Morning sickness
Morning sickness | |
---|---|
Other names | Nausea and vomiting of pregnancy, nausea gravidarum, emesis gravidarum, pregnancy sickness |
Specialty | Obstetrics |
Symptoms | Nausea,vomiting[1] |
Complications | Wernicke encephalopathy,esophageal rupture[1] |
Usual onset | 4thweek of pregnancy[2] |
Duration | Until 16th week of pregnancy[2] |
Causes | Unknown[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 callednausea and vomiting of pregnancy(NVP), is asymptom of pregnancythat involvesnauseaorvomiting.[1]Despite the name, nausea or vomiting can occur at any time during the day.[2]Typically the symptoms occur between the 4th and 16thweek 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 ashyperemesis gravidarumand results in weight loss.[1][6]
The cause of morning sickness is unknown but may relate to changing levels of the hormonehuman chorionic gonadotropin.[2]Some have proposed that morning sickness may be useful from anevolutionarypoint of view.[1]Diagnosis should only occur after other possible causes have been ruled out.[3]Abdominal pain,fever, orheadachesare typically not present in morning sickness.[1]
Takingprenatal vitaminsbefore 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 ofdoxylamine and pyridoxineis recommended initially.[3][4]There is limited evidence thatgingermay be useful.[3][7]For severe cases that have not improved with other measuresmethylprednisolonemay be tried.[3]Tube feedingmay 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 affectquality 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 anabortiondue to the severity of symptoms.[1]Complications such asWernicke encephalopathyoresophageal rupturemay occur, but very rarely.[1]
Signs and symptoms
[edit]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
[edit]The cause of morning sickness is unknown but may relate to changing levels of estrogen and the hormonehuman chorionic gonadotropin.[2][9]Some have proposed that morning sickness may be useful from anevolutionarypoint 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, orheadachesare typically not present in morning sickness.[1]
Nausea and vomiting may also occur withmolar pregnancy.[10]
Morning sickness is related to diets low in cereals and high in sugars, oilcrops, alcohol and meat.[11]
Pathophysiology
[edit]Hormone changes
[edit]![](https://upload.wikimedia.org/wikipedia/commons/thumb/0/05/Morning_sickness.svg/300px-Morning_sickness.svg.png)
- An increase in the circulating level of the hormoneestrogen.[12]However, there is no consistent evidence of differences in estrogen levels and levels ofbilirubinbetween women that experience sickness and those that do not.[13]Related to increasedestrogenlevels, a similar form of nausea is also seen in some women who usehormonal contraceptionorhormone replacement therapy.
- An increase inprogesteronerelaxes themusclesin theuterus,which prevents earlychildbirth,but may also relax thestomachandintestines,leading to excessstomach acidsandgastroesophageal reflux disease (GERD).
- An increase inhuman chorionic gonadotropin.It is probably not the HCG itself that causes the nausea. More likely, it is the HCG stimulating the maternal ovaries to secrete estrogen, which in turn causes the nausea.[14]
Defense mechanism
[edit]Morning sickness may be anevolved traitthat protects the fetus againsttoxinsingested by the mother. Independent Scholar-Biologist Margie Profet from Seattle was one of the first to investigate the morning sickness-mystery. She argued 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]
- Morning sickness is very common among pregnant women, which argues in favor of its being a functional adaptation and against the idea that it is apathology.
- Fetal vulnerability to toxins peaks at around 3 months, which is also the time of peak susceptibility to morning sickness.
- There is a good correlation between toxin concentrations in foods, and the tastes and odors that cause revulsion.
Women who havenomorning sickness are more likely tomiscarry.[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'simmune systemis suppressed during pregnancy, presumably to reduce the chances ofrejectingtissues of her own offspring.[20]Because of this, animal products containingparasitesand 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 ofanti-nausea medicationto pregnant women may have the undesiredside effectof 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
[edit]There is a lack of good evidence to support the use of any particular intervention for morning sickness.[7]
Medications
[edit]A number ofantiemeticsare effective and safe in pregnancy including:pyridoxine/doxylamine,antihistamines(such asdiphenhydramine),metoclopramide,andphenothiazines(such aspromethazine).[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 approvedpregnancy category"A" prescription treatment for nausea and vomiting of pregnancy.[23]
Ondansetronmay be beneficial, but there are some concerns regarding an association withcleft palate,[24]and there is little high quality data.[22]Metoclopramideis also used and relatively well tolerated.[25]Evidence for the use ofcorticosteroidsis weak.[26]
Alternative medicine
[edit]A recent review of studies has foundacupunctureto be safe and effective for NVP.[27]Acupressureapplied 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 ofginger,but overall the evidence is limited and inconsistent.[3][7][9][30]Safety concerns have been raised regarding itsanticoagulantproperties.[9][31][32][33]
History
[edit]Thalidomide
[edit]In the late 1950s and early 1960s, the use ofthalidomidein 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 asphocomelia,as well as thousands of miscarriages.[34][35]
Thalidomide was introduced in 1953 as a tranquilizer, and was later marketed by the German pharmaceutical companyChemie Grünenthalunder thetrade nameConterganas a medication foranxiety,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]
References
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