Nausea and Hyperemesis

Gravidarum
Kai J. Bhling1,2, Matthias David3
1

Hormone Consultation, Department of Gynecology, University

Medical Center Hamburg-Eppendorf

2 Practice

for Gynecology, Endocrinology and Reproductive Medicine,

Hamburg
3 Charit

Medical Center Berlin, Department of Gynecology and

Obstetrics, Berlin

Reviewer: Dolores Foth, Kln

and Peter Rott, Berlin

1 590 euros per case (300 euros per day, for 5.3 days). The
cost of lost working hours and outpatient treatment is not
even included in this amount. Apart from these economic
aspects, a specific medical problem should be pointed out:
m o rtalities due to HG are rare, unlike during the period prior
to the introduction of intravenous therapy, (in the UK, in
the pre-infusion era the mortality rate of women with HG
was 1.6 women per 10 000 births; Verberg et al. 2005).
However, a current study of US American cohorts showed
that hyperemesis patients with a weight-increase of less
than 7 kg during pregnancy run an increased risk of a range
of unfavorable obstetric constellations (Dodds et al. 2006)
(Tab. 1).

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Table 1: Perinatal outcome parameters for hyperemesis patients with

36

Summary
Hyperemesis gravidarum is a multifactorial illness that
frequently develops pregnancy. It is important that patients
undergo multimodal therapy, taking approaches into consideration, after diverse underlying illnesses has been the
thyroid gland. Patient counseling should take place in a
setting that is suited psychosocial aspects of the illness.
This article also deals with the results of aims to provide
physicians with an evidence-based step-by-step guide.

Introduction
Almost all pregnant women report experiencing characteristic attacks of nausea during the first trimester of pregnancy. Although this nausea is characteristically described
as morning sickness, these nauseous attacks are restricted to the morning hours in just 17 % of all pregnant women
(Ismail and Kenny 2007); in most pregnant women, attacks
can occur throughout the day. Generally, nausea and vo m i ting in (early) pregnancy are mild and self-limiting, usually
ending before the 14th week of pregnancy (Sheehan 2007).
In 1-3 % of the patients affected, symptoms are so severe
that hyperemesis gravidarum is diagnosed. However, data
on the frequency of such attacks also depend on the diagnostic criteria used to define hyperemesis gravidarum (HG)
(Eliakim et al. 2000; ACOG 2004).The following factors are
usually used for defining the illness: unrelievable vomiting
where there is no other cause, the inability to take in food,
the presence of catabolic metabolism (severe ketonuria),
loss of weight and severely impaired general well-being.
When a patient with HG presents with such criteria, she is
normally admitted to hospital, as outpatient treatment is
no longer possible due to the subjectively and objectively
greatly weakened nutritional and general condition. Hyperemesis is therefore not only one of the most frequent indications for hospital admittance during the first trimester
of pregnancy, but is by all means, a major cost factor in the
German health system. In 2005, for example, 17 574 pregnant women were admitted to hospital with this diagnosis
(Information System of Federal Health Monitoring, 2007).
The yearly cost of hospital admittances alone was about
28 million euros per year, based on an average cost of

a weight increase of less than 7 kg during pregnancy (a ccording to

Dodds et al. 2006)

Perinatal Outcome Parameter

Relative Risk

5-minute Apgar score < 7

5,0

Premature birth < 37/0 SSW

3,0

Birth weight < 2 500 g

2,8

Gestational diabetes

1,4

Induced delivery

1,4

Delivery by cesarean section

1,4

Etiology and Pathogenesis

Etiology, pathogenesis, and to a certain extent the resulting therapeutic management of HG, are the subject of a
debate that has continued for decades, in which very conflicting views are expressed on the causes of the illness
(Soltani and Taylor 2003). It is interesting that until the
middle of the 19th century excessive or unrelievable vomiting was largely unknown in the field obstetrics (Meyer
1914). Today, it is repeatedly emphasized that the symptoms of HG are only observed in humans, almost exclusively in pregnant women who live in Western societies
(Simpson et al. 2001). The illness is more frequently found
in female immigrants (David et al. 2002) in comparison
with native inhabitants. There are various theories on the
pathogenesis of HG (Fig. 1).

