Nausea and vomiting in pregnancy

'Nausea and vomiting are very common symptoms of early gestosis of pregnancy. The causes are usually uncomplicated, but we can also encounter acute and serious conditions. The diagnosis is different depending on the trimester, we always have to think about conditions that may not be directly related to pregnancy.

Vomitus matutinus (morning vomiting)
An uncomplicated condition that appears at the beginning of the 1st trimester and resolves spontaneously between the 14th and 16th. week of pregnancy. It occurs in more than 70% of pregnant women. Vomiting usually comes in the morning upon awakening, without prior nausea and a precipitating stimulus. It no longer occurs during the day.

This is a relatively natural phenomenon and usually does not require medical treatment. Relaxation before getting out of bed, "dietary measures" and possibly "psychological support" can be recommended to alleviate the discomfort of the pregnant woman.

Emesis gravidarum (pregnancy vomiting)
Pregnancy vomiting with manifestations from the 6th gestational week, which usually subsides by the 14th-16th week. weekly. It is more often observed in first-time mothers and multiple pregnancies.

The evoking stimulus is usually olfactory and odor stimuli'. It occurs at any time during the day and can be repeated. The etiology is unknown, it is assumed to be the effect of relaxation of smooth muscles and the stomach, possibly the effect of steroid hormones. Repeated vomiting can lead to weight loss, ketonuria and ion imbalance. Vomiting that is too violent can cause lacerations of the esophageal mucosa.

Psychological support of the patient is important in therapy, low doses of diazepam, pyridoxine and protazine can be administered to calm the patient down. Dietary adjustment with a preference for non-irritating foods in small portions is very important.

Hyperemesis gravidarum (excessive vomiting)
These are 'serious conditions whose symptoms appear during the 4th-10th. week of pregnancy, disappears by the 20th week. The etiology is unknown, it is assumed to be the effect of psychosomatics (PPP, effect of environmental change, etc.), hormonal changes during pregnancy (vomiting peak when hCG and estrogens increase).

Development can be influenced by risk factors (occurrence in previous pregnancy, psychiatric diseases, hyperthyroidism, pre-existing diabetes mellitus, multiparity, multiple pregnancy, obesity, stress factors, disruption of family relationships, etc.).

Clinical symptoms
Severe nausea and vomiting, making it impossible to take any food and liquids. This leads to ``dehydration and malnutrition'', sometimes to metabolic breakdown. Hospitalization is often required.

Dehydration causes an increase in urine concentration and "proteinuria", the blood count increases erythrocytes and hemoglobin concentration, vomiting causes hypochloremia and alkalosis. Starvation develops ``ketoacidosis and ketonuria'', after a longer period of time a protein metabolism disorder (hypoproteinemia, hypoglycemia) and a liver disorder (icterus, hyperbilirubinemia) develop. Frequent vomiting leads to erosion of the gastric mucosa and to 'hematemesis.

Diagnosis and Therapy
It is based on clinical symptoms. The key is repeated vomiting without a demonstrable cause, starvation with ketonuria, weight loss of more than 5%, elevation of liver enzymes (2-3x).

Non-pharmacological therapy includes avoiding nausea-inducing olfactory sensations and foods. Eat smaller portions at more frequent intervals. Reduce salting and too fatty foods. Multivitamin preparations (ginger) and an occasional change of environment are also recommended. Pharmacological therapy consists of administration of vitamin B6 (pyridoxine), antihistamine (promethazine). In case of insufficient effect and sufficient hydration of the patient, we administer metoclopramide' (Degan). We can also administer "thiethylperazine" (Torecan), methylprednisolone and ondasetron.

Differential diagnosis
First, we have to rule out benign pregnancy vomiting (vomitus matutinus) and other complications in pregnancy (preeclampsia, HELLP syndrome, acute hepatic steatosis). We have to exclude stomach ulcer disease, gastroenteritis, viral hepatitis, ileus, pancreatitis, appendicitis, gallbladder problems, gastroesophageal reflux from the gastrointestinal causes. From the ``metabolic causes'' we have to consider diabetic complications, hyperthyroidism and Addison's disease. Among the "urogenital causes" are nephrolithiasis, pyelonephritis and ovarian torsion. From neurological migraines, CNS tumors, disorders of the vestibular apparatus, pseudotumors of the brain.

Links

 * Eating disorders in pregnancy