HIPEREMESIS GRAVIDARUM
HIPEREMESIS GRAVIDARUMOleh : dr. H.B. Hafied & dr. H.M.M.
Palisuri, Sp.OG.
Pengertian
__________
Hiperemesis gravidarum adalah muntah yang terjadi sampai umur
kehamilan 20 minggu, muntah begitu hebat dimana segala apa yang
dimakan dan diminum dimuntahkan sehingga mempengaruhi keadaan umum
dan pekerjaan sehari-hari, berat badan menurun, dehidrasi, dan
terdapat aseton dalam urin bukan karena penyakit seperti
appendisitis, pielititis, dan sebagainya.(1)
Etiologi
________
Tidak jelas.(2)
Klasifikasi(2,3,4)
___________
Secara klinis, hiperemesis gravidarum dibedakan atas 3
tingkatan, yaitu :
1. Tingkat I
Muntah yang terus-menerus, timbul intoleransi terhadap makanan
dan minuman,
berat-badan menurun, nyeri epigastrium, muntah pertama keluar
makanan,
lendir dan sedikit empedu kemudian hanya lendir, cairan empedu
dan terakhir
keluar darah. Nadi meningkat sampai 100 kali per menit dan
tekanan darah
sistole menurun. Mata cekung dan lidah kering, turgor kulit
berkurang dan urin
masih normal.
2. Tingkat II
Gejala lebih berat, segala yang dimakan dan diminum dimuntahkan,
haus hebat,
subfebril, nadi cepat dan lebih 100-140 kali per menit, tekanan
darah sistole
kurang 80 mmHg, apatis, kulit pucat, lidah kotor, kadang ikterus
ada, aseton
ada, bilirubin ada dan berat-badan cepat menurun.
3. Tingkat III
Gangguan kesadaran (delirium-koma), muntah berkurang atau
berhenti, ikterus,
sianosis, nistagmus, gangguan jantung, bilirubin ada, dan
proteinuria.
Diagnosis(2,4)
_________
1. Amenore yang disertai muntah hebat (segala yang dimakan dan
diminum akan
dimuntahkan), pekerjaan sehari-hari terganggu, dan haus
hebat.
2. Fungsi vital : nadi meningkat 100 kali per menit, tekanan
darah menurun pada
keadaan berat, subfebril dan gangguan kesadaran
(apatis-koma).
3. Fisis : dehidrasi, keadaan berat, kulit pucat, ikterus,
sianosis, berat badan
menurun, porsio lunak pada vaginal touche, uterus besar sesuai
besarnya
kehamilan.
4. Laboratorium : kenaikan relatif hemoglobin dan hematokrit,
shift to the left,
benda keton dan proteinuria.
Penatalaksanaan(2,3)
________________
1. Rawat di rumah sakit, batasi pengunjung.
2. Stop per oral 24-48 jam.
3. Infus glukosa 10% atau 5% : RL = 2 : 1, 40 tetes per
menit.
4. Obat
- Vitamin B1, B2 dan B6 masing-masing 50-100 mg/hr/infus.
- Vitamin B12 200 mcg/hr/infus, vit. C 200/hr/infus.
- Phenobarbital 30 mg IM 2-3 kali per hari atau chlorpromazine
25-50 mg/hr IM
atau diazepam 5 mg 2-3 kali per hari IM.
- Antiemetik : prometazine (avopreg) 2-3 kali 25 mg per hari per
oral atau
prochlorperazine (stimetil) 3 kali 3 mg per hari per oral atau
mediamer B6 3
kali 1 per hari per oral.
- Antasida : acidrine 3 x 1 tab per hari per oral atau mylanta 3
x 1 tab per hari
per oral atau magnam 3 x 1 tab per hari per oral.
5. Diet
a. Diet hiperemesis I diberikan pada hiperemesis tingkat III.
