Clinical features and evaluation of nausea and vomiting of pregnancy
- Jerrie S Refuerzo, MD
Jerrie S Refuerzo, MD
- Associate Professor
- Division of Maternal Fetal Medicine
- Department of Obstetrics and Gynecology
- University of Texas Health Science Center at Houston
- Judith A Smith, PharmD, BCOP, CPHQ, FCCP, FISOPP
Judith A Smith, PharmD, BCOP, CPHQ, FCCP, FISOPP
- Associate Professor and Director
- Women's Health Integrative Medicine Research Program, Department of Obstetrics and Gynecology
- Susan M Ramin, MD
Susan M Ramin, MD
- Section Editor — Obstetrics
- The American Board of Obstetrics and Gynecology (ABOG)
Nausea with or without vomiting is so common in early pregnancy that mild symptoms may be considered part of the normal physiology of the first trimester. However, these symptoms can significantly impact the pregnant woman’s quality of life, especially when persistent and/or severe . Hyperemesis gravidarum is the term used to describe the severe end of the symptom spectrum (weight loss exceeding 5 percent of prepregnancy body weight), but no universally accepted criteria distinguish between mild and severe disease.
The clinical manifestations and diagnostic evaluation of women with nausea and vomiting of pregnancy will be reviewed here. Treatment and outcome of this disorder are discussed separately. (See "Treatment and outcome of nausea and vomiting of pregnancy".)
Some degree of nausea with or without vomiting occurs in up to 90 percent of pregnancies . In a prospective study including almost 800 women followed from conception, 57 percent reported nausea and 27 percent reported both nausea and vomiting by 8 weeks of gestation .
The incidence of women with severe symptoms is not well-documented; reports vary from 0.3 to 3 percent of pregnancies . Ethnic differences and differences in the definition of the disease may account, in part, for the variability.
EPIDEMIOLOGY AND RISK FACTORS
Epidemiology — The epidemiology of pregnancy-related nausea and vomiting remains unclear, but the disorder appears to be more common in Western countries and urban areas than in Africa and Asia [4,5]. Younger primigravid women are more likely to be affected than older multiparous women , but data are not consistent.
- Lacasse A, Rey E, Ferreira E, et al. Nausea and vomiting of pregnancy: what about quality of life? BJOG 2008; 115:1484.
- Matthews A, Haas DM, O'Mathúna DP, Dowswell T. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev 2015; :CD007575.
- Hinkle SN, Mumford SL, Grantz KL, et al. Association of Nausea and Vomiting During Pregnancy With Pregnancy Loss: A Secondary Analysis of a Randomized Clinical Trial. JAMA Intern Med 2016; 176:1621.
- Lacasse A, Rey E, Ferreira E, et al. Epidemiology of nausea and vomiting of pregnancy: prevalence, severity, determinants, and the importance of race/ethnicity. BMC Pregnancy Childbirth 2009; 9:26.
- Lee NM, Saha S. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am 2011; 40:309.
- Klebanoff MA, Koslowe PA, Kaslow R, Rhoads GG. Epidemiology of vomiting in early pregnancy. Obstet Gynecol 1985; 66:612.
- Association of Professors of Gynecology and Obstetrics. Nausea and vomiting of pregnancy. https://www.apgo.org/ (Accessed on December 05, 2016).
- Heinrichs L. Linking olfaction with nausea and vomiting of pregnancy, recurrent abortion, hyperemesis gravidarum, and migraine headache. Am J Obstet Gynecol 2002; 186:S215.
- Basso O, Olsen J. Sex ratio and twinning in women with hyperemesis or pre-eclampsia. Epidemiology 2001; 12:747.
- Brandes JM. First-trimester nausea and vomiting as related to outcome of pregnancy. Obstet Gynecol 1967; 30:427.
- Hou JL, Wan XR, Xiang Y, et al. Changes of clinical features in hydatidiform mole: analysis of 113 cases. J Reprod Med 2008; 53:629.
- Emelianova S, Mazzotta P, Einarson A, Koren G. Prevalence and severity of nausea and vomiting of pregnancy and effect of vitamin supplementation. Clin Invest Med 1999; 22:106.
