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Autonomic Neuroscience: Basic and Clinical 202 (2017) 62–72

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Autonomic Neuroscience: Basic and Clinical

journal homepage: www.elsevier.com/locate/autneu

Review

Nausea and vomiting of pregnancy - What's new?


Martha Bustos a, Raman Venkataramanan a,b, Steve Caritis c,d,⁎
a
School of Pharmacy, Department of Pharmaceutical Sciences, University of Pittsburgh, 716 Salk Hall, 3501 Terrace St, Pittsburgh, PA 15261, United States
b
Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15261, United States
c
Department of Obstetrics, Gynecology and Reproductive Sciences Magee Womens Hospital, 300 Halket St., Pittsburgh, PA 15213-3180, United States
d
School of Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh, 300 Halket Street, Pittsburgh, PA 15213, United States

a r t i c l e i n f o a b s t r a c t

Article history: Nausea and vomiting of pregnancy (NVP) is one of the most common disorders of pregnancy. The symptoms
Received 2 April 2016 occur predominantly during the first trimester, although in a subgroup of patients they can continue throughout
Received in revised form 10 May 2016 the entire pregnancy and can affect the woman's quality of life. A small percentage of women develop a severe
Accepted 11 May 2016
form of NVP called hyperemesis gravidarum (HG) that if left untreated may lead to significant maternal morbid-
ity and adverse birth outcomes. Overall, the morbidity in pregnant women with NVP is significant, although it
Keywords:
Nausea and vomiting of pregnancy
tends to be underestimated. The pathogenesis of NVP remains unclear, but there is consensus that the disorder
Hyperemesis gravidarum is multifactorial and that various genetic, endocrine and infectious factors may be involved. The treatment of
Pathogenesis NVP can be challenging as the optimal targets for therapy are not known. Currently, the therapy used depends
Therapy on the severity of the disorder and it is focused on improving the symptoms while minimizing risks to mother
and fetus. Therapies range from dietary changes, pharmacologic treatment or hospitalization with intravenous
fluid replacement and nutrition therapy. The aims of this review are 1) to provide an overview of NVP, 2) to pres-
ent possible links between the most important factors associated with the pathogenesis of NVP and 3) to discuss
the effectiveness and safety of the pharmacologic and non-pharmacologic options available to treat this disorder.
© 2016 Elsevier B.V. All rights reserved.

Contents

1. Nausea and vomiting of pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63


2. Hyperemesis gravidarum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
3. Pregnancy Unique Quantification of Emesis (PUQE) score . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4. Pathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.1. Genetic predisposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.2. Placentally mediated mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.3. Reproductive hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.4. Human chorionic gonadotropin (hCG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
4.5. Progesterone and estrogen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.6. Gastrointestinal dysmotility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.7. Helicobacter pylori . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.8. Serotonin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
4.9. Thyroid hormones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5. Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.1. Non-pharmacologic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.1.1. Dietary modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.1.2. Ginger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.1.3. Acupressure/acupuncture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.1.4. Thiamine supplementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.1.5. Intravenous fluid rehydration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Abbreviations: NVP, Nausea and vomiting of pregnancy; HG, Hyperemesis gravidarum; PUQE, Pregnancy-Unique Quantification of Emesis scoring; TNF-a, Tumor necrosis factor alpha;
IL-1, Interleukin 1; IL-6, Interleukin 6; hCG, Human chorionic gonadotrophin; H. pylori, Helicobacter pylori.
⁎ Corresponding author at: Magee-Womens Hospital of UPMC, 300 Halket St., Suite 0610, Pittsburgh, PA 15213., United States.
E-mail address: carisn@mail.magee.edu (S. Caritis).

http://dx.doi.org/10.1016/j.autneu.2016.05.002
1566-0702/© 2016 Elsevier B.V. All rights reserved.

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5.2. Pharmacologic treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67


5.2.1. Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.2.2. Antiemetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.2.3. Benzamides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.2.4. Serotonin receptor antagonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
5.2.5. Acid-reducing agents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
5.2.6. Corticosteroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6. Hospitalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
6.1. Intravenous fluid rehydration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
7. Future directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
8. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

