Hyperemesis gravidarum: Specialists & Information

Literally translated, the term means “excessive vomiting during pregnancy.” The prefix “hyper” distinguishes it from the classic and harmless morning sickness, or “emesis gravidarum.” This type of discomfort occurs in well over half of all pregnant women and is therefore quite normal.

In contrast, between 0.2 and 2 percent of pregnant women between the 4th and 9th weeks of pregnancy experience significantly more severe symptoms.

Without treatment, severe disturbances in fluid and electrolyte balance can occur. This can lead to serious deficiencies (minerals, sugar, vitamins, fats).

The diagnosis of hyperemesis gravidarum is assigned the international ICD code O21; depending on severity,

• O21.0 with a feeling of illness but without decompensation, or
• O21.1 with metabolic disturbance.

“Normal morning sickness” with vomiting often begins as early as the 2nd to 4th week. In 80 percent of those affected, it subsides between the 12th and 16th week and disappears without any aftereffects.

Those affected vomit mainly in the morning and recover well afterward. Sometimes heartburn and possibly slight weight loss accompany these symptoms.

With hyperemesis gravidarum, pregnant women experience more severe and prolonged symptoms. Typical symptoms and signs of hyperemesis include:

• persistent nausea,
• vomiting more than five times within 24 hours,
• vomiting on an empty stomach,
• significant weight loss (more than 5% of body weight),
• circulatory problems (dizziness, rapid pulse),
• external signs of dehydration: reddened, dry mucous membranes, dry tongue, skin folds that do not spring back, sunken eyes, thirst, and reduced urine output,
• ketosis: ketone bodies in the urine, fruity breath odor,
• elevated temperature.

In cases of hyperemesis gravidarum, pregnant women vomit significantly more frequently than normal © nenetus | AdobeStock

In cases of prolonged and severe hyperemesis gravidarum, additional symptoms may occur, such as

• jaundice,
• nerve and muscle symptoms,
• blood clotting disorders,
• drowsiness, and
• impaired consciousness, including delirium.

It is not yet fully understood why some pregnant women develop severe morning sickness. Possible causes may include pre-existing medical conditions, unfavorable circumstances surrounding the pregnancy, or fluctuations in hormone levels. 

The following factors are possible causes of severe morning sickness:

• Stress and tension,
• heightened sensitivity to odors,
• psychosomatic disorders,
• elevated hormone levels: hCG (human chorionic gonadotropin), estrogen, prostaglandin, thyroid hormones (T4, TSH),
• vitamin B deficiency,
• sluggishness of the esophagus and stomach,
• inadequate lower esophageal sphincter function,
• infection with the stomach ulcer-causing bacterium Helicobacter pylori,
• genetic predisposition.

Pregnancy places extreme physical demands on the pregnant woman. Risk factors, such as

• excess weight (obesity),
• eating disorders (bulimia, anorexia), 
• thyroid disorders (hyperthyroidism, Hashimoto’s thyroiditis),
• diseases of the parathyroid glands (hyperparathyroidism),
• a late first pregnancy (nulliparity),
• a multiple pregnancy, or
• embryonic development disorders (hydatidiform mole)

can increase the risk of developing hyperemesis.

If hyperemesis gravidarum occurred during a previous pregnancy, it may recur.

With prior knowledge, preventive measures, and close monitoring of the pregnancy, it can also proceed completely “normally.”

Severe deficiencies (water, electrolytes, vitamins, nutrients) caused by persistent vomiting are particularly harmful during pregnancy. Early treatment is all the more important to ensure that neither the mother nor the baby is at excessive risk.

Consult your doctor immediately if

• you feel constantly nauseous within the first 14 weeks of pregnancy,
• you are barely able to eat as a result,
• you vomit frequently throughout the day, and
• you feel increasingly weak.

Vomiting more than five times a day is merely a “clinical rule of thumb.” What matters much more is how you personally feel about your condition and whether you are noticeably losing weight and strength or feeling ill. 

Specialists in gynecology, obstetrics, and perinatal medicine are the right people to consult for affected women. They conduct the examinations and prescribe the appropriate treatment.

The doctor makes the diagnosis through a process of elimination. The primary factors used for this are

• clinical symptoms,
• the physical examination, and
• laboratory blood tests.

