Vomiting during early pregnancy (early toxicoses)

Vomiting during the first half of pregnancy (the first 3-4 months) is also referred to as early toxicosis, since the pathoanatomy shows changes similar to those of poisoning – intoxication.

Epidemiological data: The frequency of nausea and vomiting in pregnant women is very high – up to 60-80%. Nausea and vomiting usually start around 9-10 weeks of gestation, peak around 11-13 weeks, and usually stop around 12-14 weeks of pregnancy. In about 1-2 cases per 1000, vomiting occurs throughout pregnancy.

Causes of vomiting during early pregnancy:

The causes of early toxicosis are not clear. A connection is established with the following factors:
– hormonal – increased levels of human chorionic gonadotropin (CHG);
– relaxation of the stomach muscles during pregnancy;
– lack of vitamins;
– mental (labile psyche) and social factors.

Classification and symptoms: According to the severity of the symptoms, the following degrees are distinguished:

1. Morning sickness– (in Latin – Vomitus matutinus gravidarum; in English – Morning sickness) – the pregnant woman vomits 1-2 times in the morning, on an empty stomach, there is no change in appetite and general condition, there is no need for treatment.
2. Emesis gravidarum– pregnant women vomit more often, not only in the morning, usually after eating. The appetite may be normal or slightly reduced, but the general condition is not disturbed.
3. Hyperemesis gravidarum– this is the most severe form that progresses, dehydration and metabolic disorders occur. The frequency is 0.3-2%. A higher frequency is found in first birth, age under 20 years, non-smokers, multiple pregnancies.

Pathophysiological changes include:
– dehydration and hypovolemia – accelerated heart rate, low blood pressure, increased hematocrit.
– weight reduction.
– impaired renal function to oliguria (diuresis below 500 ml) – high relative weight of urine, increase of nitrogen fractions in the blood (urea, creatinine, uric acid).
– disturbances in the electrolyte balance – reduced levels of sodium, potassium, chlorine.
– impaired liver function – elevated liver enzymes.
– changes in the alkaline-acid balance – metabolic alkalosis (due to frequent vomiting), metabolic acidosis (formation of keto bodies due to reduced carbohydrate intake and development of ketoacidosis).
– anemia due to folic acid deficiency.
– neurological symptoms.

Clinically, the following stages are distinguished:

– 1st stage – 10-20 vomiting per day, unrelated to eating. Body weight drops by about 500 g per day. The symptoms are thirst, fatigue, disturbed sleep, oliguria, constipation.

– 2nd stage – vomiting becomes more frequent, the condition worsens and the signs of dehydration and intoxication deepen – rapid heart rate, low blood pressure, dry skin and mucous membranes, bad breath from the mouth, elevated temperature, worsened renal (oligoanuria) and liver function (jaundice), ketobodies are detected in the urine.

– 3rd stage – manifestations of damage to the central and peripheral nervous system – impaired sensitivity, paresis and paralysis, encephalopathy.

Other manifestations of early toxicosis, which may accompany the others, are:
– profuse salivation (ptyalism, sialorrhea) – up to 1-2 liters of saliva per day.
– acid eructations, burning and pain behind the sternum due to entry of gastric juice into the esophagus and irritation of the mucous membrane.

Diagnosis: The diagnosis of early toxicosis is based on the characteristic clinical symptoms and the exclusion of other causes of nausea and vomiting. Includes:
– history and physical examination – assessment of symptoms and general condition;
– laboratory tests – blood – hematocrit, electrolytes, enzymes (liver, pancreatic), etc.; urine – relative weight, ketobodies, albumin test;
– ultrasound examination – to rule out trophoblastic disease, multiple pregnancy, etc. reasons.

Differential diagnosis of early toxicosis: It is done with:
– diseases of the gastro-intestinal tract – appendicitis, cholecystitis, ulcer, gastritis, pancreatitis, intestinal obstruction, etc.;
– hepatitis;
– diseases of the urinary system – kidney stone disease, infections;
– meningitis;
– endocrine diseases and their complications – diabetic ketoacidosis, thyrotoxicosis, etc.;
– trophoblastic disease ;
– poisonings – medications, etc.

Treatment of early toxicoses:

Treatment of milder forms of vomiting during early pregnancy is outpatient. The pregnant woman is recommended to spend more time in the fresh air, eat in small portions, rest ½ – 1 hour after eating, consume more fruits and vegetables, take 2 liters of fluids, avoiding drinking water while eating. Vitamins, minerals and antiemetic medications are recommended.

Behavior in hyperemesis gravidarum consists of:
– hospitalization;
– physical and mental rest;
– resuscitation – infusion treatment and correction of dehydration, alkaline-acid and electrolyte disorders, weight loss;
– administration of antiemetics (Chlorazin, Cerucal, etc.), vitamins (vitamin C, group B vitamins), folic acid;
– diet.

In rare cases, in case of danger to the mother, severe mental and organ symptoms, it may be necessary to terminate the pregnancy – therapeutic abortion.