- Czeizel AE, Dudas I, Fritz G, et al. The effect of periconceptional multivitamin-mineral supplementation on vertigo, nausea and vomiting in the first trimester of pregnancy. Arch Gynecol Obstet 1992; 251:181.
- Gill SK, Maltepe C, Koren G. The effect of heartburn and acid reflux on the severity of nausea and vomiting of pregnancy. Can J Gastroenterol 2009; 23:270.
- Goodwin TM. Nausea and vomiting of pregnancy: an obstetric syndrome. Am J Obstet Gynecol 2002; 186:S184.
- Schiff MA, Reed SD, Daling JR. The sex ratio of pregnancies complicated by hospitalisation for hyperemesis gravidarum. BJOG 2004; 111:27.
- Weigel MM, Weigel RM. The association of reproductive history, demographic factors, and alcohol and tobacco consumption with the risk of developing nausea and vomiting in early pregnancy. Am J Epidemiol 1988; 127:562.
- Vikanes A, Skjaerven R, Grjibovski AM, et al. Recurrence of hyperemesis gravidarum across generations: population based cohort study. BMJ 2010; 340:c2050.
- Zhang Y, Cantor RM, MacGibbon K, et al. Familial aggregation of hyperemesis gravidarum. Am J Obstet Gynecol 2011; 204:230.e1.
- Fejzo MS, Ingles SA, Wilson M, et al. High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals. Eur J Obstet Gynecol Reprod Biol 2008; 141:13.
- Corey LA, Berg K, Solaas MH, Nance WE. The epidemiology of pregnancy complications and outcome in a Norwegian twin population. Obstet Gynecol 1992; 80:989.
- Outlaw WM, Ibdah JA. Impaired fatty acid oxidation as a cause of liver disease associated with hyperemesis gravidarum. Med Hypotheses 2005; 65:1150.
- Innes AM, Seargeant LE, Balachandra K, et al. Hepatic carnitine palmitoyltransferase I deficiency presenting as maternal illness in pregnancy. Pediatr Res 2000; 47:43.
- Veenendaal MV, van Abeelen AF, Painter RC, et al. Consequences of hyperemesis gravidarum for offspring: a systematic review and meta-analysis. BJOG 2011; 118:1302.
- Buckwalter JG, Simpson SW. Psychological factors in the etiology and treatment of severe nausea and vomiting in pregnancy. Am J Obstet Gynecol 2002; 186:S210.
- Matteson S, Roscoe J, Hickok J, Morrow GR. The role of behavioral conditioning in the development of nausea. Am J Obstet Gynecol 2002; 186:S239.
- Lagiou P, Tamimi R, Mucci LA, et al. Nausea and vomiting in pregnancy in relation to prolactin, estrogens, and progesterone: a prospective study. Obstet Gynecol 2003; 101:639.
- O'Leary P, Boyne P, Flett P, et al. Longitudinal assessment of changes in reproductive hormones during normal pregnancy. Clin Chem 1991; 37:667.
- Kimura M, Amino N, Tamaki H, et al. Gestational thyrotoxicosis and hyperemesis gravidarum: possible role of hCG with higher stimulating activity. Clin Endocrinol (Oxf) 1993; 38:345.
- Goodwin TM, Montoro M, Mestman JH, et al. The role of chorionic gonadotropin in transient hyperthyroidism of hyperemesis gravidarum. J Clin Endocrinol Metab 1992; 75:1333.
- Soules MR, Hughes CL Jr, Garcia JA, et al. Nausea and vomiting of pregnancy: role of human chorionic gonadotropin and 17-hydroxyprogesterone. Obstet Gynecol 1980; 55:696.
- Yamazaki K, Sato K, Shizume K, et al. Potent thyrotropic activity of human chorionic gonadotropin variants in terms of 125I incorporation and de novo synthesized thyroid hormone release in human thyroid follicles. J Clin Endocrinol Metab 1995; 80:473.