Bhling K. J. Nausea... Gynakol Geburtsmed Gynakol Endokrinol 2008;4(1):3648 publiziert 31.03.08 www.akademos.de/gyn akademos Wissenschaftsverlag 2008 ISSN 1614-8533

Hypothesis I on the patho-

Hypothesis II on the

genesis of HG: endocrine

pathogenesis of HG:

factors cause HG

nonendocrine factors
cause HG

Hypothalamus/

Cortisol/ACTH

adrenal cortex

Thyroid gland

TSH/thyroxine

overactive hypothalamic-pituitary-adrenal
axis

pregnancy-induced
transitory thyretoxi-

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cosis

Ovar/corpus luteum

HCG

overactive immune
system

immunologic causes

H.pylori infection

infectious causes

alterations in the

gastrointestinal tract

anatomic causes

gastrointestinal tract

Placenta

Estrogen/progesterone

vitamin deficit/trace
element deficit

Prolactin
raised liver enzymes
Leptin
psychological causes

nerval causes

Figure 1: Pathogenetic mechanisms involved in the development of

nausea/hyperemesis gravidarum (modified according to Verberg et
al. 2005)

Currently, the most-favored explanation of the causes of

HG is the so-called hormone theory many studies have
shown a connection between raised HCG values and the
occurrence of pathological vomiting. Numerous other
somatic causes are also under discussion, but they have
not been confirmed by any studies (Verberg et al. 2005).
A study providing an overview of the 15 prospective studies
published between 1990 und 2005 that examined the
relationship between HCG and hyperemesis, summarizes
the results. Significantly raised HCG values were found
(Verberg et al. 2005) in 11 studies.This suggests that HCG
possibly causes hyperemesis gravidarum via a stimulatory
effect on the secretory processes of the gastrointestinal
tract, or, as HCG is structurally similar to TSH (both -arms
are identical), the TSH receptor is stimulated (Ismail and
Kenny 2007).

In early pregnancy, the physiological stimulation of the

thyroid gland sometimes leads to a transient gestational
thyreotoxicosis. This occurs about twice or three times
more frequently in women with hyperemesis gravidarum
(Goodwin 1992). Eleven of the 15 prospective studies that
compared the T4 values of hyperemesis patients with
asymptomatic pregnant women found significantly increased values in the women with hyperemesis, and this
was also the case with regard to TSH values (Verberg et
al. 2005).
A current publication evaluated all studies carried out between 1966 and 2007 on the subject of HG and helicobacter pylori infection. Ten of these 14 case-control studies
found a significant relationship between HG and helicobacter pylori infection. The odds-ratio ranged from 0.55 to

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38

109.33 and only three times was it under 1, which is the signif ic an cerange.The authors therefore concluded that these
very heterogenous results were, overall, only of limited signif ic an ce(Golberg et al. 2007). As biological-somatic approaches were not able to supply any satisfactory explanation,
or because it was not possible to identify the underlying
pathophysiological mechanism of HG, the original psychogenetic model (based on psychoanalytic theory) found
many supporters (Munch 2002).The postulated psychological causes of HG can be divided into four main categories
(Verberg et al. 2005):
1. HG is an expression of conflicts, such as rejection of
the pregnancy, conflict caused by ambivalence towards
motherhood, or of an immature personality, strong
dependency on the mother, fear of pregnancy,
2. HG is an expression of sexual dysfunction(s),
3. HG is a conversion symptom, an expression of a hysterical, neurotic, or depressive dysfunction,
4. HG results from psychosocial stress, experienced
violence, and/or conflict in the relationship with the
partner.

Diagnostics
The definition of HG is not clear-cut. Severe nausea and
vomiting, and electrolyte metabolism, are typical characteristics, as well as digestion, which result in a physically
weakened condition and psychological ultimately a diagnosis of exclusion, i. e. before a patient is diagnosed recommended, numerous differential diagnostics must be
considered, gastrointestinal, metabolic, and neurological
causes (Tab. 2).
Table 2: Hyperemesis gravidarum differential diagnostics
(according to Ismail and Kenny 2007)

Gastrointestinal illnesses

reflux esophagitis
intestinal infections
peptic ulcer
(sub-) ileus
hepatitis
Endocrine dysfunctions