1. Nausea and vomiting of pregnancy gestation (World-Health-Organization, 2016). HG affects 0.3–2% of


pregnant women and if left untreated or if treatment is unsuccessful it
Nausea and vomiting of pregnancy (NVP) is a very common disorder may lead to significant maternal morbidity and adverse birth outcomes
reported in 70–80% of all pregnant women (Flaxman and Sherman, (Dodds et al., 2006; Lee and Saha, 2011; Munch, 2002; Verberg et al.,
2000; Lacroix et al., 2000; O'Brien and Zhou, 1995; Pepper and Craig 2005; Zur, 2013). In fact, women with HG have a lower health-related
Roberts, 2006). Symptoms usually begin 2–4 weeks after fertilization, quality of life (Munch et al., 2011). The condition interferes with liquid
peak between 9 and 16 weeks of gestation and generally resolve by and food intake and may lead to dehydration, electrolyte and acid-base
22 weeks gestation (Brandes, 1967; Broussard and Richter, 1998; imbalance, nutritional deficiency, ketonuria and loss of more than 5% of
Gadsby et al., 1993; Hasler et al., 1995; Klebanoff et al., 1985; Lee and body weight (Bashiri et al., 1995; Fejzo et al., 2009; Golberg et al., 2007;
Saha, 2011; Zur, 2013). Up to 10% of women have a prolonged course Goodwin, 1998; Grooten et al., 2015a; Verberg et al., 2005). In addition,
with symptoms extending until the time of delivery (Hasler et al., 1995). women with HG also can have excess salivation (Godsey and Newman,
NVP persists throughout the day in as many as 98% of women with NVP 1991), vitamin B1 and mineral deficiencies (Koch and Frissora, 2003),
(Hasler et al., 1995); therefore, the popular term “morning sickness” gastroesophageal reflux symptoms and abnormal liver function tests
doesn't properly reflect this condition (Lacroix et al., 2000; Zur, 2013). (Lee and Saha, 2011). HG is associated with morbidity such as acute kid-
Although NVP tends to be treated as a normal part of pregnancy ney injury (Machado et al., 2012), liver dysfunction (Shekhar and Diddi,
(Brandes, 1967; Tierson et al., 1986), it can significantly reduce the qual- 2015), pneumomediastinum (Gorbach et al., 1997; Liang et al., 2002),
ity of life of the pregnant woman. Women with NVP have significantly ruptured esophagus (Buchanan and Franklin, 2014), and Wernicke's en-
increased odds for high blood pressure and preeclampsia compared cephalopathy (Berdai et al., 2016; Giugale et al., 2015). In addition, a re-
with symptom-free pregnant women (Chortatos et al., 2015). In addi- cent case-control study found that psychological distress was a direct
tion, in 10–35% of patients the symptoms of NVP lead to increased feel- consequence of HG (Aksoy et al., 2015), which is in accordance with
ings of depression, and may cause a negative impact on employment, previous reports of increased risk of cognitive, behavioral, and emotion-
household duties, parenting and family relationships (Attard et al., al disorders in this population (Poursharif et al., 2008; Zur, 2013). Even
2002; Mazzotta et al., 2000a, 2000b; Niebyl, 2010; O'Brien and Naber, more, the complications associated with HG can result in termination of
1992; Smith et al., 2000). Even more concerning is the observation an otherwise wanted pregnancy (Poursharif et al., 2007; Trogstad et al.,
that women with mild NVP have also reported experiencing the same 2005). The long-term consequences of HG on mothers are still undeter-
psychosocial problems as women with severe symptoms (Mazzotta et mined, although several studies suggest increased rates of depression,
al., 2000a). These data suggest that morbidity in pregnant women post-traumatic stress disorder, and various neurological disorders
with NVP is significant although these issues tend to be overlooked. In (Goodwin, 2008; Grooten et al., 2015a).
addition, NVP also exerts a large economic impact on patients, care- HG is the most common reason for hospitalization in the first half of
givers and society. In 2012 the total economic burden of NVP was esti- the pregnancy and second only to preterm labor throughout the whole
mated to be $1.77 billion in the United States (Piwko et al., 2013). of pregnancy (Gazmararian et al., 2002). In the United States over
In contrast to the burden that NVP can be for the pregnant woman, 285,000 women are admitted to the hospital and over 26,077 are admit-
most studies have found that mild NVP is associated with favorable out- ted to the Emergency Department each year due to HG (Piwko et al.,
comes for the fetus including reduced odds for low birth weight and 2013; Zur, 2013). The cost of care is estimated to be $47,351 per HG pa-
small for gestational age (Brandes, 1967; Chortatos et al., 2015; Little, tient (Piwko et al., 2013). Although uncommon in contemporary prac-
1980; Medalie, 1957; Milkovich and van den Berg, 1976; Petitti, 1986; tice, several maternal deaths have also been reported secondary to HG
Tierson et al., 1986), reduced risk of preterm delivery (Brandes, 1967; (Daaloul et al., 2012; Kantor et al., 2014; Knight et al., 2014;
Jarnfelt-Samsioe, 1987; Klebanoff et al., 1985; Koren et al., 2014; MacGibbon et al., 2015). These fatalities illustrate the importance of
Medalie, 1957; Milkovich and van den Berg, 1976; Petitti, 1986; rapid diagnosis, preventative vitamin supplementation, and electrolyte
Tierson et al., 1986) and reductions in the likelihood of miscarriage monitoring and correction (MacGibbon et al., 2015).
(Jarnfelt-Samsioe, 1987; Klebanoff et al., 1985; Koren et al., 2014; Some studies have also found an association of HG with poor neona-
Medalie, 1957; Milkovich and van den Berg, 1976; Petitti, 1986; tal outcomes like low birth weight, preterm birth, fetal death and small
Weigel and Weigel, 1989). for gestational age (Dodds et al., 2006; Grooten et al., 2015a; Lee and
Finally, the severity of symptoms for NVP range from mild to moder- Saha, 2011; Veenendaal et al., 2011; Zhang and Cai, 1991). HG is also as-
ate nausea and vomiting to pathologic cases of women with a severe sociated with poor adult health for the offspring like decreased insulin
form of NVP called hyperemesis gravidarum (Lee and Saha, 2011). sensitivity and increased risks of psychological and behavioral disorders
(Mullin et al., 2011; Veenendaal et al., 2011). Besides, infants born to
2. Hyperemesis gravidarum women with HG and low pregnancy weight gain were more likely to
have low birth weight, have a 5-minute Apgar score of b7 and have in-
Hyperemesis gravidarum (HG) is characterized by severe nausea creased blood pressure (Dodds et al., 2006; Grooten et al., 2015a; Lee
and excessive vomiting starting before the end of the 22nd week of and Saha, 2011).

