Morning sickness

Morning sickness
Classification and external resources
Specialty	Obstetrics
ICD-10	O21.0
ICD-9-CM	643.0
MedlinePlus	003119
Patient UK	Morning sickness

Morning sickness, also called nausea and vomiting of pregnancy (NVP), nausea gravidarum, emesis gravidarum, and pregnancy sickness, is a pregnancy discomfort that affects more than half of all pregnant women. Symptoms may be present early in the morning and reduce as the day progresses. However, in spite of its common name, nausea and vomiting of pregnancy can occur at any time during the day. For most women the sickness ends around the 12th week of pregnancy (the end of the first trimester).

Related to increased estrogen levels, a similar form of nausea is also seen in some women who use hormonal contraception or hormone replacement therapy. The nausea can be mild or induce actual vomiting. In more severe cases, vomiting may cause dehydration, weight loss, high blood pH, and a low level of potassium in the blood. This condition is known as hyperemesis gravidarum and occurs in about 1% of all pregnancies. Nausea and vomiting can be one of the first signs of pregnancy and usually begin around the 6th week of pregnancy (counting gestational age from 14 days before conception).

Causes

Morning sickness

Proximate causes of pregnancy sickness include:

• Excess salivation during the first trimester, that is often bitter tasting (ptyalism), is then ingested during the mother's sleep.
• An increase in the circulating level of the hormone estrogen. However, there is no consistent evidence of differences in estrogen levels and levels of bilirubin between women that experience sickness and those that do not.
• Low blood sugar due to the placenta's draining energy from the mother, though studies have not confirmed this except for in Type I diabetic expectant mothers.
• An increase in progesterone relaxes the muscles in the uterus, which prevents early childbirth, but may also relax the stomach and intestines, leading to excess stomach acids and gastroesophageal reflux disease (GERD).
• An increase in human chorionic gonadotropin. It is probably not the human chorionic gonadotropin itself that causes the nausea. More likely, it is the human chorionic gonadotropin stimulating the maternal ovaries to secrete estrogen, which in turn causes the nausea.
• An increase in sensitivity to odors, which overstimulates normal nausea triggers.
• An increase in bilirubin levels due to increased liver enzymes.

Defense mechanism

Morning sickness may be an evolved trait that protects the baby against toxins ingested by the mother. Evidence in support of this theory, including:

• 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 a pathology.
• 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 have no morning sickness are more likely to miscarry. This may be because such women are more likely to ingest substances that are harmful to the fetus.

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. 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.

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.

Treatments

There is unclear evidence about the effectiveness of home treatments for morning sickness.

Medications

A number of antiemetics are effective and safe in pregnancy including: pyridoxine/doxylamine, antihistamines (such as diphenhydramine), metoclopramide, and phenothiazines (such as promethazine). With respect to effectiveness it is unknown if one is superior to another. 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.

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

Alternative medicine

There is tentative evidence that ginger may be useful; however, it is not clear. Safety concerns have been raised regarding its anticoagulant properties.

History

Thalidomide

Thalidomide was originally developed and prescribed as a cure for morning sickness in West Germany, but its use was discontinued when it was found to cause birth defects. The United States Food and Drug Administration never approved thalidomide for use as a cure for morning sickness.