Makanan hanya
berupa roti kering dan buah-buahan. Cairan tidak diberikan
bersama
makanan tetapi 1-2 jam sesudahnya. Makanan ini kurang dalam
zat-zat gizi
kecuali vitamin C karena itu hanya diberikan selama beberapa
hari.
b. Diet hiperemesis II diberikan bila rasa mual dan muntah
berkurang. Secara
berangsur mulai diberikan bahan makanan yang bernilai gizi
tinggi. Minuman
tidak diberikan bersama makanan. Makanan ini rendah dalam semua
zat-zat
gizi kecuali vitamin A dan D.
c. Diet hiperemesis III diberikan kepada penderita dengan
hiperemesis ringan.
Menurut kesanggupan penderita minuman boleh diberikan bersama
makanan.
Makanan ini cukup dalam semua zat gizi kecuali kalsium.
Daftar Pustaka
______________
1. Fairwether. Nausea and Vomity in Pregnancy, Am J Obst. &
gynec. 1968. vol. 102;
135-171.
2. Mannor SM. Hyperemesis Gravidarum. In : Iffty L, Kaminetzky
HA eds. Principles
and Practise of Obstetric and Perinatology. Vol. 12. Toronto : A
Wiley Medical
Publication. 1981. 1155-1164.
3. Greenhill. Obstetrics 12 th. ed. Philadelphia : WB. Saunders
Company. 1961. 375-
377.
4. Belscher NA, Macky. Obstetric and the Newborn and Illustrated
Textbook 2nd. ed.
Sydney : WB. Saunders Company 1986. 305.
Update : 15 Februari 2006
Sumber :
Pedoman Diagnosis dan Terapi Obstetri dan Ginekologi, dr. I.M.S.
Murah Manoe, Sp.OG., dr. Syahrul Rauf, Sp.OG., dr. Hendrie Usmany,
Sp.OG. (editors). Bagian / SMF Obstetri dan Ginekologi Fakultas
Kedokteran Universitas Hasanuddin, Rumah Sakit Umum Pusat, dr.
Wahidin Sudirohusodo, Makassar, 1999.
/www.geocities.com/klinikobgin/kelainan-kehamilan/hiperemesis-gravidarum.htm
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Copyright 1999, 2002, 2003, 2006
NORD is grateful to Dr. Gideon Koren, Director of the Motherisk
Program at The Hospital for Sick Children of Toronto, and Caroline
Maltepe, nausea and vomiting of pregnancy counselor, for assistance
in the preparation of this report.
Synonyms of Hyperemesis Gravidarum No synonyms found Disorder
Subdivisions
No synonyms found
General DiscussionHyperemesis gravidarum (HG) is a rare disorder
characterized by severe and persistent nausea and vomiting during
pregnancy that may necessitate hospitalization. As a result of
frequent nausea and vomiting, affected women experience
dehydration, vitamin and mineral deficit, and the loss of greater
than five percent of their original body weight.
Nausea and vomiting of pregnancy (NVP), more widely known as
morning sickness, is a common condition of pregnancy. Many
researchers believe that NVP should be regarded as a continuum of
symptoms that may impact an affected woman's physical, mental and
social well-being to varying degrees. Hyperemesis gravidarum
represents the severe end of the continuum. No specific line exists
that separates hyperemesis gravidarum from NVP; in most cases,
affected individuals progress from mild or moderate nausea and
vomiting to hyperemesis gravidarum. The exact cause of hyperemesis
gravidarum is not known.
SymptomsHyperemesis gravidarum may develop rapidly within a few
weeks or gradually over a few months. Individuals with hyperemesis
gravidarum experience severe and persistent nausea and vomiting
that occur before the 20th week of pregnancy (gestation) and are
severe enough to result in progressive weight loss of greater than
five percent of their original body weight. In addition, frequent
vomiting may also lead to dehydration and vitamin and mineral
deficit. Hyperemesis gravidarum often leads to hospitalization to
restore lost fluids and nutrients to affected women.
