Morning sickness

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Morning sickness
Other namesNausea and vomiting of pregnancy, nausea gravidarum, emesis gravidarum, pregnancy sickness
Specialty Obstetrics
Symptoms Nausea, vomiting [1]
Complications Wernicke encephalopathy, esophageal rupture [1]
Usual onset4th week of pregnancy [2]
DurationUntil 16th week of pregnancy [2]
CausesUnknown [2]
Diagnostic method Based on symptoms after other causes have been ruled out [3]
Differential diagnosis Hyperemesis gravidarum [1]
Prevention Prenatal vitamins [3]
Treatment Doxylamine and pyridoxine [3] [4]
Frequency~75% of pregnancies [4] [5]

Morning sickness, also called nausea and vomiting of pregnancy (NVP), is a symptom of pregnancy that involves nausea or vomiting. [1] Despite the name, nausea or vomiting can occur at any time during the day. [2] Typically the symptoms occur between the 4th and 16th week of pregnancy. [2] About 10% of women still have symptoms after the 20th week of pregnancy. [2] A severe form of the condition is known as hyperemesis gravidarum and results in weight loss. [1] [6]

Contents

The cause of morning sickness is unknown but may relate to changing levels of the hormone human chorionic gonadotropin. [2] Some have proposed that morning sickness may be useful from an evolutionary point of view. [1] Diagnosis should only occur after other possible causes have been ruled out. [3] Abdominal pain, fever, or headaches are typically not present in morning sickness. [1]

Taking prenatal vitamins before pregnancy may decrease the risk. [3] Specific treatment other than a bland diet may not be required for mild cases. [2] [6] [3] If treatment is used the combination of doxylamine and pyridoxine is recommended initially. [3] [4] There is limited evidence that ginger may be useful. [3] [7] For severe cases that have not improved with other measures methylprednisolone may be tried. [3] Tube feeding may be required in women who are losing weight. [3]

Morning sickness affects about 70–80% of all pregnant women to some extent. [4] [5] About 60% of women experience vomiting. [2] Hyperemesis gravidarum occurs in about 1.6% of pregnancies. [1] Morning sickness can negatively affect quality of life, result in decreased ability to work while pregnant, and result in health-care expenses. [3] Generally, mild to moderate cases have no effect on the fetus, and most severe cases also have normal outcomes. [1] Some women choose to have an abortion due to the severity of symptoms. [1] Complications such as Wernicke encephalopathy or esophageal rupture may occur, but very rarely. [1]

Signs and symptoms

About 66% of women have both nausea and vomiting while 33% have just nausea. [1] Symptoms of both nausea and vomiting will normally climax around 10 and 16 weeks of pregnancy, subsiding around 20 weeks. [8] However, after around 22 weeks, up to 10% of women continue to have lingering symptoms. [8]

Cause

The cause of morning sickness is unknown but may relate to changing levels of estrogen and the hormone human chorionic gonadotropin. [2] [9] Some have proposed that morning sickness may be useful from an evolutionary point of view, arguing that morning sickness may protect both the pregnant woman and the developing embryo just when the fetus is most vulnerable. [1] Diagnosis should only occur after other possible causes have been ruled out. [3] Abdominal pain, fever, or headaches are typically not present in morning sickness. [1]

Nausea and vomiting may also occur with molar pregnancy. [10]

Morning sickness is related to diets low in cereals and high in sugars, oilcrops, alcohol and meat. [11]

Pathophysiology

Hormone changes

Pathophysiology of vomiting in pregnancy Morning sickness.svg
Pathophysiology of vomiting in pregnancy

Defense mechanism

Morning sickness may be an evolved trait that protects the fetus against toxins ingested by the mother. Biologist Margie Profet believes that nausea and food aversions during pregnancy evolved to impose dietary restrictions on the mother in the early weeks of pregnancy, when the mother and the embryo are most immunologically vulnerable, to minimize fetal exposure to toxins such as mutagens and teratogens. [15] A woman and her embryo are very vulnerable to toxins during pregnancy. By reducing exposure to such chemicals, morning sickness reduces impairments on normal embryonic development and increases the reproductive success of the mother and survival success of both the mother and her offspring. Evidence in support of this theory includes: [16] [11]

Women who have no morning sickness are more likely to miscarry. [17] [18] This may be because such women are more likely to ingest substances that are harmful to the fetus. [19]

