergency Physicians, South Carolina Medical Association
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Employed contractor – Chief Editor for Medscape.
Assaad J Sayah, MD, FACEP Senior Vice President and Chief Medical Officer, Cambridge Health Alliance
Disclosure: Nothing to disclose.
Susan Renee Wilcox, MD Instructor, Harvard Medical School; Critical Care Fellow, Department of Anesthesia and Critical Care and Pain Medicine, Department of Emergency Medicine, Massachusetts General Hospital
Susan Renee Wilcox, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.
Hyperemesis Gravidarum in Emergency Medicine
Research & References of Hyperemesis Gravidarum in Emergency Medicine|A&C Accounting And Tax Services