Additional symptoms associated with hyperemesis gravidarum may
include rising pulse rate, excessive salivation (ptyalism), and a
rapid heartbeat (tachycardia). In some cases, affected individuals
may have a distinct odor to their breath (ketonic odor). Symptoms
associated with the disorder may subside and recur ("wax and wane")
resulting in affected individuals being hospitalized more than once
during their pregnancy.
Quality of life is also affected. Individuals are often unable
to work, complete daily household tasks and routines, care for
young children and, in some cases, may elect to skip social
activities and functions. Persistent and severe nausea and vomiting
associated with hyperemesis gravidarum may put a strain on various
family relationships as well.
Significant debate exists in the medical literature as to the
effect hyperemesis gravidarum may have on the fetus. Most studies
fail to demonstrate any difference between infants of women who
experience hyperemesis gravidarum during pregnancy, and women who
do not. However, some researchers have reported that infants of
women who experienced hyperemesis gravidarum often exhibit a lower
birth weight than infants of women who did not have the disorder.
In addition, some research has shown that low birth weight was more
common in infants of women who were repeatedly hospitalized for
hyperemesis gravidarum than infants of women who were hospitalized
only once.
CausesThe exact cause of hyperemesis gravidarum is not known.
Most researchers believe that biological, psychological and
sociological factors may all play a role. Some theories concerning
the cause of hyperemesis gravidarum include vitamin B deficiency;
hyperthyroidism; endocrine imbalances; gastroesophageal reflux
occurring in association with abnormalities in the electrical
properties of muscles affecting the stomach (gastric dysrhythmias);
Helicobacter Pylori infections; psychological factors; and
disturbances in carbohydrate metabolism. Despite several clinical
studies, researchers have been unable to definitively determine why
hyperemesis gravidarum occurs.
Some researchers have reported that certain factors may be
associated with an increased risk of developing hyperemesis
gravidarum including younger maternal age, high body weight
(obesity), no previous completed pregnancies (nulliparity),
carrying twins, a first-time pregnancy, and/or a history of
hyperemesis gravidarum in previous pregnancies.
Affected PopulationsHyperemesis gravidarum is estimated to occur
in .5 percent to two percent of pregnant women. Approximately 4,000
Canadian women a year experience hyperemesis gravidarum, according
to estimates from the Society of Obstetricians and Gynecologists of
Canada based upon American data. Nausea and vomiting of pregnancy
in general is estimated to occur in 50 percent to 90 percent of all
pregnancies.
Hyperemesis gravidarum, like nausea and vomiting of pregnancy,
usually occurs before the 20th week of pregnancy often between the
fourth and tenth week. In many cases, as with mild or moderate
nausea and vomiting of pregnancy, symptoms resolve before 20 weeks.
However, cases have been reported in which symptoms persisted after
20 weeks. Hyperemesis gravidarum often occurs during first
pregnancies and usually recurs in subsequent pregnancies.
Related DisordersSymptoms of the following disorders can be
similar to those of hyperemesis gravidarum. Comparisons may be
useful for a differential diagnosis:
Many disorders and conditions affecting the digestive tract
(gastrointestinal disorders) are associated with nausea and
vomiting. Such disorders and conditions include acute inflammation
of the appendix (appendicitis), inflammation of the pancreas
(pancreatitis), bowel obstruction, peptic disorders and a flu-like
illness that is characterized by nausea, vomiting, fever, and
diarrhea and is caused by a virus (viral gastroenteritis) (For more
information on these disorders, choose the specific disorder name
as your search term in the Rare Disease Database.)
Many disorders and conditions affecting the reproductive and
urinary systems (genitourinary tract) may also be associated with
nausea and vomiting. Such disorders or conditions include
inflammation of the kidneys and pelvis (pyelonephritis),
degeneration of abnormal growths of fibrous tissue (fibroid
degeneration), and a twisted ovarian cyst (ovarian torsion). (For
more information on these disorders, choose the specific disorder
as your search term in the Rare Disease Database.)
