Hyperemesis Gravidarum: More Than Just Morning Sickness

• Pregnancy and nausea are terms used in unison with one another. 
• While mild nausea and vomiting is a common discomfort of pregnancy, patients with severe cases become diagnosed with hyperemesis gravidarum.    
• There are multiple options with both non-pharmacological and pharmacological options, as well as outpatient and inpatient treatment options.

What is Hyperemesis Gravidarum?

Pregnancy and nausea are terms used in unison with one another. The connection between both is very plausible since about 70% of pregnancies have reported nausea or vomiting, making it a frequently experienced pregnancy symptom.   

While mild nausea and vomiting is a common discomfort of pregnancy, patients can experience moderate and even severe cases of nausea and vomiting episodes. The severe cases become diagnosed as hyperemesis gravidarum.    

Establishment of a patient’s severity level can be achieved through clinical evaluation and patient assessment. Discussing with the patient the frequency of nausea episodes with or without vomiting, impact experienced of quality of life, assessing for development of complications, and ruling out other etiologies aides in determining appropriate management plans.   

Clinical evaluation and assessment are performed through obtaining patient’s weight, vital signs, CBC, CMP, urinalysis, and patient historical reports to provide insight on patient clinical status and overall health impact.  

It is important to note that even while the phrase “morning sickness” is a more common term associated with nausea and vomiting during pregnancy, pregnancy related symptoms could be experienced at any time day or night.  

After evaluation and assessment of the patient, a hyperemesis gravidarum diagnosis typically aligns with the criteria below: 

• Onset prior to 16 weeks gestation 
• Three or more nausea and vomiting episodes daily 
• Weight loss greater than 5% of pre-pregnancy weight 
• Inability to consume food and drink regularly 
•  Hypovolemia with symptoms of 
  •  Tachycardia 
  •  Decreased urine output 
  •  Dizziness 
  •  Electrolyte imbalances 

Once the severity of the pregnancy associated nausea and vomiting has been determined, symptom management or treatment options can be discussed. Management and treatment plans based on the patient’s condition is a critical component in consideration of patient outcomes. Considering the overall health of both the maternal patient and fetus. Ongoing evaluation throughout pregnancy is warranted to provide adjustments in patient symptom management plans appropriately.  

Treatment and management plans may require multiple interventions or minimal interventions and may fluctuate by increasing and decreasing throughout the pregnancy. There are multiple options with both non-pharmacological and pharmacological options, as well as outpatient and inpatient treatment options.  

It is strongly encouraged to educate patients that prior to making any dietary changes or taking over the counter medications, they discuss it with their OB provider to ensure proper patient safety.  

Non-Pharmacological Treatment for Hyperemesis Gravidarum

Dietary modifications or alterations to eating habits have been shown to be an excellent method for symptom management for those with mild nausea and vomiting. These can include any or all of the following: 

• Balance contents of the stomach with never having it too empty or too full 
• Eating before going to bed and before getting up to reduce nausea aggravation 
• Eating small frequent meals 
• Reviewing diet for foods that have been known to create nausea previously, even before pregnancy and eliminating them from diet 
• Keeping plenty of fluids introduced prior to eating and throughout the day to prevent an empty stomach and maintain hydration 
• Consume sports drinks with additional electrolytes 
• Introducing teas with mint, lemon, or peppermint that have been known to be soothing to the stomach 

Additional non-pharmacological interventions that have alleviated nausea and vomiting for some patients: 

• Acupuncture 
• Hypnosis 
• Acupressure
  

Pharmacological Treatments for Hyperemesis Gravidarum

Vitamins and supplements are typically the next step for patients that do not achieve relief though dietary modifications. Patients can purchase these over-the-counter, but discussing the right dosage and frequency to consume is a very critical piece of education.  

• Ginger supplement products 
• B6 vitamins 

Once dietary modifications and over-the-counter medications have been proven to be ineffective, resorting to antiemetic prescriptions would be the next step to symptom management.  

While there are multiple antiemetic medications available, some of these have limited or conflicting safety information during pregnancy. Patient discussions with their OB/GYN clinician will review individualized risks versus benefits to obtaining a prescription and recommendations for each specific patient.  

Prescription medications can include: 

• Antivert 
• Dramamine 
• Diphenhydramine 
• Zofran 
• Diclegis 

Inpatient and Outpatient Therapies for Hyperemesis Gravidarum

Additional therapy may be required if hyperemesis gravidarum cannot be controlled.

Outpatient Therpay

For some patients that dietary modifications and oral medications have still not been effective, will be referred to outpatient therapy management. Patients may come in to have fluid and electrolyte intravenous replacements, lab testing, fluid maintenance evaluation, or intravenous antiemetic.  

Inpatient Therapy

Inpatient therapy is performed when patients have continued to have persistent vomiting, even after IV replacement therapy and medications. These patients in addition to persistent nausea and vomiting have abnormal electrolytes and acid base imbalances. 

Enteral and parenteral nutrition is based on clinical judgement and is typically initiated on patients that can’t maintain their weight after continuous pharmacologic interventions have been unsuccessful. Once a patient has been stabilized through shown electrolyte balance  and acid base balance, patients will have an oral reintroduction of liquids and bland low-fat foods after appropriate gut rest has been performed

The Bottom Line

All prenatal patients should be educated on common discomforts of pregnancy that could be experienced and when to seek further medical evaluation for those discomforts.  

In regard to nausea and vomiting, educating patients on hypovolemia signs and symptoms or unable to keep fluids down for more than 12 hours to seek medical attention.  

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