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64 M. Bustos et al. / Autonomic Neuroscience: Basic and Clinical 202 (2017) 62–72

3. Pregnancy Unique Quantification of Emesis (PUQE) score An important function of the placenta is the production of reproduc-
tive hormones that have been implicated in the pathogenesis of HG
The severity of NVP has a broad spectrum therefore it is critical to (Goodwin et al., 1994; Jarnfelt-Samsioe et al., 1986; Kauppila et al.,
have a graded scale to track the severity of symptoms as a guide to de- 1979; Lagiou et al., 2003; Masson et al., 1985; Soules et al., 1980). Tro-
termine the appropriate treatment and response to treatment. In 2002 phoblast-derived tumor necrosis factor (TNF)-a, interleukin (IL)-1 and
the Pregnancy-Unique Quantification of Emesis (PUQE) scoring system IL-6 regulate the production and release of human chorionic gonadotro-
was introduced (Koren et al., 2002). The updated PUQUE score assesses phin (hCG) (Kaplan et al., 2003). This hormone stimulates placental
the severity of NVP based on three physical symptoms: nausea, prostaglandin E2 which peaks between 9 and 12 weeks of gestation
vomiting, and retching over the previous 24 h (Birkeland et al., 2015; (Lee and Saha, 2011). North et al. quantified maternal serum prosta-
Ebrahimi et al., 2009; Koren et al., 2005). The PUQE-scoring has been glandin E2 and found levels to be higher during periods of nausea and
validated as a robust indicator of HG with higher PUQE-score values in vomiting (North et al., 1991).
HG patients compared to controls (median 13; 95% CI 11–14 vs. 7;
95% CI 4–8) (Birkeland et al., 2015). The calculation of the PUQE score 4.3. Reproductive hormones
is simple and there are several online tools freely available for this pur-
pose (APGO, 2016; HER-Foundation, 2016). Hormone levels change dramatically in pregnancy, especially in the
first trimester. Several studies suggest that reproductive hormones
4. Pathogenesis (hCG, estrogen and progesterone) may be directly and indirectly re-
sponsible for the symptoms of NVP (Furneaux et al., 2001; Goodwin et
Although the pathogenesis of NVP and HG remain unclear, it is wide- al., 1994; Jarnfelt-Samsioe et al., 1986; Kauppila et al., 1979; Ladyman
ly accepted that it is likely to be multifactorial and that various genetic, and Grattan, 2004; Ladyman et al., 2011; Lagiou et al., 2003; Masson
endocrine, and gastrointestinal factors may be involved. et al., 1985; Soules et al., 1980).

4.1. Genetic predisposition 4.4. Human chorionic gonadotropin (hCG)

Maternal genetics appear to be a risk factor for NVP. For example, The most commonly implicated hormone in NVP and HG pathology
there is a higher use of nausea medication in pregnancy among female is the human chorionic gonadotropin (hCG). This is based largely on the
monozygotic twins compared to female dizygotic twins (Corey et al., temporal relationship between the peak of NVP and the peak of hCG
1992). A recent study on 1723 women with either monozygotic or dizy- production, both of which occur simultaneously with the most intense
gotic twins as well as twin-sister pairs demonstrated that NVP is highly symptoms of NVP—weeks 9 to 12 of gestation (Braunstein and
heritable. In this study genetic effects accounted for 73% of the variance, Hershman, 1976; Patil et al., 2012). Besides, hCG levels plateau or de-
51% for duration of NVP and 53% for severity of NVP (Colodro-Conde et cline in a similar manner to the resolution of the HG symptoms (Sanu
al., 2016). In addition, family history of HG is also a risk factor with ap- and Lamont, 2011). In addition, nausea and vomiting are often worse
proximately 28% of women reporting a history of HG in their mothers in pregnant women with conditions associated with elevated hCG levels
and 19% reporting their sisters had HG symptoms (Fejzo et al., 2008; such as molar pregnancies, multiple gestations, Down syndrome and
Gadsby et al., 1997; Zhang et al., 2011). In accordance with this findings, pregnancies of female fetuses (Davis, 2004; Niebyl, 2010; Verberg et
it has been reported that the risk of HG in a pregnant woman is three- al., 2005). In fact, an association between HG and female gender of the
fold if the woman's mother had ever experienced hyperemesis in a fetus has been found in several studies (Kallen, 1987; Schiff et al.,
pregnancy (Vikanes et al., 2010). Besides, women who experienced 2004; Veenendaal et al., 2011). Furthermore, higher urinary hCG (Lee
HG in their first pregnancy have a significant risk of recurrence when and Saha, 2011) and serum hCG levels have also been found in
compared to women who did not experience the condition in their women with NVP (Masson et al., 1985). Finally, concentrations of hCG
first pregnancy (Trogstad et al., 2005). correlate positively with the severity of symptoms in women with HG
The incidence of NVP also appears to vary with ethnicity and ranges (Goodwin et al., 1992).
between 3 and 20 per 1000 pregnancies (Bashiri et al., 1995; Lee and Despite the numerous studies linking hCG to NVP and HG, the role of
Saha, 2011). It is more commonly diagnosed in women in India, Paki- hCG in these pathologies is not yet clear. Research to date has offered
stan, Asian, New Zealanders compared to European, American Indian, conflicting results about the relationship between serum hCG levels
and Eskimo populations (Verberg et al., 2005). and severity of symptoms of NVP (Verberg et al., 2005). For example,
Soules et al. did not find relationship between serum hCG in pregnant
4.2. Placentally mediated mechanisms women during the first trimester and the occurrence and severity of
nausea and vomiting (Soules et al., 1980). Jarnfelt-Samsioe et al. also re-
A possible involvement of the placenta in the pathology of NVP has ported the lack of correlation between hCG and HG and suggested in-
been suggested by Niebyl. The evidence in support of this hypothesis stead an association of HG with steroidal hormones and liver function
is based on the observation that pregnancies with no fetus (complete (Jarnfelt-Samsioe et al., 1983). In addition, a recent systematic review
hydatidiform mole) are associated with clinically significant NVP indi- showed inconsistent association of hCG with HG (Niemeijer et al.,
cating that the stimulus is produced by the placenta, not the fetus. Ac- 2014).
cording to this hypothesis, NVP is less common in older women, A possible explanation for the conflicting data about the role of hCG
multiparous women, and smokers and this observation has been attrib- in NVP is based on reports suggesting it is the ratio of the hCG isoforms
uted to the smaller placental volumes in these women (Niebyl, 2010). rather than the total serum hCG that may explain hCG's effect on NVP.
Some studies have found an association between HG and placental An increased proportion of acidic hCG isoforms, appears to play a role
dysfunction disorders like pre-eclampsia and placental abruption in pa- in HG (Jordan et al., 1999). Each hCG isoform has a unique half-life
tients where the HG diagnosis was made in the second trimester of and potency; for example, isoforms without the carboxy-terminal por-
pregnancy (Bolin et al., 2013; Wood, 2014). On the other hand, tion have shorter half-lives but are more powerful stimulants of the lu-
Vandraas et al. found a positive association between HG and high pla- teinizing hormone and thyroid-stimulating hormone. In contrast,
cental weight-to-birth weight ratio limited to female offspring hyperglycosylated hCG isoforms have a longer half-life and longer dura-
(Vandraas et al., 2013). Based on these reports, it is possible that chang- tion of action (Jordan et al., 1999). These different isoforms of hCG are
es in placenta characteristics and function in HG patients may be related likely the result of genetic or epigenetic factors which may thus explain
to changes in the production of hormones by this organ. the differences in HG incidence found in different populations (Lee and

