Nausea and Vomiting During Early Pregnancy
Up to 80% of pregnant women have nausea and vomiting to some
extent. Nausea and vomiting are most common and most severe during the 1st
trimester. Although commonly called morning sickness, such symptoms may occur
at any time during the day. Symptoms vary from mild to severe.
Hyperemesis gravidarum is a severe, persistent form of
pregnancy-related vomiting. Women with hyperemesis gravidarum vomit so much
that they lose weight and become dehydrated. Such women may not consume enough
food to provide their body with energy. Then the body breaks down fats,
resulting in a buildup of waste products (ketones) called ketosis. Ketosis can
cause fatigue, bad breath, dizziness, and other symptoms. Women with
hyperemesis gravidarum often become so dehydrated that the balance of
electrolytes, needed to keep the body functioning normally, is upset.
If women vomit occasionally but gain weight and are not
dehydrated, they do not have hyperemesis gravidarum. Morning sickness and hyperemesis
gravidarum tend to resolve during the 2nd trimester.
Causes
Usually, nausea and vomiting during pregnancy are related to
the pregnancy. However, sometimes they result from a disorder unrelated to the
pregnancy.
Common causes
The most common causes of nausea and vomiting in pregnancy
are
- Morning sickness (most common)
- Hyperemesis gravidarum
- Gastroenteritis (infection of the digestive tract)
The causes of morning sickness and hyperemesis gravidarum
during pregnancy are unclear. However, these symptoms may be related to an
increase in the levels of two hormones during pregnancy: human chorionic
gonadotropin (hCG), which is produced by the placenta early in pregnancy, and
estrogen, which helps maintain the pregnancy. Estrogen levels are particularly
high in women with hyperemesis gravidarum. Also, hormones such as progesterone
(produced continuously during pregnancy) may slow the movement of the stomach’s
contents, possibly contributing to nausea and vomiting.
Less common causes
Occasionally, prenatal vitamins with iron cause nausea.
Rarely, severe, persistent vomiting results from a hydatidiform mole (abnormal
placental growth with or without a fetus due to an abnormally fertilized egg).
Causes of nausea and vomiting unrelated to the pregnancy
include
Disorders of the abdomen such as appendicitis, a blockage in
the intestine ( intestinal obstruction), or inflammation of the gallbladder (
cholecystitis)
Brain disorders such as severe headaches (particularly
migraine headaches), bleeding within the brain ( intracranial hemorrhage), and,
rarely, increased pressure within the brain (increased intracranial pressure),
which can be caused by a number of disorders, such as infection, tumors, or
bleeding
However, these disorders usually cause other symptoms that
are more prominent, such as abdominal pain or headaches.
Evaluation
Doctors first try to determine whether nausea and vomiting
are caused by a serious disorder. Morning sickness and hyperemesis gravidarum
are diagnosed only after other causes are ruled out.
Warning signs
In pregnant women who are vomiting, the following symptoms
are cause for concern:
Abdominal pain
Signs of dehydration, such as decreased urination, decreased
sweating, increased thirst, a dry mouth, a racing heart, and dizziness when
standing up
Fever
Vomit that is bloody, black (resembling coffee grounds), or
green
No movement of the fetus if the fetus is older than 24 weeks
Confusion, weakness or numbness of one side of the body,
speech or vision problems, or sluggishness
Vomiting that persists or that is worsening
When to see a doctor
Women with warning signs should see a doctor right away, as
should those with vomiting that is particularly severe or is worsening.
Women without warning signs should talk to their doctor. The
doctor can help them decide whether and how quickly they need to be seen based
on the nature and severity of their symptoms. Women who have mild to moderate
nausea and vomiting, have not lost weight, and are able to keep some liquids
down may not need to see a doctor unless their symptoms worsen.
What the doctor does
Doctors ask about symptoms and the medical history. Doctors
then do a physical examination. What they find during the history and physical
examination often suggests a cause and the tests that may need to be done (see
table Some Causes and Features of Nausea and Vomiting During Early Pregnancy).