Hepatitis is an inflammation of the liver that, in some cases,
may cause temporary or permanent damage. At least six forms of
hepatitis have been identified (i.e., hepatitis types A, B, C, D,
E, and G). Common symptoms associated with hepatitis include
fatigue, mild fever and gastrointestinal problems such as nausea
and vomiting and a general feeling of discomfort in the stomach.
Hepatitis is usually caused by viruses. However, other causes have
been identified, including bacteria, certain chemicals, alcoholism,
and other medical disorders. (For more information on this
disorder, choose "hepatitis" as your search term in the Rare
Disease Database.)
Additional disorders and conditions associated with nausea and
vomiting include diabetes, lesions of the central nervous system,
thyroid dysfunction, toxic effects of certain drugs (drug toxicity)
and disorders affecting the ear and/or ear canal (vestibular
disorders). Certain conditions associated with pregnancy may also
cause nausea and vomiting, including carrying twins, high blood
pressure caused by pregnancy (pregnancy-induced hypertension),
excess amniotic fluid (hydramnios) and hydatidiform mole (a
condition in which a mass of cysts develops in the fertilized egg).
(For more information on these disorders, choose the specific
disorder as your search term in the Rare Disease Database.)
The following disorder may be associated with hyperemesis
gravidarum as a secondary characteristic. It is not necessary for a
differential diagnosis:
Wernicke's encephalopathy is a neurological disorder
characterized by confusion, an impaired ability to coordinate
voluntary movements (ataxia), and paralysis of certain eye muscles
(ophthalmoplegia). Additional symptoms may include drowsiness, lack
of emotions (apathy) and rapid, involuntary eye movements
(nystagmus). Wernicke's encephalopathy is caused by a deficiency of
vitamin B1 (thiamine). (For more information on this disorder,
choose "Wernicke " as your search term in the Rare Disease
Database.)
Standard TherapiesThe diagnosis of hyperemesis gravidarum may be
confirmed by a thorough clinical evaluation, detailed patient
history, and the identification of characteristic symptoms (e.g.,
persistent and severe nausea and vomiting, dehydration, and weight
loss). The diagnosis is one of exclusion as other causes of nausea
and vomiting during pregnancy must be ruled out. Physicians should
determine the frequency of nausea and vomiting and the extent to
which they affect an affected individual's daily life.
Treatment The diagnosis of hyperemesis gravidarum should lead to
immediate hospitalization of an affected individual in order to
restore fluids and replace electrolytes by infusing medications and
fluids through veins (intravenously). Food should not be given
through the mouth (orally) until vomiting stops and dehydration has
been corrected. Instead, food may be supplied by way of the
intestines (enteral feeding) or by injection through some other
route (parenteral feeding).
Vitamin supplementation (particularly vitamins B6, C and
thiamine) may also be recommended. Thiamine supplementation is
specifically recommended to prevent the development of Wernicke's
encephalopathy.
With these treatments, in many cases, vomiting may stop. If
vomiting continues, antiemetic drug therapy may be recommended.
(For more information on antiemetic drugs, see the Investigational
Therapies section of this report.)
After vomiting stops, affected individuals should receive
enteral nutritional supplementation as needed to calm nausea.
Physicians should then slowly and carefully reintroduce fluids and
small, frequent meals into an affected individual's diet. Meals
should consist of foods that are high in carbohydrates and low in
fat.
In some cases, counseling may be recommended for women to help
deal with the complications of hyperemesis gravidarum. In addition,
treatments for mild or moderate nausea and vomiting in pregnancy
may also be of benefit. These common treatments include plenty of
bed rest, avoiding odors that may trigger an episode of nausea or
vomiting, and dietary changes (i.e., avoiding foods that worsen
nausea and vomiting). However, no clinical data exist to prove the
effectiveness of these treatments.