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M. Bustos et al. / Autonomic Neuroscience: Basic and Clinical 202 (2017) 62–72 65

Saha, 2011). In addition to hCG isoform variation and hCG receptor mu- 4.7. Helicobacter pylori
tations may also explain some of the variability in the relationship be-
tween NVP and hCG (Goodwin, 2008). Helicobacter pylori (H. pylori) is more common identified in the
stomach of women with HG than in women without HG (Lee and
Saha, 2011; Shaban et al., 2014). Furthermore, several studies have
4.5. Progesterone and estrogen demonstrated a positive relationship between the symptoms of HG
and H. pylori seropositivity (Cardaropoli et al., 2014; Erdem et al.,
Estrogen and progesterone, which increase dramatically in pregnan- 2002; Gungoren et al., 2013; Kocak et al., 1999; Salimi-Khayati et al.,
cy, have also been implicated in the pathogenesis of NVP and HG 2003). For example, Frigo et al. (1998) reported that more than 90% of
(Jarnfelt-Samsioe, 1987). In support of their causal role in NVP, studies women with HG were positive for H. plyori compared to 46.5% of con-
have shown that some women experience nausea when taking oral trols. One study that used the gold standard of testing, histologic exam
contraceptives, which typically contain a combination of estrogen and of the mucosal biopsy (Bagis et al., 2002) found that 95% of HG patients
progesterone (Huxley, 2000). In addition, women who experience nau- tested positive for H. pylori compared with 50% in the control group.
sea while taking oral contraceptives are more likely to experience NVP Bagis et al. also found higher H. pylori densities in the gastric antrum
and HG (Jarnfelt-Samsioe et al., 1983; Jordan et al., 1999; Vandormael and corpus in HG patients. Besides, three systematic reviews found a
et al., 1987). Furthermore, states of high estrogen concentration such significant association between maternal H. pylori infection and HG
as low parity and high maternal body mass index have been associated (Golberg et al., 2007; Niemeijer et al., 2014; Sandven et al., 2009).
with a higher incidence of HG (Depue et al., 1987; Verberg et al., 2005). In contrast, other studies found no significant difference in infection
Similarly, levels of total estradiol are reported to be higher in patients rates between the HG group and the control group (Berker et al., 2003;
with HG (Depue et al., 1987; Verberg et al., 2005; Yoneyama et al., Jacobson et al., 2003). Even more, infection does not necessarily corre-
2004), although other studies could not confirm these findings late with symptoms of nausea, vomiting, or reflux during pregnancy
(Verberg et al., 2005). (Weyermann et al., 2003; Wu et al., 2000). In fact, most infected
In terms of the mechanism behind the role of estrogen and proges- women are asymptomatic (Verberg et al., 2005).
terone in NVP, it has been reported that stimulation with hCG increase The conflicting data on the association of maternal H. pylori infection
serum concentrations of progesterone and estrogen in a mouse model and HG could be explained by the following findings. Serologic testing
(Ezoe et al., 2014). Progesterone and estrogen can alter gastric rhythms for H. pylori cannot distinguish between active infection and past
in non-pregnant women increasing gastric intestinal transit time and infection (Cutler and Prasad, 1996) and active versus past infection
slowing gastric emptying which may lead to increased nausea and may produce different symptoms (Lee and Saha, 2011). Accordingly, a
vomiting (Bruce et al., 1978; Lee and Saha, 2011; Milenov and case report suggests that treatment and eradication of active infection
Kazakov, 1973; Walsh et al., 1996). For example, estrogen is thought of H. pylori can decrease NVP (Mansour and Nashaat, 2011). In addition,
to stimulate the production of nitric oxide via nitrogen oxidase syn- most studies do not differentiate between H. pylori strains, which is im-
thase, which in turn relaxes smooth muscle slowing gastric intestinal portant since some strains H. pylori that express the CagA protein are
transit time and gastric emptying (Lee and Saha, 2011). Similar disrup- more aggressive and can increased the risk for peptic ulcers (Ali et al.,
tions in the gastric rhythms in pregnant women may be mediated by el- 2005). In this context, a study that considered H. pylori strains, reported
evations of these two hormones (Spiegel and Webb, 2012). In that CagA positivity is more prevalent in patients with HG (Xia et al.,
accordance with this idea, Walsh et al. showed that the same slow- 2004).
wave gastric rhythm disruption found in women with NVP could be in- In terms of the role of H. pylori on the pathogenesis of HG, it has been
duced in non-pregnant women by progesterone alone or in combina- suggested that H. pylori may exacerbate hormone-induced changes in
tion with estradiol in doses that reproduce levels in pregnancy (Walsh the nerve and electric functioning of the stomach, increasing the risk
et al., 1996). for infected women to be at the more severe end of the spectrum of nau-
sea and vomiting (Golberg et al., 2007).
Screening for H. pylori can be done in patients with HG, especially
4.6. Gastrointestinal dysmotility those with prolonged conditions that are refractory to conventional
management as well as cases that extend to the second trimester
As we mentioned previously, estrogen and progesterone are the (Shaban et al., 2014).
likely mediators of esophageal dysmotility in pregnancy (Richter,
2005) and changes in gastric rhythmic activity are associated with nau- 4.8. Serotonin
sea (Koch and Frissora, 2003) and may contribute to NVP (Lee and Saha,
2011). Serotonin is a key factor in the regulation of some autonomic gastroin-
In support of gastrointestinal dysmotility as part of the pathogenesis testinal functions including motility, secretion and visceral sensitivity
of NVP, some studies reported that individuals with normal slow wave (Browning, 2015). This neurotransmitter has also been hypothesized to
activity were less likely to complain of nausea during pregnancy contribute to NVP (Lee and Saha, 2011). However, a study of serotonin ex-
(Koch et al., 1990). In contrast, individuals with higher or lower rates cretion and its association with NVP did not show any difference in sero-
were more likely to complain of nausea. In addition, pregnant women tonin levels in urine among pregnant women with HG, pregnant women
with NVP had more unstable elastogastrography activity compared without nausea and vomiting, and nongravid women (Borgeat et al.,
with women after pregnancy termination and non-pregnant controls 1997). If serotonin contributes to the pathogenesis of NVP it would be ex-
(Riezzo et al., 1992). pected that serotonin receptor antagonists would be superior to other
Despite data linking gastrointestinal dysmotility to the pathogenesis medications at reducing NVP, yet the results reported in randomized con-
of NVP, its role, is controversial. Many studies have found no difference trol trials on the superiority of serotonin receptor antagonist over dopa-
in the liquid emptying rate between pregnant women before voluntary mine antagonists and antihistamines are still conflicting. A randomized
abortion, 6 weeks after abortion, and in non-pregnant control women controlled trial comparing the serotonin 5-HT3 receptor antagonist,
(Lee and Saha, 2011). Another study that used the C-octanoic breath ondansetron to promethazine (dopamine antagonists) demonstrated no
test found no abnormalities in the timing of gastric emptying of benefit of ondansetron over promethazine in patients hospitalized for
women with HG, compared with those without HG (Maes et al., HG (Sullivan et al., 1996). On the other hand, a randomized controlled
1999). Similarly, studies using paracetamol showed no gastric emptying trial performed by Oliveira et al. showed that ondansetron is superior to
delay in the first, second, or third trimester (Macfie et al., 1991). the combination of pyridoxine and doxylamine (antihistamine) in the

