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Pregnancy, Hyperemesis Gravidarum - Diagnosis and Differentials

Author Information and Disclosures

Contents

Clinical

History:
  • Nausea and vomiting occur in early pregnancy and are nonresponsive to simple measures, such as reassurance and dietary changes.
  • Fever and abdominal pain are not characteristic of hyperemesis gravidarum.
  • If vomiting begins after 9 weeks' gestation, other causes should be investigated.

Physical: Findings at physical examination may include the following:

  • Weight loss
  • Dehydration
    • Decreased skin turgor
    • Postural changes in blood pressure (BP) and pulse
  • Abdominal tenderness, fever, and goiter likely indicate another process.

Causes:

  • 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, high or low pregestational weight, 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.

Differentials

Appendicitis, Acute
Cholecystitis and Biliary Colic
Diabetic Ketoacidosis
Gastritis and Peptic Ulcer Disease
Gastroenteritis
Hepatitis
Obstruction, Small Bowel
Ovarian Torsion
Pancreatitis
Pregnancy, Preeclampsia
Urinary Tract Infection, Female

Other Problems to be Considered:

Pyelonephritis
Molar pregnancy
Pseudotumor cerebri
Acute fatty liver of pregnancy

Workup

Lab Studies:
  • Obtain electrolyte levels.
  • Measure urine gravity and ketones.
  • Perform liver function tests (LFTs) if hepatitis is a concern. Of note, LFTs can be slightly elevated with hyperemesis gravidarum.
  • Perform a complete blood count and urinalysis to rule out other causes, with particular concern for pyelonephritis.
  • Hyperthyroidism causing nausea and vomiting is rare, a T3 and T4 level should be drawn if this is a concern. (Thyroid-stimulating hormone [TSH] can be suppressed in hyperemesis gravidarum.)
  • Obtain serum amylase-to-creatinine ratio if pancreatitis is a concern.
  • Serum hCG levels are not clinically useful in a patient with a known intrauterine pregnancy (IUP) and hyperemesis.

Imaging Studies:

  • The patient should have an ultrasonographic evaluation of her pregnancy to look for molar pregnancy or multiple gestations.
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Synonyms And Related Keywords

hyperemesis gravidarum, nausea and vomiting in pregnancy, pernicious vomiting in pregnancy, uncontrollable vomiting in pregnancy, severe nausea and vomiting in pregnancy, morning sickness, miscarriage

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Author Information and Disclosures

Author: Susan Renee Wilcox, MD, Resident, Department of Emergency Medicine, Harvard Medical School

Coauthor(s): Alison Edelman, MD, Assistant Professor, Department of Obstetrics and Gynecology, Oregon Health Sciences University; Judith R Logan, MD, MS, Assistant Professor, Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University

Susan Renee Wilcox, MD, is a member of the following medical societies: Phi Beta Kappa

Editor Information

Editor(s): Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Pamela Dyne, MD, Program Director, Associate Professor, Department of Medicine, Division of Emergency Medicine, University of California at Los Angeles School of Medicine

 
 
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