Hyperemesis gravidarum: current concepts and management

Kuşçu, Naci Kemal; Koyuncu, Faik Mümtaz

doi:10.1136/pmj.78.916.76

Cited by 80 publications

(48 citation statements)

References 54 publications

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“…Immunological, hormonal, and psychological factors associated with pregnancy may play an etiologic role and risk factors include hyperthyroidism, psychiatric illness, molar pregnancy, preexisting diabetes, and multiple pregnancies. 2,3 The diagnosis is clinical-intractable, dehydrating vomiting, typically between 4 and 10 weeks' gestation. Liver dysfunction occurs in 50% patients with aminotransferases up to 20-fold elevation and with occasional jaundice.…”

mentioning

confidence: 99%

Liver disease in pregnancy

2008

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Abnormal liver tests occur in 3%-5% of pregnancies, with many potential causes, including coincidental liver disease (most commonly viral hepatitis or gallstones) and underlying chronic liver disease. However, most liver dysfunction in pregnancy is pregnancy-related and caused by 1 of the 5 liver diseases unique to the pregnant state: these fall into 2 main categories depending on their association with or without preeclampsia. The preeclampsiaassociated liver diseases are preeclampsia itself, the hemolysis (H), elevated liver tests (EL), and low platelet count (LP) (HELLP) syndrome, and acute fatty liver of pregnancy. Hyperemesis gravidarum and intrahepatic cholestasis of pregnancy have no relationship to preeclampsia. Although still enigmatic, there have been recent interesting advances in understanding of these unique pregnancy-related liver diseases. Hyperemesis gravidarum is intractable, dehydrating vomiting in the first trimester of pregnancy; 50% of patients with this condition have liver dysfunction. Intrahepatic cholestasis of pregnancy is pruritus and elevated bile acids in the second half of pregnancy, accompanied by high levels of aminotransferases and mild jaundice. Maternal management is symptomatic with ursodeoxycholic acid; for the fetus, however, this is a high-risk pregnancy requiring close fetal monitoring and early delivery. Severe preeclampsia itself is the commonest cause of hepatic tenderness and liver dysfunction in pregnancy, and 2%-12% of cases are further complicated by hemolysis (H), elevated liver tests (EL), and low platelet count (LP)-the HELLP syndrome. Immediate delivery is the only definitive therapy, but many maternal complications can occur, including abruptio placentae, renal failure, subcapsular hematomas, and hepatic rupture. Acute fatty liver of pregnancy is a sudden catastrophic illness occurring almost exclusively in the third trimester; microvesicular fatty infiltration of hepatocytes causes acute liver failure with coagulopathy and encephalopathy. Early diagnosis and immediate delivery are essential for maternal and fetal survival. (HEPATOLOGY 2008;47:1067-1076.) M ost pregnant women are young and healthy, and physiological changes in pregnancy must not be mistaken for liver dysfunction (Table 1). Abnormal liver tests occur in 3%-5% of pregnancies, with many potential causes (Table 2). Although relatively uncommon, any liver disease can occur coincidentally in the pregnant patient and pregnancy may occur in a patient with underlying chronic liver disease. However, most liver dysfunction in pregnancy is pregnancy-related 1 and due to one of the 5 liver diseases unique to the pregnant state-hyperemesis gravidarum (HG), intrahepatic cholestasis of pregnancy (ICP), preeclampsia, the HELLP syndrome, and acute fatty liver of pregnancy (AFLP). These conditions are complications of pregnancy itself, and each has a characteristic timing in relation to the trimesters of pregnancy: HG in the first trimester, ICP in the second half of pregnancy, and the other 3 in the third trimes...

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confidence: 99%

Liver disease in pregnancy

2008

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“…Figure 1, illustrates how psychological stress may exacerbate NVP and steroids are involved but the use of hydrocortisone and methylprednisolone on successful cessation of HG is not clear. 8,29 The antiemetic properties of corticosteroid are possibly due to various factors acting in concert or individually and prostaglandin antagonism, 47 stimulation of endorphins that elevate mood and appetite stimulation and reduction in tryptophan in neural tissue have been suggested. 48,49 It can be postulated that in pregnancy, disturbances in metabolic control and increased requirements for glucose give rise to mild hypoglycaemia and during these situations, such as following overnight fasting; hypoglycaemia may trigger nausea and vomiting.…”

Section: Metabolic Control In Pregnancymentioning

confidence: 99%

“…6,22,40 Kuscu and Koyuncu, suggested that NVP beyond the second trimester are indicative of H. Pylori infection and other studies reported that the severity of NVP experienced correlated with the density of H. Pylori. 29,40 Maternal diet, during pre-conception and in pregnancy is associated with the incidence and severity of NVP. Adequate sea-food, vegetables and water intake in prepregnancy reduce development of HG and it has been observed that women with NVP had diet high in calories, carbohydrates and added dietary sugars that came mostly from soft drinks but the study could not determine if consumption of such diet was to mitigate symptoms of NVP.…”

Section: External Factorsmentioning

confidence: 99%

“…11 However, the use hydrocortisone and methylprednisolone in successful cessation of HG is not clear. 8,29 It is important to ascertain the roles of these hormones in NVP and it is possible that a metabolic control concept involving various factors that are shown in Figure 1 is involved. 23 Other studies have also confirmed ethnicity to correlate with severity and incidence of NVP.…”

Section: Hormonalmentioning

confidence: 99%

“…24 Studies have demonstrated a relationship between oestradiol levels and NVP 28 and it has been noted that considering that physiological levels of oestrogens rise during the entirety of pregnancy, it is prudent to question why HG and NVP are most severe during the first trimester. 23 An association between ACTH and cortisol via the HPA in HG has been proposed 29 and corticosteroids are used to treat nausea and vomiting in oncology patients. 11 However, the use hydrocortisone and methylprednisolone in successful cessation of HG is not clear.…”

Section: Hormonalmentioning

confidence: 99%

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