The fact that the incidence of HG is usually low during war

and postwar periods has been taken as pro of of the psychogenesis of this complaint. It should, however, be taken into
consideration that during periods of adversity and hunger
other problems are much more strainful than morning
sickness, and therefore the symptoms of HG are possibly
paid less attention at such times.
Apart from the psychoanalysis-based conversion dysfunction, Buckwalter and Simpson (2002) particularly emphasize stress factors such as fear, lack of information on
pregnancy, bad communication, amongst others, as possible triggers of increased nausea or HG. Studies on the subject have produced various results; some studies confirmed
the connection between social factors and increased vomiting and others could establish no connection. It would
definitely appear that the relationship between the partners plays a very important role in the womans ability to
deal with the negative physical and psychological effects
of stress.
Finally, HG can be an expression of an immature coping
mechanism. Vomiting could be an adopted unconscious
method of evading situations that are difficult to tolerate
or that are stressful (Buckwalter and Simpson 2002).
According to current knowledge, HG is a classical example
of the interaction of biological-somatic, psychological, and
social factors.

gastritis

diabetes
hyperthyroidism
Addisons disease
hypercalcemia

Drug-induced vomiting

antibiotics
iron substitution
other drugs

Neurovestibular dysfunction
Psychiatric illnesses

Some laborato ry parameters, in particular the hematocrit

values, electrolytes, transaminases, bilirubin, and above all,
TSH and free thyroid hormones, play a significant role in
diagnosis.With re ga rd to HG, sys t e m atic endocrine diagnostics are carried out, depending on the severity of the
symptoms. Pregravida parameters should be consulted, if
on hand. In cases with no previous findings, basic laborato ry diagnostics should be performed at least o n ce. As functional diagnostics, the TSH (TSH may be physiologically
suppressed by the cross re a ction of HCG in the first t r i m e ster, but pronounced suppression may also be an indication
of malfunction), fT3, and fT4 values should be determined.
Free thyroid hormones directly re f l e ct the endocrine function of the thyroid gland, while TSH values provide information on the required degree of thyroid gland stimulation.
With a co n s t e l l ation of suppressed TSH (due to a cross reaction with HCG) and normal fT3/fT4 values, no further t re atment is nece s s a ry. If findings are abnormal, the thyroid antibody TPO-Ab and the TSH-receptor-Ab in particular, should
be determined.The benefits of thyreostatic treatment of
latent hyperthyreosis (suppressed TSH, fT3 increased; fT4
in the upper ra n ge) must be considered in each individual

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case; h owever, the benefits of thyreostatic treatment appear to be slight in comparison with the risks. In pronounced symptomatic hyperthyreosis during pregnancy,
which can be diffe re ntiated from M. B a s e d ow(rare during
pregnancy) by determining the thyreotropine re ce p to r
autoantibody (TRAK), l ow-dose thyreostatic treatment
should be commenced (2.5-5.0 mg thiamazol or 50-100 mg
propylthiouracil [PTU]) (Bohnet, 1995). It should alays be
remembered that HCG is slightly physiologically raised in
multiple pregnancies, which is why HG is more frequent in
such cases (Grun et al. 1997). In order to assess the severity
of the illness, and as a criterion for hospital admittance , it
is important to determine the ke tone bodies in the urine.
During initial examination or on admittance , ultrasound
should always be performed on HG pat i e nts (e. g. to determine int a ct gravidity, multiple birth, placenta structure, or
to exclude a hydatidiform mole).
The physician should discuss the psychosocial components
with the pat i e nt in an appropriate manner; for example,
the relationship with the partner (the partners re a ction to
the pregnancy, the partners re a ction to HG), the social circumstances (pressure due to other children or members of
the family, the living conditions, and the work situation),
the possibility, and the need of help. These topics are, h owever, not usually subjects for discussion during the initial
meeting (in an acute situat i o n , for instance , or on admitt a n ce to the clinic) but should be approached during the
second or third meeting.

Step 1
Exclusion of a manifest dysfunction o f the thyroid gland by clinical
and laboratory tests, evaluation of psychosomatic components, and
if necessary, suggestions on possibilities of improving the situation

Step 2
Alteration o f daily habits: nutritional adjustment, smaller meals,
taking the first meal (crisp bread, for instance) in the morning
before getting up; acupressure if required (manual or with an
acupressure band)

Step 3
Ginger tea, raw ginger, ginger capsules (e. g. Zintona 4 x1 capsule)

Step 4
Vitamin B6, 10 mg 3 x daily (e. g. 3 x 1 tab. Nausan)

Step 5
Meclozine (12.5 mg max. 4 x daily), metoclopramide
(10 mg max. 4 x daily or promethazine (12.5 mg max. 4 x daily)
Figure 2: Algorithm on an evidence-based five-step regimen for
nausea and (hyper-)emesis gravidarum.