Investigational TherapiesIn some persistent cases of hyperemesis
gravidarum, drugs that prevent or lessen nausea and vomiting may be
prescribed (antiemetic drug therapy). In Canada, the drug
diclectin, which contains an antihistamine (doxylamine succinate)
and vitamin B6 (pyridoxine), is approved for treatment of nausea
and vomiting of pregnancy. Diclectin is the only drug in Canada
labeled as safe and effective to treat nausea and vomiting of
pregnancy. It is not currently available in the United States, but
papers presented at a May 2002 conference on Understanding and
Treating Nausea and Vomiting of Pregnancy, sponsored by the
National Institute of Child Health and Human Development and The
Office of Rare Diseases, National Institutes of Health, proposed
that its possible use in the U.S. be studied.
The ingredients of diclectin are the same as those of bendectin,
a drug used to treat nausea and vomiting in pregnancy in the United
States from 1956 to 1983. After numerous lawsuits were filed
claiming bendectin caused various birth defects, the drugs
manufacturer voluntarily withdrew it from the market, citing rising
legal costs and negative publicity. However, despite bendectins
becoming the most studied drug in regard to pregnancy, no research
has ever demonstrated an increased incidence of birth defects in
association with the use of bendectin. In fact, the Food and Drug
Administration (FDA) has determined that bendectin was not
withdrawn from the market for reasons of safety or
effectiveness.
Other antihistamines have been used to treat nausea and vomiting
in pregnancy, sometimes in conjunction with diclectin. These
include dimenhydrinate (Gravol), hydroxyzine (Atarax), and
promethazine (Phenergan). However, these drugs have not been
studied thoroughly in pregnant women, and their FDA approval
labeling cautions that they are not approved for pregnant or
nursing women. These drugs have been studied in pregnant women and
have not been shown to increase the risk of congenital
anomalies.
http://www.rarediseases.org/search/rdbdetail_abstract.html?disname=Hyperemesis+Gravidarum+
Hiperemesis GravidarumEmesis Gravidarum
Kriteria: Mual dan mutah selama kehamilan muda (6-16 minggu)
Masih dapat melakukan aktivitas sehari-hari
Sering timbul pada pagi hari (morning sickness).
Penatalaksaan: Pendekatan psikologis>> terangkan bahwa itu
merupakan gejala kehamilan muda, akan hilang sendiri setelah
kehamilan 16 minggu
Perbanyak istirahat
Kurangi beban kerja sehari-hari dan beban psikologis
Medikamentosa : pasang infus RL / D10% , jika KU jelek atau
pre-shock>> Antivomitus (Primperan inj. +/ oral)
tranguliser.
Hiperemesis GravidarumKreteria: Mual dan mutah semakin hebat
Tidak dapat lagi melakukan aktivitas sehari-hari.
Penatalaksaan: Rawat inap
Stop makan / minum dalam 24 jam pertama
Obat-obat diberikan parenteral
Infus D10% (2000 ml) + RD5% (2000 ml) / hari tiap botol
tambahan: Antiemetik (metoklopramid hidrochlorid) 1 amp (10 mg),
Vit. B Komplek 2 ml, Vit.C 1 amp, Kalau perlu Diazepam 10 mg im
Psikoterapi
Dalam 24 jam pertama>> evaluasi
Bila membaik : boleh makan / minum bertahap
Bila tetap : Stop makan minum ? lanjutka R/ di atas untuk 24 jam
kedua
Bila dalam 24 jam kedua tidak membaik>> pertimbangan
rujukan
Infus dilepas setelah 24 jam bebas mual dan mutah
Kriteria pulang: Mual dan mutah tidak ada lagi
Keluhan subyektif tidak ada
Tanda-tanda vital baik
http://cakmoki.blogsome.com/2006/09/22/hiperemesis-gravidarum/OverviewHyperemesis
gravidarum (HG) is a severe form of nausea and vomiting in
pregnancy. It is generally described as unrelenting, excessive
pregnancy-related nausea and/or vomiting that prevents adequate
intake of food and fluids. If severe and/or inadequately treated,
it is typically associated with:
loss of greater than 5% of pre-pregnancy body weight (usually
over 10%)
dehydration and production of ketones
nutritional deficiencies
metabolic imbalances
difficulty with daily activities
HG usually extends beyond the first trimester and may resolve by
21 weeks; however, it can last the entire pregnancy in less than
half of these women. Complications of vomiting (e.g. gastric
ulcers, esophageal bleeding, malnutrition, etc.) may also
contribute to and worsen ongoing nausea.