In addition to protecting the fetus, morning sickness may also protect the mother. A pregnant woman's immune system is suppressed during pregnancy, presumably to reduce the chances of rejecting tissues of her own offspring. [20] Because of this, animal products containing parasites and harmful bacteria can be especially dangerous to pregnant women. There is evidence that morning sickness is often triggered by animal products including meat and fish. [21]

If morning sickness is a defense mechanism against the ingestion of toxins, the prescribing of anti-nausea medication to pregnant women may have the undesired side effect of causing birth defects or miscarriages by encouraging harmful dietary choices. [16]

Also, morning sickness is a defense mechanism because when analyzing embryonic growth, several critical periods are identified in which there is mass proliferation and cell division resulting in the development of the heart and central nervous system that are very sensitive. In that period, the fetus is most at risk from damage to toxins and mutagens. These developments occur through week 6-18 which is in the same time frame in which the most nausea and vomiting of pregnancy (NVP) occurs. This relationship between the time at which the embryo is most susceptible to toxins lines up exactly with when the most severe NVP symptoms are seen, suggesting that this NVP is an evolutionary response developed in the mother, to indicate the sensitivity of the fetus hence making her wary to her health and in turn protecting the fetus. [21]

Treatments

There is a lack of good evidence to support the use of any particular intervention for morning sickness. [7]

Medications

A number of antiemetics are effective and safe in pregnancy including: pyridoxine/doxylamine, antihistamines (such as diphenhydramine), metoclopramide, and phenothiazines (such as promethazine). [22] [23] With respect to effectiveness it is unknown if one is superior to another. [22] In the United States and Canada, the doxylamine-pyridoxine combination (as Diclegis in US and Diclectin in Canada) is the only approved pregnancy category "A" prescription treatment for nausea and vomiting of pregnancy. [23]

Ondansetron may be beneficial, but there are some concerns regarding an association with cleft palate, [24] and there is little high quality data. [22] Metoclopramide is also used and relatively well tolerated. [25] Evidence for the use of corticosteroids is weak. [26]

Alternative medicine

A recent review of studies has found acupuncture to be safe and effective for NVP. [27] Acupressure applied at the acupuncture point PC6 with finger pressure or a nausea band has some evidence of effectiveness, [28] [29] [7] as does auricular (ear acupuncture). [7]

Some studies support the use of ginger, but overall the evidence is limited and inconsistent. [3] [7] [9] [30] Safety concerns have been raised regarding its anticoagulant properties. [9] [31] [32] [33]

History

Thalidomide

In the late 1950s and early 1960s, the use of thalidomide in 46 countries by women who were pregnant or who subsequently became pregnant resulted in the "biggest man‐made medical disaster ever," with more than 10,000 children born with a range of severe deformities, such as phocomelia, as well as thousands of miscarriages. [34] [35]

Thalidomide was introduced in 1953 as a tranquilizer, and was later marketed by the German pharmaceutical company Chemie Grünenthal under the trade name Contergan as a medication for anxiety, trouble sleeping, "tension", and morning sickness. [36] [37] It was introduced as a sedative and medication for morning sickness without having been tested on pregnant women. [38] While initially deemed to be safe in pregnancy, concerns regarding birth defects were noted in 1961, and the medication was removed from the market in Europe that year. [36] [39]

Related Research Articles

Obstetrics is the field of study concentrated on pregnancy, childbirth and the postpartum period. As a medical specialty, obstetrics is combined with gynecology under the discipline known as obstetrics and gynecology (OB/GYN), which is a surgical field.

<span class="mw-page-title-main">Miscarriage</span> Natural premature termination of pregnancy

Miscarriage, also known in medical terms as a spontaneous abortion, is an end to pregnancy resulting in the loss and expulsion of an embryo or fetus from the womb before it can survive independently. Miscarriage before 6 weeks of gestation is defined as biochemical loss by ESHRE. Once ultrasound or histological evidence shows that a pregnancy has existed, the term used is clinical miscarriage, which can be "early" or "late". Spontaneous fetal termination after 20 weeks of gestation is known as a stillbirth. The term miscarriage is sometimes used to refer to all forms of pregnancy loss and pregnancy with abortive outcomes before 20 weeks of gestation.

An antiemetic is a drug that is effective against vomiting and nausea. Antiemetics are typically used to treat motion sickness and the side effects of opioid analgesics, general anaesthetics, and chemotherapy directed against cancer. They may be used for severe cases of gastroenteritis, especially if the patient is dehydrated.

<span class="mw-page-title-main">Dysmenorrhea</span> Pain during and sometimes before menstruation

Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the pelvis or lower abdomen. Other symptoms may include back pain, diarrhea or nausea.