Conservative Treatment Strategies

Treatment
Patients with nausea gravidarum or less severe cases of
hyperemesis gravidarum can be treated as outpatients.
An exact anamnesis should first be carried out when naus e a/HG develops. Eating early in the morning often leads
to improve m e nt if the illness is strictly morning sickness.
Longer periods of fasting should be avoided (Newman et
al. 1993), as well as possible t r i gger fa ctors (odors, foods)
(Bhling and Bohnet 2006).Water and electrolyte metabolisms that are still balance d , good compliance of the pre gnant woman, and the possibility of psychosomatic-oriented
basic care are preconditions for treating pat i e nts with re gular vomiting as outpatients. Besides the important p syc h osocially oriented, emotionally supportive discussions with
the patient, therapeutic emphasis should be placed on nutritional advice , with the aim of bringing about a change
in life style during pregnancy. The scheme favored by the
authors is shown in Figure 2.

Acupuncture
In various studies, acupuncture or acupressure at the P6
point (inner gate) improved symptoms. Bands were
also used to apply pressure (Roscoe 2002), achieving good
results. These acupressure bands are little known in Germany, but they proved very effective in some random, place b o -co nt rolled studies, that is to say, the symptoms were
alleviated significantly (e. g. www.akupressur-band.de).
Patients themselves should also attempt to apply acupre ssure to P6 eve ry four hours (see Fig. 3); in a randomized,
placebo-co nt rolled study, this also brought good results
(Roscoe 2002).The significance of acupressure and acupuncture in treat m e nt of HG is, h owever, co nt roversial.
This is shown by the ve ry va rying results of the studies on
hand. One study by Knight and coworkers showed that
real acupuncture is not more effective than mock acupuncture (without p u n cturing the skin) (Knight 2001).
There is therefore no pro of that this type of treat m e nt is
more effective than mock-acupressure or acupuncture,
alterations in eating habits, or counseling on changes in
life style (J ewell and Young 2006).

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P6

40

Figure 3: Acupressure at P6 every 4 hours, either manually or using

an acupressure band

Ginger
Ginger is a classical remedy used throughout Asia to treat
nausea and vomiting during pregnancy. Several current
studies have compared the effectiveness of ginger to that
of a placebo in the treatment of nausea or vomiting in
pregnancy. Several studies have proved that ginger (at a
dose of about 1 g/day) reduces nausea, thus providing a
naturopathic therapeutic approach (Fischer-Rasmussen et
al. 1990; Vutyavanich et al. 2001; Niebyl 2002; Ismail 2007).
Balanced Supplements
As early as the beginning of the 1990s, Czeizel and coworkers showed that administration of multivitamin supplements, which, apart from containing lower doses of
vitamin B6 (2.6 mg), also contained 4.0 g vitamin B12,
statistically reduces HG by 50 %. This result was based on
a study in which the multivitamin supplement was administered to 500 pregnant women, and 500 pregnant
women in the control group were given a placebo containing only vitamin C. Interviews carried out during the
first trimester showed that the incidence of pregnancy
accompanied by nausea was substantially higher in the
placebo group (6.6 % vs. 3 % at the end of the first trimester). The authors presumed this to be the result of a latent
vitamin deficiency that normalized due to substitution,
thus leading to a distinct improvement in the clinical sy m ptoms (Czeizel et al. 1992). Virtually at the same time, two
controlled randomized studies were published which examined the effe cts of vitamin B6 substitution as a monothera py on HG (Sahakian et al. 1991;Vutyavanich et al. 1995).
In 1991, Sahakian and coworkers reported on the results of
a study performed on 59 pregnant women with HG, who
were randomly allocated to two study branches. 31 test