There are numerous theories regarding the etiology of
hyperemesis gravidarum. Unfortunately, HG is not fully understood
and conclusive research on its potential cause is rare. New
theories and findings emerge every year, substantiating that it is
a complex physiological disease likely caused by multiple
factors.
Diagnosis is usually made by measuring weight loss, checking for
ketones, and assessing the overall condition of the mother. If she
meets the standard criteria and is having difficulty performing her
daily activities, medications and/or other treatments are typically
offered.
Treating HG is very challenging and early intervention is
critical. HG is a multifaceted disease that should be approached
with a broad view of possible etiologies and complications. When
treating mothers with HG, preventing and correcting nutritional
deficiencies is a high priority to promote a healthy outcome for
mother and child.
Most studies examining the risks and outcomes for a pregnant
woman with nausea and vomiting in pregnancy find no detrimental
effects long-term for milder cases. Those with more severe symptoms
that lead to complications, severe weight loss, and/or prolonged
nausea and vomiting are at greatest risk of adverse outcomes for
both mother and child. The risk increases if medical intervention
is inadequate or delayed.
The list of potential complications due to repeated vomiting or
severe nausea is extensive, all of which may worsen symptoms.
Common complications from nausea and vomiting include debilitating
fatigue, gastric irritation, ketosis, and malnutrition. Aggressive
care early in pregnancy is very important to prevent these and more
life-threatening complications such as central pontine myolinolysis
or Wernicke's encephalopathy. After pregnancy and in preparation of
future ones, it is important to address any resulting physical and
psychological complications.
Hyperemesis Gravidarum impacts societies, families and
individuals. Recent, conservative estimations suggest HG costs
nearly $200 million annually just for inpatient hospitalization.
Considering many women are treated outside the hospital to save
costs, the actual cost is likely many times greater. Beyond
financial impact, many family relationships dissolve and future
family plans are almost always limited. Women often lose their
employment because of HG, and women are frequently undertreated and
left feeling stigmatized by a disease erroneously presumed to be
psychological.
OverviewThere are numerous theories regarding the etiology of
HG; however, none are, as of yet, conclusive. A cause is very
difficult to determine and is most likely not due to only one
factor. It may vary between women depending on biological make-up
(genetics), body chemistry, and overall health. However, as is
common in poorly understood disorders, a psychological cause is
named when a physiological one is not known.
This is especially true when so many of the symptoms like nausea
are not objectively measurable. Thus it is easy to dismiss a
woman's symptoms as being psychological, exaggerated, or imaginary,
when in fact they are very real and may in fact be very severe.
However, accurately determining severity is difficult, especially
if there is not obvious "proof" of how sick a woman is. Proof, such
as severe weight loss or dehydration, often comes after she is very
sick for some time, and it is then more difficult to manage her
symptoms.
Early Research & Perspectives
Hyperemesis gravidarum became a recognized disorder several
centuries ago, but the first research appears to have been
published in the 18th century. Incidence in the United States is
reported to be about 60,000 cases annually; however, that number
only reflects those treated as inpatients, not those treated at
home or in outpatient/urgent care facilities. With the focus on
cost reduction in health care, the majority of women are not
admitted to the hospital. Thus the incidence of HG is likely
several times greater than suggested. It is not actually a rare
disorder. If it is not treated, a mother can suffer greatly and may
even have acute or chronic anxiety and/or depression from the
trauma of incessant nausea and vomiting.