The blood test provides a complete blood count, which

• the inflammatory marker CRP,
• electrolyte,
• liver,
• kidney, and
• thyroid levels

are measured and monitored. A urine sample provides information about possible ketone bodies in the urine: substances produced when fatty acids are broken down in the body. The urine analysis also includes the specific gravity and pH of the urine.

An ultrasound examination (sonography) shows how the unborn baby or babies are developing. This also allows the doctor to monitor the progress of the pregnancy.

If the condition of constant vomiting and severe nausea has persisted for some time, the doctor will look for other possible causes. Hyperemesis gravidarum can occur simultaneously with various conditions:

• preeclampsia (high blood pressure and kidney dysfunction),
• pregnancy-related fatty liver,
• inflammation in the digestive tract or urogenital area,
• neurological diseases,
• metabolic disorders,
• side effects of medications.

Treatment depends on the severity of the symptoms and the specific deficiency. To address this, the doctor will adjust several—or even many—factors. The primary goal is to stop nausea and vomiting and replenish the body’s stores.

Your OB-GYN will provide you with targeted assistance and give you tips on what you can do yourself—including preventive measures.

Optimizing Eating Habits for Hyperemesis Gravidarum

You can alleviate mild cases on your own by making a few changes to your eating habits. Avoid triggers such as fatty, spicy, sour, or sweet foods, as well as strong odors.

Eat six to eight small meals spread out throughout the day. Don’t go hungry. Prepare tasty meals rich in protein and carbohydrates. Drink plenty of fluids between meals, but in small sips—preferably cold, clear, and not too sweet: lemonade, sports drinks, or peppermint tea.

Make sure to get plenty of rest and avoid heat or high humidity.

Complementary Medicine and Alternative Therapies

For normal morning sickness and mild forms of hyperemesis gravidarum, 1 to 4 g of ginger root daily is very effective.

Some people also find relief from acupressure on the wrist (Pericardium 6), acupuncture, or psychotherapy.

Medication for Hyperemesis Gravidarum

In addition, a gynecologist will manage the medication regimen.

• Antihistamines,
• anticholinergics, and
• antiemetics

calm and relieve nausea; the doctor may prescribe some of these in combination with vitamin B6.

Serotonin receptor antagonists such as metoclopramide (MCP) or ondansetron, when taken with B vitamins, carry certain risks. For this reason, they are only considered in cases of severe symptoms.

A medication containing the active ingredient meclozine acts directly on the vomiting center and is intended to curb nausea. Its marketing has been discontinued in Germany, but it remains available through foreign pharmacies under the brand name Agyrax.

H2 receptor blockers such as ranitidine help relieve

• heartburn,
• reflux (acid regurgitation), or
• Helicobacter infection.

The doctor carefully weighs the benefits and risks of these medications for hyperemesis gravidarum to avoid placing additional strain on the mother and child.

Hospital Admission and Treatment

Following severe weight loss, inpatient clinical treatment is necessary in conjunction with medication. During her hospital stay, the pregnant woman receives intravenous fluids for several days to correct nutritional deficiencies. In some cases,

• tube feeding,
• short-term glucocorticoids (methylprednisolone), or
• an antidepressant (mirtazapine)

may also be necessary. 

The goal of treatment is to maintain the pregnancy for as long as possible. The baby should continue to develop as much as possible, and preterm birth should be avoided whenever possible.

A birth—whether spontaneous or induced—occurring on or after the 37th week of gestation (SSW) or at least 260 days is no longer considered a preterm birth. At the same time, it is very important to ensure the well-being and health of the expectant mother. 

With early treatment, the multi-pronged approach is highly effective. Patients recover quickly, and the pregnancy continues normally. You can take preventive measures using the simple methods mentioned above—eating light meals and drinking in small sips. If you’re prone to nausea, try ginger and vitamin B6. Your gynecologist can offer further advice.

The severe nausea leads to

• severe nutritional deficiencies,
• physical weakness, and
• severe psychological distress.

Depending on the severity, some women face an increased risk of

• esophageal damage,
• preeclampsia (high blood pressure during or after pregnancy), and
• delayed fetal development with premature birth.

In very rare cases, the mother may develop vitamin B-deficiency damage to the brain (Wernicke’s encephalopathy) or the nervous system.

The unborn child is at increased risk of preterm birth. In addition, due to the mother’s nutritional deficiencies, the child may be slightly smaller and have a lower birth weight of less than 2,500 grams.