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66 M. Bustos et al. / Autonomic Neuroscience: Basic and Clinical 202 (2017) 62–72

treatment of NVP (Oliveira et al., 2014). Similarly, conflicting results com- rehydration (including electrolytes, vitamins, and thiamin), pharmaco-
paring two serotonin receptor antagonist are also reported. Abas et al. logic treatment, and hospitalization.
(2014) showed that ondansetron and metoclopramide (dopamine and
serotonin receptor antagonist) demonstrated similar antiemetic and
antinauseant effects in patients with HG. While another randomized 5.1. Non-pharmacologic
trial reported that patients with HG treated with ondansetron had signif-
icantly lower vomiting scores versus the patients treated with 5.1.1. Dietary modifications
metoclopramide (Kashifard et al., 2013). All in all, the role of serotonin Dietary changes are basic for the initial therapy for NVP. Eating small
in NVP and HG is still controversial. amounts of food several times a day instead of large meals has been rec-
ommended (Bischoff and Renzer, 2006; Jednak et al., 1999; Newman et
al., 1993). The meals should be bland and low in fat as fatty foods may
4.9. Thyroid hormones further delay gastric emptying and spicy foods may trigger nausea
(Jednak et al., 1999). Eating meals that are high in protein and low in
Pregnancy has profound but reversible effects on the thyroid gland; carbohydrates and taking in more liquids than solids may also improve
it is actually a state of excessive thyroid stimulation leading to an in- the gastric dysrhythmias associated with NVP (Jednak et al., 1999).
crease in thyroid size (Nazarpour et al., 2015). The prevalence of thyroid Drinking small volumes of fluids between meals including beverages
dysfunction in pregnant women is relatively high occurring in 2–3% of with electrolytes is also advisable (Bischoff and Renzer, 2006;
pregnancies (Nazarpour et al., 2015). The most common reason for hy- Jueckstock et al. 2010; Newman et al., 1993). If the smell of hot foods
perthyroidism during pregnancy is the transient hyperthyroidism also triggers nausea, cold foods should be used instead (Broussard and
found in HG patients (Glinoer and Spencer, 2010; Nazarpour et al., Richter, 1998; Jednak et al., 1999).
2015). In fact, abnormal results in thyroid function are found in up to
70% of women with HG (Goodwin et al., 1992; Sun et al., 2014). Because
hCG cross-reacts with the alpha-subunit of thyroid stimulating hor- 5.1.2. Ginger
mone (TSH) receptor and stimulates the thyroid gland, TSH is typically The American College of Obstetrics and Gynecology (ACOG, 2004)
suppressed (Goodwin et al., 1992). This gestational hCG effect is charac- recommends ginger as a non-pharmacologic intervention to treat
terized by suppressed TSH and slightly elevated free thyroxine (T4). In NVP. Recently, a systematic review and meta-analysis of randomized
the majority of cases, these laboratory abnormalities are not clinically trials found that ginger improved nausea compared to placebo, but did
relevant as women with HG are generally euthyroid with no history of not decrease the episodes of emesis (Viljoen et al., 2014).
prior thyroid diseases, without a goiter and with negative anti-thyroid Several studies suggest that ginger may be effective in treating nau-
antibodies (Kuscu and Koyuncu, 2002). This apparent hyperthyroid sea and gastric hypomotility (Haniadka et al., 2013; Hu et al., 2011;
state usually resolves spontaneously and almost all women with HG Pertz et al., 2011; Yamahara et al., 1990). In this context, it has been re-
have normal TSH levels by the second trimester without any interven- ported that ginger contains gingerols and shogaols that inhibit choliner-
tion (Goodwin and Hershman, 1997; Lee and Saha, 2011; Sun et al., gic M3 receptors and serotonergic 5-HT3 receptors and acts on the
2014). Besides, treatment with propylthiouracil does not alleviate the gastrointestinal tract as a dopamine and serotonin antagonist enhanc-
nausea and vomiting in HG patients (Kirshon et al., 1988) and there is ing gastric motility (Pertz et al., 2011; Yamahara et al., 1990). In addi-
no relationship between thyroid dysfunction and the severity of HG tion, gingerols inhibit the growth of H. pylori (Mahady et al., 2003),
symptoms (Evans et al., 1986). In addition, patients with primary hy- which is now considered to play a possible role in HG pathogenesis.
perthyroidism rarely have vomiting (Eliakim et al., 2000) and transient Clinical trials that used the powdered root of ginger to treat women
gestational hyperthyroidism does not affect pregnancy outcomes (Sun with HG have demonstrated that ginger provided a significantly greater
et al., 2014). relief of symptoms compare to placebo (Fischer-Rasmussen et al., 1991;
Few studies have suggested that HG patients with gestational hyper- Vutyavanich et al., 2001). Regarding the safety of ginger in pregnancy, a
thyroidism may have thyroid gland hypersensitivity to hCG. In fact, two case-control study of pregnant women found no increase in the rate of
cases of HG and gestational thyrotoxicosis caused by mutations of the major malformations with first trimester use (Portnoi et al., 2003). On
thyroid stimulating hormone receptor (TSHR) have been described the other hand, the use of ginger in patients on anticoagulants is not rec-
(Coulon et al., 2016; Rodien et al., 2004). The mutations, in the lysine ommended because ginger may inhibit platelet function (Backon,
183 into asparagine or arginine, located in the extracellular domain of 1991).
the TSHR resulted in increased sensitivity to hCG. These data suggest a
direct relationship between hyperthyroidism and HG, since treatment
5.1.3. Acupressure/acupuncture
of thyrotoxicosis led to disappearance of vomiting (Rodien et al.,
Acupressure applied to the pericardium 6 (P6 or Neiguan) has been
2004). On the other hand, there are reports that suggests that some pa-
reported by several studies to significantly decrease the occurrence of
tients with gestational thyrotoxicosis secrete hCG with a higher thyro-
nausea, vomiting and retching in patients with nausea related to che-
trophic activity (Kimura et al., 1993) possible caused by different
motherapy (Genc and Tan, 2015; Molassiotis et al., 2007; Taspinar and
isoforms of hCG (Tsuruta et al., 1995; Yoshimura et al., 1994a, 1994b).
Sirin, 2010), surgery (Vickers, 1996) and women with NVP (Vickers,
1996; Werntoft and Dykes, 2001).
5. Treatment In a controlled trial, pregnant women receiving traditional acupunc-
ture or pericardium 6 acupuncture reported less nausea and less dry
The pathogenesis of NVP and HG are still unknown therefore the retching compared to controls (Smith et al., 2002). Similarly, a random-
treatment can be challenging as neither the optimal targets for treat- ized study of women with HG comparing treatment with
ment nor the full effects of potential treatments on the developing metoclopramide and cyanocobalamin versus acupuncture sessions
fetus are known. Currently there are no evidence based treatments for demonstrated that HG symptoms were equally relieved in both groups
HG although a randomized controlled trial that aims to clarify whether (Neri et al., 2005).
early enteral tube feeding is more effective in treating HG than intrave- These data suggest that acupressure and acupuncture therapy may
nous rehydration alone is being performed (Grooten et al., 2016). Ther- be helpful for NVP treatment, although the benefits of these therapies
apy is focused on improving symptoms while minimizing risks to are still inconclusive. In a systematic review of randomized trials, P6
mother and fetus. Treatment modalities depend on the severity of the acupuncture or an acupressure wristband was not significantly more ef-
symptoms and range from dietary changes, intravenous fluid fective than placebo (Matthews et al., 2015).

