Intended for healthcare professionals

Practice Clinical Updates

Management of severe pregnancy sickness and hyperemesis gravidarum

BMJ 2018; 363 doi: (Published 30 November 2018) Cite this as: BMJ 2018;363:k5000
  1. Caitlin R Dean, chairperson, PhD candidate12,
  2. Manjeet Shemar, trustee, consultant obstetrician and gynaecologist13,
  3. Gillian A U Ostrowski, trustee, general practitioner,, associate director145,
  4. Rebecca C Painter, consultant obstetrician2
  1. 1Pregnancy Sickness Support, Dunmore Farm, Par, Cornwall, UK
  2. 2Amsterdam UMC, University of Amsterdam, Obstetrics and Gynaecology, Amsterdam, The Netherlands
  3. 3Birmingham Women’s & Children’s Hospital, Birmingham, UK
  4. 4Bridge Lane Group Practice, Battersea, London, UK
  5. 5NHS England, London, UK
  1. Correspondence to C Dean caitlinrdean{at}

What you need to know

  • Nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) can have a profound psychosocial effect on women and their families; some women become suicidal or can consider termination

  • Use an holistic approach to assessing women, including perinatal mental health support, and recognise that no one measure, including ketones, can reliably assess severity of HG

  • Several medications are available to manage HG with a pragmatic stepwise approach

  • Evidence is mounting from biological research that GDF15, the key driver of cancer cachexia, is linked to severe NVP

Nausea and vomiting in pregnancy (NVP) affects around 70% of pregnancies. It is mild for around 40% of women, moderate for 46%, and severe for 14%.1 Mild to moderate NVP usually resolves in the second trimester, with 90% of cases resolving by 20 weeks.2 It does not generally require treatment. By contrast, hyperemesis gravidarum (HG) is a complication of pregnancy rather than a normal part of it and occurs in around 1.5% of pregnancies.3 It is not unusual for HG to persist throughout pregnancy.45 The psychosocial burden of HG can be heavy for women and their families, but effective and holistic treatment may reduce this.67

What causes it?

Historically, the aetiology of HG was poorly understood and it was thought to be caused by endocrine, infectious, psychosocial, and hereditary factors.4 However, recent studies in twins showed that severity and duration of NVP are highly genetic.8 Family history of HG leads to a threefold increased chance of the condition occurring among offspring.9 A genome wide association study found that genetic variants of the growth and differentiation factor 15 protein (GDF15) and insulin like growth factor binding protein 7 (IGFBP7) genes were strongly associated with NVP and HG.10 In another study, women with severe NVP symptoms who were …

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