persons received 25 mg of vitamin B6 3 x daily; the other

28 test persons received a placebo. The parameters of both
groups were comparable at the start of the study. After a
three-day treatment, the severe cases of nausea decreased
significantly (median difference 4.3 2.1 vs. 1.8 2.2; p < 0.1).
The number of pregnant women with vomiting also decreased from 15 to 8/31 in this branch of the study; in the
placebo group, on the other hand, the rate increased from
10 to 15/28. The authors hereby confirmed, in a randomized
double-blind study, the results of a study performed by
Willis and colleagues in 1942.
In 1995, the results of a further randomized, double-blind
study by Vutyavanich and coworkers from Thailand were
published: 169 pregnant women were administered 30 mg
of vitamin B6 daily (divided into three separate doses);
167 pregnant women received a placebo applied in the
same manner (Vutyavanich et al. 1995). The results were
evaluated by way of a score. The decrease in symptoms
was more statistically significant in the group receiving
vitamin B6 than in the placebo group, particularly during
the first three days. The authors therefore recommend
vitamin B6 as the substance of choice for treatment of HG.
Another vitamin with possible antiemetic effects, vitamin
B12, is also under discussion.There is, however, little data on
this subject. A study performed by Conklin and coworkers
in 1958 was not able to show any significant effects (Conklin
and Nesbitt 1958). In the studies available, the laboratory
parameters of pregnant women with and without symptoms were unfortunately, not compared, but they did uniformly show the positive effects of vitamin substitution.

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In view of the effectiveness of vitamin B6 on the symptoms

of hyperemesis gravidarum, it must be assumed that hypovitaminosis of this vitamin (at least latent) is a further pathogenetic factor.

Pharmacological Intervention
Drugs are usually classified according to the criteria shown
in Table 3.
Table 3: Classification of drugs according to embryotoxic/teratogenic

In Germany, Nausan, an approved supplement that makes

use of the antiemetic characteristics of high doses of vitamin B6, has been available for the treatment of nausea/hyperemesis gravidarum since 2007. It also contains a small
amount of vitamin B12. Nausan should be taken from at
least 3 times, up to a maximum of 6 times daily.

risks (Red Lists 2008)

Group

Description

There was no suspicion of embryotoxic/teratogenic effects after

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extensive use in humans. Animal experiments also showed no

Another illness should be taken into consideration within

the framework of HG thera py. Recently, Chiossis workgroup
pointed out that world literature describes 49 cases of a
first manifestation of Wernickes encephalopathy during
pregnancy. Wernickes encephalopathy is caused by a lack
of vitamin B1 (lack of thiamine). The authors concluded
that patients with HG, who also suffer from neurological
symptoms (e. g. impaired vision, confusion, and ataxia),
could suffer from this illness, and high-dose thiamine substitution should be commenced immediately (Chiossi et al.
2006). Robinson and colleagues made a similar recommendation when reporting on the case of a pregnant woman
with HG and diathesis. A lack of vitamin K proved to be
the cause in this case, whereby, the symptoms improved
quickly after suitable substitution (Robinson et al. 1998).

indication of embryotoxic/teratogenic effects.

2

There was no suspicion of embryotoxic/teratogenic effects after

extensive use in humans.

There was no suspicion of embryotoxic/teratogenic effects after

extensive use in humans

Indications of embryotoxic/teratogenic effects were observed in

animal experiments.These appear to bear no significance for
humans.

Insufficient data are available on use in humans. Animal experiment

showed no indication of embryotoxic/teratogenic effects.

Insufficient data are available on use in humans.

Insufficient data are available on use in humans. Indications of

embryotoxic/teratogenic effects were observed in animal experiments.

Risk of embryotoxicity/teratogenicity in humans.

(1st trimester).

Risk of fetotoxicity in humans.

(2nd and 3rd trimesters).

10

Risk of perinatal complications or damage in humans.

11

Risk of undesired hormone-specific effects in human progeny.