Electroacupuncture is a form of acupuncture where a small electric current is passed between pairs of acupuncture needles.

<span class="mw-page-title-main">Stretch marks</span> Form of scarring

Stretch marks, also known as striae or striae distensae, are a form of scarring on the skin with an off-color hue. Over time, they may diminish, but will not disappear completely. Striae are caused by tearing of the dermis during periods of rapid growth of the body, such as during puberty or pregnancy, in which they usually form during the last trimester. Usually on the belly, these striae also commonly occur on the breasts, thighs, hips, lower back, and buttocks. Pregnancy-related striae are known as striae gravidarum. Striae may also be influenced by the hormonal changes associated with puberty, pregnancy, bodybuilding, or hormone replacement therapy. There is no evidence that creams used during pregnancy prevent stretch marks. Once they have formed, there is no clearly effective treatment, though various methods have been attempted and studied.

<span class="mw-page-title-main">Pregnancy</span> Time of offspring development in mothers body

Pregnancy is the time during which one or more offspring develops (gestates) inside a woman's uterus (womb). A multiple pregnancy involves more than one offspring, such as with twins.

Hyperemesis gravidarum (HG) is a pregnancy complication that is characterized by severe nausea, vomiting, weight loss, and possibly dehydration. Feeling faint may also occur. It is considered more severe than morning sickness. Symptoms often get better after the 20th week of pregnancy but may last the entire pregnancy duration.

<span class="mw-page-title-main">Complications of pregnancy</span> Medical condition

Complications of pregnancy are health problems that are related to, or arise during pregnancy. Complications that occur primarily during childbirth are termed obstetric labor complications, and problems that occur primarily after childbirth are termed puerperal disorders. While some complications improve or are fully resolved after pregnancy, some may lead to lasting effects, morbidity, or in the most severe cases, maternal or fetal mortality.

Pyridoxine/doxylamine, sold under the brand name Diclectin among others, is a combination of pyridoxine hydrochloride (vitamin B6) and doxylamine succinate. It is generally used for nausea and vomiting of pregnancy (morning sickness); even though its efficacy has not been proven and subsequent research has led to the removal of recommendations in medical journals.

<span class="mw-page-title-main">Nausea</span> Medical symptom or condition

Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat.

Cannabinoid hyperemesis syndrome (CHS) is recurrent nausea, vomiting, and cramping abdominal pain that can occur due to prolonged, high-dose cannabis use. Complications are related to persistent vomiting and dehydration which may lead to kidney failure and electrolyte problems.

<span class="mw-page-title-main">Maternal physiological changes in pregnancy</span>

Maternal physiological changes in pregnancy are the adaptations that take place during pregnancy that enable the accommodation of the developing embryo and fetus. These are normal physiological adaptations that cause changes in behavior, the functioning of the heart, blood vessels, and blood, metabolism including increases in blood sugar levels, kidney function, posture, and breathing. During pregnancy numerous hormones and proteins are secreted that also have a broad range of effects.

Marlena Schoenberg Fejzo is an American medical scientist and professor of research on hyperemesis gravidarum.

A pre-existing disease in pregnancy is a disease that is not directly caused by the pregnancy, in contrast to various complications of pregnancy, but which may become worse or be a potential risk to the pregnancy. A major component of this risk can result from necessary use of drugs in pregnancy to manage the disease.

<span class="mw-page-title-main">Cannabis in pregnancy</span> Effects of cannabis consumption during pregnancy

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Signs and symptoms of pregnancy are common, benign conditions that result from the changes to the body that occur during pregnancy. Signs and symptoms of pregnancy typically change as pregnancy progresses, although several symptoms may be present throughout. Depending on severity, common symptoms in pregnancy can develop into complications. Pregnancy symptoms may be categorized based on trimester as well as region of the body affected.

<span class="mw-page-title-main">Pregnancy Sickness Support</span>

Pregnancy Sickness Support is a UK charity supporting women experiencing nausea and vomiting in pregnancy and Hyperemesis gravidarum.

Jennifer R. Niebyl (1942) is a Canadian obstetrics and gynecology researcher and professor. She has made significant contributions to the understanding of drugs in pregnancy and lactation.

Prenatal dental care is the care of the oral cavity during fetal development. The woman’s body is subject to hormonal changes leading to several physical changes in the oral cavity during pregnancy. Some of these changes may cause tooth decay, erosion and periodontal health changes.

References

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