Hyperemesis gravidarum does not usually recur in each pregnancy

Women who have suffered from Hyperemesis gravidarum can now be reassured that severe morning sickness does not necessarily recur in each pregnancy according to the results of the study published August 16 in the American Journal of Obstetrics & Gynecology.

The Finnish study provides evidence that 3 out of 4 women who suffered from hyperemesis gravidarum will not experience it in the subsequent pregnancy. The incidence of hyperemesis is 0.5-2.0% and is the most common cause of first-trimester hospital admissions.

The exact etiology of hyperemesis is still unknown, and both maternal and paternal genetics, family history and environmental causes have all been implicated in its causation. Hyperemesis recently hit the headlines when Kate Middleton, the Duchess of Cambridge and wife of Britain's Prince William, was hospitalized with hyperemesis gravidarum during her first pregnancy.

Finnish researchers identified 1836 women over a period of 7 years who were diagnosed with hyperemesis during their first pregnancy and who had at least one more subsequent delivery. The first pregnancy with hyperemesis was considered as an index pregnancy, and the recurrence rate was calculated based on the incidence of hyperemesis and the total number of subsequent pregnancies. 

There were 2,267 later pregnancies, of whom hyperemesis occurred in 544 or 24% of pregnancies, while in 1723 pregnancies no morning sickness was noted. In case of more than 1 subsequent pregnancy, 333 (11%) of women suffered from hyperemesis in all of their pregnancies.

Women who were second para during the index pregnancy were 33% more likely to suffer from hyperemesis as compared to those who were para one (adjusted odds ratio, 1.33, P = .046).

Being overweight and smokers were at decreased odds of recurrence of hyperemesis in subsequent pregnancy. Women with female fetuses were also at 29% increased odds of recurring hyperemesis (adjusted odds ratio, 1.29, P = .012).

Miina Nurmi, lead author of the study, told Reuters Health by email, “It is good to know that hyperemesis gravidarum (HG) is not a ‘lifelong sentence’ to everyone - sometimes HG patients have been told that HG would be with them in every pregnancy.”

 “It is reassuring to know that hyperemesis does not appear to become more likely with each pregnancy and that after 1 pregnancy with hyperemesis, the following pregnancy may be different,” the authors concluded, admitting that comparison of recurrence is difficult given the lack of universal definition of hyperemesis gravidarum.

The authors further suggested that "Large prospective studies concentrating on HG patients' future pregnancies, studied with both symptom diaries and medical records, would be an ideal way, though slow and somewhat expensive, to come as close to the actual recurrence rate as possible."

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ACOG updates its guidelines on Nausea and Vomiting in Pregnancy

The American College of Obstetricians and Gynecologists have updated its practice guidelines about managing Nausea and Vomiting in Pregnancy, published in the January issue of Obstetrics & Gynecology.

The guidelines replace the earlier document published in September 2015.

Nausea and vomiting of pregnancy affects nearly 50%-80% of women and ACOG urges obstetrician to start the treatment early before it progresses to hyperemesis gravidarum. "Hyperemesis gravidarum is the most common indication for admission to the hospital during the first part of pregnancy and is second only to preterm labor as the most common reason for hospitalization during pregnancy," they write.

The authors draw attention to the importance of timing of the onset. They explain "The timing of the onset of nausea and vomiting is important — symptoms of nausea and vomiting of pregnancy manifest before 9 weeks of gestation in virtually all affected women. When a patient experiences nausea and vomiting for the first time after 9 weeks of gestation, other conditions should be carefully considered in the differential diagnosis. A history of a chronic condition associated with nausea and vomiting that predates pregnancy should be sought (eg, cholelithiasis or diabetic gastroparesis)."

Level A recommendations (good and consistent scientific evidence):

Treatment should always be started with Vitamin B₆ (pyridoxine) alone or in combination with doxylamine as the first line therapy, as it is safe and effective.

Women should be encouraged to start the pregnancy multivitamin 1 month before conception as it is known to decrease the incidence and severity of nausea and vomiting of pregnancy.

ACOG recommends avoiding antithyroid therapy for the transient gestational thyrotoxicosis or hyperemesis gravidarum and urges physicians to only use supportive therapy.

Level B recommendations (limited or inconsistent scientific evidence, include):

Ginger has been found to be effective in some cases of nausea and vomiting and it is recommended as non-pharmacologic therapy.

Methylprednisolone is found effective in some refractory cases of nausea and vomiting of pregnancy, but it should only be used as a last resort, when other treatments have been ineffective.   

Level C recommendations (based on consensus and expert opinion):

Intravenous fluid support should be offered to patients who exhibit sign of dehydration and are unable to tolerate oral fluids.

Dextrose and vitamins should be included in the therapy for prolonged vomiting to correct ketosis and vitamin deficiency, but always administer thiamine before dextrose infusion to prevent Wernicke encephalopathy.

Enteral tube feeding (nasogastric or nasoduodenal) should be started as first line therapy in women with hyperemesis gravidarum who fail to respond to oral medication. Peripheral parenteral nutrition should be used as last resort as it is associated with significant maternal morbidity.

Treating the nausea and vomiting of pregnancy at the very start may prevent it from progressing to hyperemesis gravidarum.

The bulletin also recommends that after the initial workup and hospitalization rules out other comorbidities as cause of vomiting, patient can have the rest of treatment at home too.

Finally, the authors concluded, “Nevertheless, the option of hospitalization for observation and further assessment should be preserved for patients who experience a change in vital signs or a change in mental status, continue to lose weight, and are refractory to treatment."

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