Various studies have been carried out on the use of methylprednisolone, but they generally showed no positive influence on HG (Magee et al. 2002).There are few data available
for benzodiazepine, and symptoms did not decrease after
its use (Jewell 2006). Anticholinergics are contraindicated
due to the lack of knowledge on their safety.
Two groups of substances are therefore generally used to
treat HG:
Antihistamines (H1 blockers): seven prospective studies
showed subjective improvements in the patients treated
(Mazzotta and Magee 2000). No increased risk of fetal
abnormalities was found in over 200 000 pregnant

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42

women who took H1 blockers in early gravidity. A metaanalysis even showed a slightly reduced risk of fetal malformation (Seto et al. 1997). If the above-mentioned
measures are unsuccessful, the H1 antihistamine meclozine (Peremesin) can be administered (12.5 mg max. 4 x
daily). Although the substance was shown to be embryotoxic in animal experiments, similar effects were not
found in humans; the substance is therefore classified in
Group 3 of the classification of drug safety in pregnancy
(see Tab. 3). In 1979, the very strict American FDA even
reapproved the drug for use during pregnancy (Schaefer
and Spielmann 2001; Magee et al. 2002). The soporific
doxylamine (Hoggar N; 12.5 mg up to 3x daily), which is
often used in the USA, is a further option. Some studies
show that the H1 antagonist doxylamine is effective in
treating nausea/HG. Doxylamine is classified as a Group 4
drug with regard to its use during pregnancy (see Tab. 3)
(Schaefer and Spielmann 2001; Magee et al. 2002).
Dopamine antagonists: within this context, metoclopramide (MCP) is probably the most widely used drug. Surprisingly enough, there are no randomized studies on this
drug. It is unlikely that the drug has teratogenic effects,
based on the data available (corresponding to Group 4 of
the classification of drugs for use during pregnancy, see
Tab. 3), but only a limited number of studies have been
carried out on the drug. In spite of this, MCP is one of
most frequently used drugs in Germany for treating HG;
the dosage is 10 mg (max. 4 x daily). Evidence is available,
however, that promethazine, which belongs to the same
group of substances, reduces emesis (Atosil; 12.5 mg,
max. 4 x daily). Promethazine is also classified in the drug
safety Group 4 (Schaefer and Spielmann 2001; Magee et
al. 2002). Dimenhydrinate (Vomex A), which also belongs
to this group of active ingredients, was also shown to
have positive effects (Cartwright 1951). Although no tera
togenic effects were found in animal experiments, themanufacturers have stated that the extent of the experiments was not sufficient to exclude such characteristics.
Therefore, if the use of a dopamine antagonist is indicated,
promethazine is the preferred drug. At least one study on
800 mother-child pairs has been published on the safety
of this drug.

summarized in Table 4. It should be mentioned that in the

USA, in Bendectin (in the United Kingdom Debendox, in
Canada Diclectin) a pro d u ct is, or was available, which contains a combination of 10 mg of vitamin B6 and 10 mg dox ylamine. At the time of the Contergan scandal, a study was
published in which the authors pointed out a slightly increased risk of lip-jaw-palate cleft associated with the use
of Bendectin (Golding et al. 1983). This led the manufacturers to recall the drug, but although the results of some
high-quality studies contra d i cted these findings, the manufacturers did not re-release the drug onto the market. In
Canada, where health authorities are as strict as those in
Germany, Diclectin is still on the market (Mitchell et al.
1981; Mitchell et al. 1983; Elbourne et al. 1985).

Patients should be informed that all the above-mentioned

active ingredients reduce the capability to react (Red Lists
2007). Experience has shown, however, that there is a much
higher acceptance of drugs that are indicated for treating
vomiting than drugs prescribed as sleeping pills or psychotropic drugs.
In rare therapy-resistant cases, after the appropriate riskbenefit analysis, the possibility of administering the antiemetic antidepressive mirtazapine (Remergil) or the antiemetic ondansetrone (Zof ran) remains (Rohde et al. 2003).
In a ve ry small study, it was found that the latter is not more
effective than promethazine, even if clinical practice provides a different impression (Sullivan 1995). The products are

Bhling K. J. Nausea... Gynakol Geburtsmed Gynakol Endokrinol 2008;4(1):3648 publiziert 31.03.08 www.akademos.de/gyn akademos Wissenschaftsverlag 2008 ISSN 1614-8533

Table 4: Pharmacological options for treating nausea/hyperemesis

gravidarum

Effectiveness in treating
Active ingredient

Product (example)

Dosage

Teratogenic/embryotoxic

HG according to the study

potential

situation

Antihistamines
Meclozine*

Peremesin N, Postadoxine N 12,5 mg max. 4 x daily

Gr. 3

Doxylamine

Hoggar Night;

12,5 mg max. 3 x daily

Gr. 4

Metoclopramide

Paspertin drops

10 mg max. 4 x daily

Gr. 4

(+)