Doctors ask about the vomiting:
When it started
How long it lasts
How many times a day it occurs
Whether anything relieves or makes it worse
What the vomit looks like
How much there is
The woman is asked whether she has other symptoms,
particularly abdominal pain, diarrhea, and constipation, and how her symptoms
have affected her and her family—whether she can work and care for her
children. The woman is also asked about vomiting in previous pregnancies, about
previous abdominal surgery, and use of drugs that may contribute to vomiting.
During the physical examination, doctors first look for
signs of serious disorders, such as blood pressure that is too low or too high,
fever, confusion, and sluggishness. A pelvic examination may be done to check
for evidence of a hydatidiform mole and other abnormalities.
This information helps doctors determine whether vomiting
results from the pregnancy or another, unrelated disorder. For example,
vomiting probably results from the pregnancy if it:
Began during the 1st trimester
Lasts or recurs over several days to weeks
Is not accompanied by abdominal pain
Vomiting probably results from another disorder if it:
Began after the 1st trimester
Is accompanied by abdominal pain, diarrhea, or both
TABLE
Some Causes and Features of Nausea and Vomiting During Early
Pregnancy
Testing
Doctors often use a handheld Doppler ultrasound device,
placed on the woman's abdomen, to check for a heartbeat in the fetus. If no
heartbeats are detected by the time they should be (at about 11 weeks), a
hydatidiform mole is possible.
If the woman is vomiting often or appears dehydrated or if a
hydatidiform mole is possible, tests are usually done. Which tests are done
depend on the cause doctors suspect:
Hyperemesis gravidarum: Urine tests (to measure ketone
levels) and possibly blood tests (to measure electrolyte levels and other
substances)
A hydatidiform mole: Ultrasonography of the pelvis
A disorder unrelated to the pregnancy: Tests specific for
that disorder
Treatment
If vomiting is due to a disorder, that disorder is treated.
If vomiting is related to pregnancy, some changes in diet or eating habits may
help:
Drinking or eating small amounts more frequently (5 or 6
small meals a day)
Eating before getting hungry
Eating only bland foods, such as bananas, rice, applesauce,
and dry toast (called the BRAT diet)
Keeping crackers by the bed and eating one or two before
getting up
Drinking carbonated drinks (sodas)
If vomiting results in dehydration, the woman may be given
fluids intravenously. If vomiting persists, she may be hospitalized. She may be
given sugar (glucose), electrolytes, and occasionally vitamins intravenously
with the fluids. After vomiting has subsided, she is given fluids by mouth. If
she can keep these fluids down, she can begin eating frequent, small portions
of bland foods. The size of the portions is increased as the woman can tolerate
more food.
If needed, drugs to relieve nausea (antiemetic drugs) are
given. Doctors choose drugs that appear to be safe during early pregnancy.
Vitamin B6 is used first. If it is ineffective, another drug (doxylamine,
metoclopramide, ondansetron, or promethazine) is also given.
Ginger (available as capsules or lollipops), acupuncture,
motion sickness bands, and hypnosis may help, as may switching from prenatal
vitamins to children's chewable vitamins with folate.
Rarely, weight loss continues and symptoms persist despite
treatment. Then the woman is fed through a tube passed through the nose and
down the throat to the small intestine. Tube feeding is continued for as long
as necessary.
Key Points
Usually, nausea and vomiting during pregnancy do not cause
weight loss or other problems, and they resolve before or during the 2nd
trimester.
Hyperemesis gravidarum, a severe, persistent form of
pregnancy-related vomiting, is less common and can cause dehydration and weight
loss.
Nausea and vomiting may be due to disorders not related to
pregnancy, such as gastroenteritis, a urinary tract infection, or, rarely, a
blockage in the intestine.
Modifying the diet may help relieve mild nausea and vomiting
that are related to pregnancy.
If women with hyperemesis gravidarum become dehydrated, they
may need to be given fluids intrav
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