- Brzana RJ, Koch KL. Gastroesophageal reflux disease presenting with intractable nausea. Ann Intern Med 1997; 126:704.
- Niemeijer MN, Grooten IJ, Vos N, et al. Diagnostic markers for hyperemesis gravidarum: a systematic review and metaanalysis. Am J Obstet Gynecol 2014; 211:150.e1.
- Mansour GM, Nashaat EH. Role of Helicobacter pylori in the pathogenesis of hyperemesis gravidarum. Arch Gynecol Obstet 2011; 284:843.
- Goodwin TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am 2008; 35:401.
- Fell DB, Dodds L, Joseph KS, et al. Risk factors for hyperemesis gravidarum requiring hospital admission during pregnancy. Obstet Gynecol 2006; 107:277.
- Kirshon B, Lee W, Cotton DB. Prompt resolution of hyperthyroidism and hyperemesis gravidarum after delivery. Obstet Gynecol 1988; 71:1032.
- Goodwin TM. Hyperemesis gravidarum. Clin Obstet Gynecol 1998; 41:597.
- Golberg D, Szilagyi A, Graves L. Hyperemesis gravidarum and Helicobacter pylori infection: a systematic review. Obstet Gynecol 2007; 110:695.
- Godsey RK, Newman RB. Hyperemesis gravidarum. A comparison of single and multiple admissions. J Reprod Med 1991; 36:287.
- Koren G, Boskovic R, Hard M, et al. Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy. Am J Obstet Gynecol 2002; 186:S228.
- Lacasse A, Rey E, Ferreira E, et al. Validity of a modified Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) scoring index to assess severity of nausea and vomiting of pregnancy. Am J Obstet Gynecol 2008; 198:71.e1.
- Rhodes VA, McDaniel RW. The Index of Nausea, Vomiting, and Retching: a new format of the lndex of Nausea and Vomiting. Oncol Nurs Forum 1999; 26:889.
- Abell TL, Riely CA. Hyperemesis gravidarum. Gastroenterol Clin North Am 1992; 21:835.
- Larrey D, Rueff B, Feldmann G, et al. Recurrent jaundice caused by recurrent hyperemesis gravidarum. Gut 1984; 25:1414.
- Abell TL. Nausea and vomiting of pregnancy and the electrogastrogram: old disease, new technology. Am J Gastroenterol 1992; 87:689.
- Knox TA, Olans LB. Liver disease in pregnancy. N Engl J Med 1996; 335:569.
- Robertson C, Millar H. Hyperamylasemia in bulimia nervosa and hyperemesis gravidarum. Int J Eat Disord 1999; 26:223.
- Frulloni L, Patrizi F, Bernardoni L, Cavallini G. Pancreatic hyperenzymemia: clinical significance and diagnostic approach. JOP 2005; 6:536.
- Goldman AM, Mestman JH. Transient non-autoimmune hyperthyroidism of early pregnancy. J Thyroid Res 2011; 2011:142413.
- Goodwin TM, Montoro M, Mestman JH. Transient hyperthyroidism and hyperemesis gravidarum: clinical aspects. Am J Obstet Gynecol 1992; 167:648.
- Sun S, Qiu X, Zhou J. Clinical analysis of 65 cases of hyperemesis gravidarum with gestational transient thyrotoxicosis. J Obstet Gynaecol Res 2014; 40:1567.
- Hershman JM. Physiological and pathological aspects of the effect of human chorionic gonadotropin on the thyroid. Best Pract Res Clin Endocrinol Metab 2004; 18:249.
- American College of Obstetricians and Gynecologists. Practice Bulletin No. 148: Thyroid disease in pregnancy. Obstet Gynecol 2015; 125:996. Reaffirmed 2017.
- Nash E, Ranka P, Tarigopula G, Rashid T. Primary hyperparathyroidism in pregnancy leading to hypercalcaemic crisis and uraemic encephalopathy. BMJ Case Rep 2015; 2015.
- Yilmaz BA, Altay M, Değertekin CK, et al. Hyperparathyroid crisis presenting with hyperemesis gravidarum. Arch Gynecol Obstet 2014; 290:811.