Dimenhydrinate

Vomex A

50 mg max. 4 x daily

contraindicated during the

Dopamine antagonists

last weeks of pregnancy

(possibly triggers premature
contractions of the uterus)

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during the 2st and 2nd trimesters, only if strictly indicated (only to be used if
non-medicinal measures
are unsuccessful)
Promethazine

Atosil tablets 25 mg

12,5 mg, max. 4 x daily

Gr. 4

Zofran

10 mg max. 3 x daily

Gr. 4

Selective 5-hydroxytryptamine (HT)

receptor antagonist
Ondansetrone

* Products containing this active ingredient is no longer available

in Germany.

Inpatient treatment
In severe cases of HG with unrelievable vomiting accompanied by at least a pronounced ketonuria (urine dipstick
test: ++), the patient should be admitted to hospital.The
risk factors for HG or for hospital admittance are listed
in Table 5. In practice, the decisive factor is a ketone body
test using a urine dipstick, which should be performed
regularly in pregnant women with HG.

Table 5: Risk factors for hyperemesis gravidarum with regard to

hospital admittance (according to Fell et al. 2006)

Risk factor

Relative risk

previous hyperemesis

29

hyperthyreoidism

4,5

psychiatric illness

4,1

previous molar pregnancy

3,3

multiple pregnancy
boy/girl

3,7

only boys

2,4

only girls

1,7

preexisting diabetes mellitus

2,6

gastrointestinal dysfunctions

2,5

asthma

1,5

age of mother < 20 years

1,5

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Somatic treatment consists of abstention from food,

volume and electrolyte substitution, vitamin intake and
administration of antiemetics, as shown above. Food intake
should not be built up until there has been a significant
decrease in vomiting. The patient cannot be discharged
until the ketone bodies in the urine are negative, the nutritional condition has stabilized, and there has been improvement in the overall condition of the patient. It is also important that the above-mentioned laboratory tests are
performed and that the patients body-weight is monitored. Admittance to hospital, for instance, is a form of psychosomatic intervention, as the patient is thus removed
from stressful domestic surroundings. In addition, psychosomatic-oriented treatment (psychodynamic intervention,
behavioral therapy) may be necessary. This should be discussed with the patient. The pregnant woman should be
taken seriously; labeling the patient a hysterical psychological case is just as inappropriate, as treatment that is
limited to antiemetic therapy and electrolyte balance.

44

CME Prakt Fortbild Gynakol Geburtsmed Gynakol

Endokrinol 2008; 4(1): 3648
Keywords
Hyperemesis gravidarum, Nausea gravidarum, vitamin
supplementation, pregnancy

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45

Associate Professor Dr. med. Kai J. Bhling

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Hormone Consultation
Department of Gynecology
University Medical Center Hamburg-Eppendorf
Martinistr. 52
20246 Hamburg
Germany

46

Associate Professor (PD) Dr. med. Kai J. Bhling commenced

his training as a specialist in Hamburg at the General Hospital, Altona (Prof. V. Lehmann) after completing his studies
in Hamburg and Berlin and gaining his doctorate in Berlin.
In 1997, Dr. Bhling returned to Berlin and finished his specialist training at the Department of Obstetrics (Director:
Prof. J. W. Dudenhausen) and Department of Gynecology
(Director: Prof. Dr. W. Lichtenegger). In 2004, he received his
qualification as a university lecturer at the Berlin Charit,
after completion of his thesis on the subject of gestational
diabetes. From 2004 to 2005, Dr. Bhling carried out clinical
and scientific work, focussing on gynecological endocrinology, for Prof. H. Lbbert, and continued this work after
moving to Hamburg and joining the group practice Bohnet,
Knuth and Graf. Since 2007, he has his own practice and is
consultant and director of Hormone Consulting at the University Medical Center Hamburg-Eppendorf, where he is
also qualified to teach. Dr. Bhling has specialist qualifications in obstetrics and perinatal medicine, gy n e cological
endocrinology and reproductive medicine, as well as being
an approved diabetologist. Apart from his work on diabetes, diseases of the thyroid gland, and on nutrition during
pregnancy, his scientific work focuses on the diagnostics
and treatment of gynecological-endocrinological disease.
Conflict of interest
The author Kai J. Bhling declares that this article was
written without the influence of any industrial interests.
He also states that he has received material or financial
support from the company Steripharm for an expertise.
The gratuity has no influence on the contents of this art i c l e.
The author Matthias David declares that there is no
conflict of interest as defined by the guidelines of the
International Committee of Medical Journal Editors
(ICMJE;www.icmje.org).
Manuscript information
Submitted on: 08.03.2008
Accepted on: 20.03.2008
Bhling K. J. Nausea... Gynakol Geburtsmed Gynakol Endokrinol 2008;4(1):3648 publiziert 31.03.08 www.akademos.de/gyn akademos Wissenschaftsverlag 2008 ISSN 1614-8533

