NAUSEA AND VOMITING OF PREGNANCY

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The gastrointestinal tract is commonly affected by the physiologic changes that occur during pregnancy. Nausea and vomiting during pregnancy (NVP) is a common experience, affecting 50% to 90% of all women.10, 43, 46, 94 Its association with pregnancy was documented on papyrus dating as far back as 2000 bc. The earliest reference is in Soranus' Gynaecology from the second century ad.26 The socioeconomic impact of NVP on time lost from either paid employment or household work is substantial. In one prospective study, Deuchar20 noted 8.6 million hours of paid employment and 5.8 million hours of housework lost each year because of NVP. Although in most women NVP is usually limited to the first trimester, in 20% symptoms continue throughout pregnancy. In those who have prolonged or intractable symptoms, including the most severe and least common manifestation known as hyperemesis gravidarum, physicians may have a dilemma about appropriate diagnosis, evaluation, and therapy for these patients. Gastroenterologists and obstetricians, in particular, should become familiar with the pathogenesis and natural history of NVP, in addition to having a systematic approach to diagnostic evaluation and therapeutic management. This article describes the epidemiology, pathogenesis, diagnosis, and treatment of NVP.

Section snippets

Epidemiology

NVP is more common in Westernized countries, in predominantly urban compared with rural populations, and is rare in African, Native American, Eskimo, and some Asian populations except for the industrialized Japanese.86 Hypothesized demographic factors contributing to NVP include ethnicity,103 occupational status,103 and maternal age.46, 103 Certain reproductive history characteristics may also be influential, including nausea and vomiting in a prior pregnancy,61, 103 parity,46, 78 history of

HYPEREMESIS GRAVIDARUM

Hyperemesis gravidarum is the most severe manifestation of the spectrum of NVP. Historically known as “pernicious vomiting of pregnancy,”26 it is characterized by intractable nausea and vomiting, so severe as to cause dehydration, electrolyte and metabolic disturbances, and nutritional deficiency necessitating hospitalization.1, 26, 39 Although it shares much of the epidemiology, pathogenesis, and clinical features of NVP, it has important unique features.

THERAPY FOR NAUSEA AND VOMITING OF PREGNANCY AND HYPEREMESIS GRAVIDARUM

The management of NVP, depending on severity, ranges from conservative dietary modifications in the mildly symptomatic woman, to drug therapy and total parenteral nutrition for those with severe intractable symptoms (Table 1). Termination of pregnancy because of hyperemesis gravidarum was first reported in 1813, although the indications and the need for therapeutic abortions were discussed openly first in 1852.31 The performance of therapeutic abortions for hyperemesis gravidarum has decreased

SUMMARY

NVP is a spectrum of disorders ranging from the physiologically typical mild to moderate nausea and vomiting that is usually self-limited, to the pathologic, intractable symptoms of hyperemesis gravidarum that are associated with metabolic and electrolyte disturbances and weight loss. Up to 90% of pregnant women experience NVP. The pathogenesis remains poorly understood with multifactorial theories proposed combining both biologic and psychological factors. Diagnosing this syndrome is

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    Address reprint requests to Joel E. Richter, MD, Department of Gastroenterology S-40, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195

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    From the Department of Gastroenterology, The Cleveland Clinic Foundation, Cleveland, Ohio

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