HG was first thought to be related to a physiological cause such
as toxins, ulcerations, or infection in a related organ. A physical
cause such as abnormalities of the female reproductive system was
also suggested. Early in the 20th century, a psychological cause
was proposed by those subscribing to psychoanalytic theories.
Unfortunately, despite the lack of evidence in these biased
studies, their assumptions have persisted to this day. Every type
of medical professional from pharmacist to nurse and allopathic to
naturopathic physician is typically taught that HG is a
psychological disorder. Many textbooks and published medical
research still erroneously suggest that HG is psychosomatic, as
well. It is no surprise that women suffering from HG are often left
untreated or not taken seriously. This belief has been passed from
generation to generation of health professional despite the
multitude of evidence showing many contributing factors unrelated
to psychological conflicts.
Currently, many theories are being tested, and new ones emerge
every year. Most center around known pregnancy-related factors like
hormonal changes (e.g. estrogen increase) and physical changes
(e.g. relaxed esophageal sphincter) since the onset is related to
pregnancy and ends before or at delivery. Research is limited and
minimal funding is granted for hyperemesis research, so
high-quality studies with decisive results are uncommon.
Human Chorionic Gonadotropin (hCG) & Estrogen HormonesMost
theories center around the increase in hCG & estrogen hormones
like progesterone in early pregancy.
Psychological CausesSome mistakenly state psychological causes,
but most if not all women experience psychological effects (e.g.:
frustration, feelings of helplessness, isolation, depression, etc.)
secondary to HG.
Thyroxine LevelsIncrease in serum thyroxine levels have been
documented in 70% of pregancies complicated by HG.
Gastric Neuromuscular DysfunctionsA recent theory cites a
dysfunction that results in regurgitation of duodenal content back
into the stomach and subsequent nausea and vomiting.
Deficiencies of NutrientsAnother theory attributes HG to
deficiencies of pyridoxine and zinc, though results are not
conclusive.
Other Theories & Resource LinksLinks & abstracts to
various other physiological and immunological theories.
HormonesHormonal changes are the most studied theory but fail to
show consistency among all women with HG. Most studies focus on the
changes in hCG and steroid hormones like cortisol, estrogen, and
progesterone in early pregnancy because onset and peak of symptoms
correlate with elevations in these hormones.Offsite Research:
Human Chorionic Gonadotropin and Hyperemesis GravidarumT. Murphy
Goodwin, MD
There are a number of reasons for considering the association of
human chorionic gonadotropin (hCG) with hyperemesis gravidarum. The
temporal relationship between peak hCG levels and the most common
time of nausea and vomiting has long been noted. More recently, the
relationship of hCG to transient hyperthyroidism of hyperemesis
gravidarum (THHG) has been described. Several experiments of nature
have suggested that hCG plays a role. We will consider these
interrelated lines of evidence.
Pathophysiology of the gastrointestinal tract during
pregnancySinger AJ, Brandt LJ.Department of Medicine, Montefiore
Hospital and Medical Center, Albert Einstein College of Medicine,
Bronx, New York. Am J Gastroenterol 1991
Dec;86(12):1695-712Pregnancy is associated with a wide variety of
physiologic changes in virtually all the organ systems of the body.
Some of these changes, such as the hyperventilation of pregnancy
with its resulting respiratory alkalosis, are clinically silent,
whereas others, such as heart-burn and hemorrhoids, cause
significant distress. The effects of pregnancy on the hepatobiliary
system have been the subject of much scrutiny and many
publications, whereas disturbances of the hollow viscera have been
infrequently reviewed. In this report, we will discuss the major
pathophysiologic changes that occur along the length of the hollow
viscera of the gastrointestinal tract during pregnancy.