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M. Bustos et al. / Autonomic Neuroscience: Basic and Clinical 202 (2017) 62–72 67

5.1.4. Thiamine supplementation 5.2.2. Antiemetics


Of importance is the initiation of thiamine supplementation in preg- The central and peripheral dopamine antagonists chlorpromazine
nant women with HG. Thiamine pyrophosphate is the biological active (Thorazine) and prochlorperazine maleate (Compazine) have been
form of vitamin B1; it is an essential coenzyme in many biochemical shown to reduce symptoms in NVP and HG (Leathem, 1986). They are
pathways in the brain (Sechi and Serra, 2007). The daily requirement antiemetics that fall in the pregnancy category C and their use in the
of thiamine is around 1.1 mg/day for females, and it increases to first trimester of pregnancy has been associated with a slightly in-
1.5 mg/day, particularly during pregnancy (Chiossi et al., 2006) and creased risk of birth defects (Lee and Saha, 2011; Rumeau-Rouquette
even more by the impaired absorption due to HG. Early thiamine re- et al., 1977). Promethazine (Phenergan), another member of the pheno-
placement will reduce maternal morbidity, especially Wernicke's en- thiazine family, is widely used to treat NVP in many countries, despite
cephalopathy (Berdai et al., 2016). its classification of pregnancy category C (Zur, 2013). In several studies
promethazine use during pregnancy was not found to be associated
with teratogenic effects (Anderka et al., 2012; Bartfai et al., 2008;
5.1.5. Intravenous fluid rehydration Witter et al., 1981), although it has anticholinergic side effects including
In HG patients with more severe dehydration or ketonuria, inpatient dry mouth, drowsiness, and sedation (Zur, 2013). For this reason it is
admission is commonly suggested. Prompt maternal hydration will considered as a second line treatment for NVP (Zur, 2013) specially as
commonly relieve many of the symptoms on HG. In addition to hydra- a substitute for doxylamine (Niebyl, 2010; Zur, 2013).
tion, parenteral nutrition and vitamin and mineral replacement/supple-
mentation will help correct any electrolyte imbalance. Adding glucose
5.2.3. Benzamides
to an infusion will provide a much needed energy source (Jueckstock
Metoclopramide is a dopamine and serotonin receptor antagonist
et al., 2010).
(Milkovich and van den Berg, 1976), widely used for the treatment of
NVP (Tan et al., 2010). This benzamide increases gastric transit and cor-
rects gastric dysrhythmias by stimulating antral contractions and pro-
5.2. Pharmacologic treatment
moting antroduodenal contractions (Lee and Saha, 2011).
Metoclopramide is pregnancy category B and its use during pregnancy
5.2.1. Antihistamines
has shown to be free of any increased risk of congenital malformations,
Antihistamines, are commonly used during early pregnancy for the
low birth weight, preterm delivery, or perinatal death (Matok et al.,
treatment of nausea and vomiting (Gilboa et al., 2014). First generation
2009; Milkovich and van den Berg, 1976; Sanu and Lamont, 2011;
H1-receptor antagonists diphenhydramine (Benadryl), dimenhydrinate
Sorensen et al., 2000). Despite its efficacy, metoclopramide use is limit-
(Dramamine), meclizine (Antivert) and doxylamine indirectly affect
ed by its side effects which includes drowsiness, dizziness, dystonia and
the vestibular system, decreasing stimulation of the vomiting center
the risk of tardive dyskinesia with chronic use (Lee and Saha, 2011; Tan
(Badell et al., 2006). These antihistamines are pregnancy category B
et al., 2010). Despite its side effects, metoclopramide is considered as a
and have been shown to be effective in controlling NVP symptoms
third-line therapy for NVP (Zur, 2013).
(Leathem, 1986; Mazzotta et al., 2000a). The majority of 31 cohort
studies and 23 case-control studies that aimed at identifying positive
associations between antihistamines and birth defects demonstrated 5.2.4. Serotonin receptor antagonists
