••• Chapter 15^ Gastrointestinal Disorders in Pregnancy^161
❍ What are the adverse effects of severe nausea and vomiting on the mother and her fetus?
Significant morbidity to the mother might include Wernicke encephalopathy, splenic avulsion, esophageal rupture,
pneumothorax, and acute tubular necrosis. A higher incidence of LBW is associated with hyperemesis gravidarum,
but not with mild to moderate vomiting. Both maternal and fetal deaths are very rare.
❍ What features distinguish hyperemesis gravidarum from the more common nausea and vomiting that occurs
during early pregnancy?
The following criteria are often used to diagnose hyperemesis gravidarum: persistent vomiting not related to
other causes, acute starvation with large ketonuria, loss of at least 5% the prepregnancy weight, and electrolyte
abnormalities. Hyperemesis is also associated with abnormal liver function tests. Serum bilirubin can be increased
up to five times the upper normal limit. Transaminases and alkaline phosphatase (ALP) can show mild to moderate
increases. Serum amylase may be increased; however, the origin of this is mainly the salivary glands.
❍ What are the risk factors for hyperemesis gravidarum?^3
Risk factors include increased placental mass including advanced molar gestation and multiple gestation, family
history, history of hyperemesis gravidarum, female fetus, history of motion sickness, or migraines.
❍ What are the fetal complications of hyperemesis gravidarum?
Infants born of women who had been admitted for hyperemesis gravidarum are more likely to be LBW, small for
gestational age, born prematurely, and have a 5-minute APGAR <7. These effects are largely attributable to poor
maternal weight gain, defined as <7 kg.
❍ What are some common treatments of hyperemesis gravidarum?^3
Nonpharmacologic therapies: Avoidance of sensory stimuli, frequent and small meals, avoiding spicy or fatty
foods, eliminating pills with iron, eating bland or dry foods, high-protein snacks, crackers in the morning before
arising. Acustimulation has conflicting results.
Pharmacologic therapies: Pyridoxine (vitamin B6) or in combination of doxylamine, and ginger capsules effectively
reduces nausea and vomiting and should be considered first-line pharmacotherapy. Other commonly used
medications include ginger capsules, promethazine, dimenhydrinate, metoclopramide, and ondansetron. Oral
methylprednisolone was found to reduce hospital readmission rates; caution should be taken especially during
first trimester secondary to its teratogenic effects.
❍ True or False: Helicobacter pylori infection is responsible for symptomatic dyspepsia in pregnancy.
False. In a study of 416 pregnant patients, although 42% were found to be seropositive for H. pylori, they were no
more likely to experience dyspepsia than seronegative controls.
❍ Describe the factors that lead to the decreased risk of peptic ulcer disease in pregnant women.
(1) Avoidance of NSAIDs and smoking during pregnancy.
(2) Protective effect of estrogen on gastric and duodenal mucosa.
(3) Immunological tolerance to H. pylori, thus decreasing the inflammatory response.
❍ What antisecretory medications are safe for use during pregnancy?
H 2 receptor antagonists are pregnancy category B. Proton pump inhibitors have documented safety and are
category B, except for omeprazole that is category C. Regarding other drugs, metoclopramide and sucralfate are
both category B.