Serum chorionic gonadotrophin (hCG), schwangerschaftsprotein 1
(SP1), progesterone and oestradiol levels in patients with nausea
and vomiting in early pregnancy.Masson GM, Anthony F, Chau E.
British Journal of Obstetrics Gynaecology. 1985
Mar;92(3):211-5Serum concentrations of human chorionic
gonadotrophin (hCG), schwangerschaftsprotein 1(SP1), progesterone
and oestradiol were measured in 116 pregnant women experiencing
varying degrees of nausea and vomiting or no nausea at all at
between 9 and 16 weeks gestation. The patients were categorized
into four groups, namely asymptomatic, nausea alone, nausea and
vomiting and hyperemesis gravidarum. The distribution of levels for
each group were examined in relation to the calculated normal
ranges. Statistically higher hCG levels were found in out-patients
with nausea alone or nausea and vomiting than in the asymptomatic
women. No significant differences were found between the groups for
any of the other measured variables, including the
progesterone/oestradiol concentration ratio.
Psychological
Some mistakenly suggest psychological causes, but most if not
all women experience secondary psychological effects (e.g.:
frustration, feelings of helplessness, isolation, depression, etc.)
due to the misery and stress of HG. These emotions are
well-documented in women on bed rest for non-hyperemesis causes.
Unfortunately, studies of this nature have been cited for many
decades, despite the poor study quality and lack of conclusive
results. HG is a poorly understood disorder and as a result is
often blamed on psychological causes because a physiological cause
is still unknown.
Offsite Research:
Chicken or the egg? The biological-psychological controversy
surrounding hyperemesis gravidarum.Munch S.School of Social Work,
Rutgers, The State University of New Jersey, New Brunswick 08901,
USA. (e-mail: [email protected]) Social Science & Medicine
2002 Oct;55(7):1267-78Women's somatic complaints are more likely to
be labeled by physicians and other health care professionals as
psychologically based when the condition has an obscure etiology.
Perhaps because of this, there are a number of medical conditions
which have been under investigated and where erroneous assumptions
about them exist. Hyperemesis gravidarum (HG)--severe nausea and
vomiting during pregnancy--is an example of such an illness. HG
remains a puzzling condition for both physicians and patients
because there is no known cause or cure. By its very nature, HG has
a clearly established biological cause--pregnancy. Yet, because the
exact causal pathophysiological mechanism is unknown, the
organicity of the pregnant state is either minimized or ignored.
This paper examines how HG is characterized in the literature and
the empirical basis for psychogenesis. Analysis of the literature
reveals a tension in the discourse such that both biologic and
psychologic approaches to HG have existed in parallel tracks
throughout history. Still, results support that sociocultural
factors rather than scientific evidence have shaped the overarching
and predominant illness paradigm of psychogenesis. Implications for
women's health care and HG, in particular, are presented.
Psychological factors and hyperemesis gravidarum.Simpson SW,
Goodwin TM, Robins SB, Rizzo AA, Howes RA, Buckwalter DK,
Buckwalter JG.Graduate School of Psychology at Fuller Theological
Seminary, Pasadena, California, USA. Journal of Womens Health and
Gender Based Medicine 2001 Jun;10(5):471-7Hyperemesis gravidarum
(HG) is a condition of severe, intractable nausea and vomiting
during pregnancy. It has long been held that HG is a psychosomatic
illness reflective of a long-term psychological trait, that is,
conversion disorder. We investigated this possibility by conducting
a two-phase study: (1) a comparison of women with (n = 9) and
without (n = 10) HG during pregnancy and (2) a comparison of
nonpregnant women who did (n = 10) and did not (n = 12) have HG
during their most recent pregnancies. The pattern of findings
differed between experiments 1 and 2. During pregnancy, women with
HG scored significantly higher on three scales associated with
conversion disorder (all p values