a lack of association between prenatal antihistamine exposure and Serotonin receptor antagonists are the most effective antiemetic
birth defects (Gilboa et al., 2014; Milkovich and van den Berg, drugs available in the market (Goodwin, 2008) and are also the most
1976; Seto et al., 1997). commonly prescribed antiemetics (Rubenstein et al., 2006).
Of special interest is the use of doxylamine with or without pyridox- Ondansetron (Zofran) works both centrally and peripherally by
ine to treat NVP. The American College of Obstetricians and Gynecolo- blocking serotonin receptors in the small bowel and medullary
gists (ACOG, 2004) currently recommends that these agents singly or vomiting center (Badell et al., 2006). Ondansetron is classified as preg-
in combination be used as first line treatment for NVP. nancy category B (Lee and Saha, 2011) and in the United States, it is
Pyridoxine (vitamin B6, pregnancy category A) is a water soluble vi- used more often for the treatment of HG than in other countries
tamin that is involved in the metabolism of amino acids, lipids, and car- (Goodwin, 2008). Its safety in pregnancy is controversial. Some studies
bohydrates (Spiegel and Webb, 2012). Randomized, placebo controlled have shown no significant increase of adverse fetal outcomes when
trials have shown effectiveness of vitamin B6 in the treatment of NVP ondansetron was taken during early pregnancy (Einarson et al., 2004;
(Sahakian et al., 1991; Vutyavanich et al., 1995; Zur, 2013). Doxylamine Pasternak et al., 2013). In contrast, other studies including a systematic
(pregnancy category B) directly inhibits the action of histamine at the review of women who had taken ondansetron in early pregnancy found
H1-receptor, acts indirectly at the vestibular system, and exhibits that the teratogenic risk with ondansetron is low but an increased risk
some inhibition of muscarinic receptors to decrease stimulation of the for a cardiac septum defect is likely (Carstairs, 2016; Danielsson et al.,
vomiting center (Spiegel and Webb, 2012). 2014). Finally, a recent review about ondansetron safety during preg-
In April 2013, the FDA approved the sale of Diclegis, an identical nancy concluded that there is insufficient evidence of harm to preclude
combination to the original Bendectin and its Canadian equivalent its use in pregnancy (Siminerio et al., 2016).
Diclectin, after a randomized blinded placebo controlled trial demon- Several randomized controlled trials comparing ondansetron to
strated its effectiveness to treat NVP (Koren et al., 2010). The delayed- other medications have been published. Some trials reported that pa-
release tablet contains doxylamine succinate 10 mg and pyridoxine hy- tients with HG treated with ondansetron had significantly lower
drochloride 10 mg (Koren et al., 2010). This drug combination has been vomiting scores versus the patients treated with metoclopramide
widely used in different countries around the world (Zur, 2013) and (Kashifard et al., 2013). Similarly, ondansetron is reported to be superior
several studies and meta-analyses over the last 3 decades support its ef- to the combination of pyridoxine and doxylamine in the treatment of
ficacy (Niebyl and Goodwin, 2002) as well as its fetal and maternal safe- NVP (Oliveira et al., 2014). On the contrary, other studies in HG patients
ty (Einarson et al., 1988; Holmes, 1983; Koren et al., 2015; Madjunkova demonstrated no benefit of ondansetron over promethazine (Sullivan
et al., 2014; McKeigue et al., 1994). Drowsiness is the most common side et al., 1996) and similar antiemetic and antinauseant effects of
effect reported for this drug (Sanu and Lamont, 2011). A factor that may ondansetron and metoclopramide (Abas et al., 2014). Considering the
affect the utility of this and other oral medications is the inability of equal effectiveness of ondansetron compared with promethazine, and
some women with NVP or HG to swallow any oral medication (Zur, no sedative effect (Sullivan et al., 1996), ondansetron has been sug-
2013). gested to be the preferred medication in women who have responded