CME-Continuing Medical
Education
Nausea and hyperemesis gravidarum

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Question 1
Nausea gravidarum
a. is a very rare illness,
b. only affects women with a low standard of
education,
c. is a very frequent illness,
d. cannot be treated,
e. must be treated by psychotherapy.
Question 2
Nausea gravidarum develops in
a. 0,1 % of all pregnant women,
b. 0,5 % of all pregnant women,
c. 1 % of all pregnant women,
d. 10 % of all pregnant women,
e. > 50 % of all pregnant women.
Question 3
Which statement is incorre ct with re ga rd to possible
causes of hyperemesis gravidarum (HG)?
a. HG is an expression of conflicts, such as rejection
of pregnancy, conflict caused by ambivalence
toward motherhood, an immature personality,
dependency on the mother, fear of pregnancy.
b. HG is an expression of sexual dysfunction(s).
c. HG occurs in connection with exaggerated
solicitousness on behalf of the partner.
d. HG is a conversion symptom, as an expression of
a hysterical, neurotic, or depressive dysfunction.
e. HG is the result of psychosocial stress, violence,
and/or conflict in the relationship between the
partners.
Question 4
Which of the following illnesses must be excluded
in patients with hyperemesis gravidarum in early
pregnancy?
a. Restless legs syndrome (RLS).
b. Hyperthyreosis.
c. Fibromyalgia.
d. Preeclampsia.
e. Coronary heart disease.
Question 5
The pregnancy hormone HCG
a. stimulates the function of the thyroid gland,
b. inhibits the function of the thyroid gland,
c. does not influence thyroid gland function,
d. leads to a decrease in SHBG,
e. is generated in the pituitary gland.

Question 6
If TSH is suppressed during pregnancy,
a. thyreostatic treatment should be commenced
immediately,
b. no further measures are necessary,
c. it is a primarily physiological process,
d. low doses of L-thyroxine should be administered,
e. it is a symptom of latent hypothyreosis.
Question 7
A psychosocial component in the development of
hyperemesis gravidarum
a. can be excluded if the patient denies that such a
component exists during her first conversation
with the physician,
b. is a precondition for inpatient treatment,
c. is an indication for psychotherapy,
d. is improbable if the patient has just separated
from her partner,
e. can often be elicited in a second conversation
with the patient.
Question 8
The most significant therapeutic life-style alterations in patients with nausea gravidarum are:
a. to eat three large meals,
b. to eat a small meal (crisp bread) before getting
up in the morning, particularly in the case of
morning sickness
c. to avoid eating proteins,
d. to drink two liters of fruit juice a day,
e. to continue a fast that has possibly already
begun.
Question 9
Which of the following options are effective in
treating hyperemesis gravidarum, according to
evidence-based criteria?
1. Acupressure.
2. Prescription of preparations containing ginger.
3. Removing the patient from the domestic
surroundings by admittance to hospital.
4. High-dosage vitamin B6 supplementation
(e. g. Nausan)
5. Administration of promethazine (e. g. Atosil)
a. All answers are correct.
b. Only answers 1, 2 and 3 are correct.
c. Only answers 1, 2, 4 and 5 are correct.
d. Only answer 5 is correct.
e. None of the answers are correct.

47

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Question 10
In which of the following instances, in connection
with hyperemesis gravidarum, should hospital
admittance be considered?
1. Ketonuria (++).
2. Exsiccosis.
3. A stressful domestic situation.
4. A weakened general condition.
5. Uterine bleeding.

48

a. All answers are correct.

b. Only answer 1 is correct.
c. Only answers 1 and 5 are correct.
d. Only answers 3 and 4 are correct.
e. None of the answers are correct.