Hyperemesis gravidarum is the most severe form of nausea and vomiting in pregnancy, characterized by persistent nausea and vomiting

associated with ketosis and weight loss (>5% of prepregnancy weight). This condition may cause volume depletion, electrolytes and acid-base imbalances, nutritional deficiencies, and even death. Severe hyperemesis requiring hospital admission occurs in 0.3-2% of pregnancies.[1]

Essential update: Antihistamine use associated with poor outcomes in hyperemesis gravidarum
A case-control study of 254 women who experienced hyperemesis gravidarum during their pregnancies and were treated with intravenous fluids and 308 women who had had normal pregnancies found that use of antihistamines to help alleviate symptoms of hyperemesis gravidarum was associated with adverse outcomes, including preterm birth and lower birth weight.[2, 3] The women with hyperemesis gravidarum were 4 times more likely to experience adverse outcomes than women with normal pregnancies were (P < .0001).[3] Such outcomes were linked to the use of methylprednisolone (P < .0217) promethazine (P < .0386), and other antihistamines (P < .0151; including diphenhydramine, dimenhydrinate, doxylamine, hydroxyzine, and doxylamine-pyridoxine) independent of effectiveness. Gestational hypertension and early onset of symptoms were both linked to poor outcomes as well.

Signs and symptoms

The defining symptoms of hyperemesis gravidarum are gastrointestinal in nature and include nausea and vomiting. Other common symptoms include ptyalism (excessive salivation), fatigue, weakness, and dizziness. Patients may also experience the following: Sleep disturbance Hyperolfaction Dysgeusia Decreased gustatory discernment Depression Anxiety Irritability Mood changes Decreased concentration See Clinical Presentation for more detail.

Diagnosis
Physical examination in women with suspected hyperemesis gravidarum is usually unremarkable. Findings may be more helpful if the patient has unusual complaints suggestive of other disorders (eg, bleeding, abdominal pain). Examination includes the following: Vital signs, including standing and lying blood pressure and pulse Volume status (eg, mucous membrane condition, skin turgor, neck veins, mental status) General appearance (eg, nutrition, weight) Thyroid evaluation Abdominal evaluation Cardiac evaluation Neurologic evaluation Laboratory tests

Initial laboratory studies used in the evaluation of women with hyperemesis gravidarum should include the following: Urinalysis for ketones and specific gravity Serum levels of electrolytes and ketones Liver enzymes and bilirubin levels[4] Amylase/lipase levels Thyroid stimulating hormone, free thyroxine levels [5] Urine culture Calcium level Hematocrit level Hepatitis panel[1] Imaging studies The following imaging studies may be used to assess women with hyperemesis gravidarum: Obstetric ultrasonography: Usually warranted to evaluate for multiple gestations or trophoblastic disease Upper abdominal ultrasonography: If clinically indicated, to evaluate the pancreas and/or biliary tree Abdominal computed tomography scanning or magnetic resonance imaging: If appendicitis is suspected as a cause of nausea and vomiting in pregnancy Additional imaging studies may be warranted if the patients clinical presentation is atypical (eg, nausea and/or vomiting beginning after 9-10 wk of gestation, nausea and/or vomiting persisting after 20-22 wk, acute severe exacerbation) or if another disorder is suggested based on the history or physical examination findings. Procedures In patients with abdominal pain or upper gastrointestinal bleeding, upper gastrointestinal endoscopy appears to be safe in pregnancy, although careful monitoring is suggested. See Workup for more detail.

Management
Initial management in pregnant women with hyperemesis gravidarum should be conservative and may include reassurance, dietary recommendations, and support. Alternative therapies may include acupressure and hypnosis.[6] Pharmacotherapy The only FDA-approved drug for treating nausea and vomiting in pregnancy is doxylamine/pyridoxine. However, antihistamines, antiemetics of the phenothiazine class, and promotility agents (eg, metoclopramide) have also been used to manage nausea and vomiting during pregnancy. In cases refractory to standard therapy, ondansetron and steroids may be considered. The following medications may be used in women with hyperemesis gravidarum: Vitamins (eg, pyridoxine) Herbal medications (eg, ginger) Antiemetics (eg, doxylamine-pyridoxine, prochlorperazine, promethazine, chlorpromazine, trimethobenzamide, metoclopramide, ondansetron) corticosteroids (eg, methylprednisolone) Antihistamines (eg, meclizine, diphenhydramine) Surgery In some refractory severe cases of hyperemesis gravidarum, if maternal survival is threatened, or if hyperemesis gravidarum is causing severe physical and psychological burden, termination of the pregnancy should be considered.[7]

See Treatment and Medication for more detail.