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68 M. Bustos et al. / Autonomic Neuroscience: Basic and Clinical 202 (2017) 62–72

to antiemetics but experience significant sedation (Sanu and Lamont, methylprednisolone, or intravenous hydrocortisone found no significant
2011). effect of corticosteroids on readmission rates for HG (Grooten et al.,
Many pregnant women can't swallow oral medications because of 2015b).
the severe sensitivity of the upper gastrointestinal tract in the first tri- The use of corticosteroids during the first trimester of pregnancy
mester. For these patients the transdermal route as a simple method demonstrated a slight increase in major malformations and an increase
to deliver drug has a significant added value and can improve patient's in orofacial cleft in infants exposed to this drugs (Park-Wyllie et al.,
compliance (Zur, 2013). In this context our group has recently evaluated 2000; Pradat et al., 2003). In contrast, data from the National Birth De-
the pharmacodynamics of granisetron (category B), administered with fect Prevention Study show no association between maternal cortico-
a transdermal patch to women with NVP (Caritis et al., 2016). The steroid use and cleft lip and palate in the offspring (Skuladottir et al.,
study demonstrated that granisetron significantly improved symptoms 2014).
of NVP. The granisetron patch also provided another option for treating Currently, there are no established guidelines for the use of cortico-
NVP and may be particularly useful in women who cannot tolerate oral steroids for NVP or HG and its use remains controversial.
medications. Although the results of granisetron administered as a
transdermal patch for treating NVP are promising, further studies eval- 6. Hospitalization
uating this treatment option are necessary.
6.1. Intravenous fluid rehydration
5.2.5. Acid-reducing agents
Heartburn and acid reflux during pregnancy should be treated, as In HG patients with more severe dehydration or ketonuria, inpatient
some studies report that symptoms of gastroesophageal reflux disease admission is required. Maintaining hydration or, in the case of severe
have been associated with an increased severity of NVP (Gill et al., dehydration achieving quick and sufficient rehydration, is the most im-
2009b; Law et al., 2010). Furthermore, treatment of heartburn and re- portant intervention. Volume and electrolyte replacement (at least 3 L/
flux results in improved PUQE scores and quality of life scores (Gill et day), correction of potential electrolyte imbalance, administration of vi-
al., 2009a). tamins and parenteral administration of carbohydrate and amino acid
Antacids containing aluminum or calcium are recommended as first- solutions (about 8400 to 10,500 kJ/day) are recommended. Rehydration
line of treatment during pregnancy for acid reflux and heartburn and is most easily and quickly accomplished intravenously and this reduces
can be used to treat women with NVP considering that these drugs adverse symptoms very effectively.
were not found to be teratogenic (Law et al., 2010; Mahadevan, 2007;
Zielinski et al., 2015). Histamine-2 receptor antagonists such as raniti-
dine (Zantac) or famotidine (Pepcid) are another treatment option if 7. Future directions
antacids are no longer working. These drugs are considered safe (cate-
gory B) to treat acid reflux and/or heartburn in women with NVP (Gill Since HG is the most common reason for hospitalization in the first
et al., 2009c, 2009d; Zielinski et al., 2015). Several studies to date indi- half of the pregnancy it is of concern that currently there are no evi-
cate that proton pump inhibitors are most likely safe in pregnancy, al- dence-based treatments for HG. In this context, it is critical to increase
though omeprazole (Prilosec) is classified as a category C drug the number of randomized clinical trials that assess the effectiveness
because its use in early pregnancy may increase the risk of birth defects of different potential treatments for HG. Further advancements will
(Zielinski et al., 2015). not occur without a better understanding of the pathophysiologic ante-
On the other hand, high-dose and prolonged use of magnesium cedents of NVP and HG. In this regard, it would be important to perform
trisilicate-containing antacids are not recommended during pregnancy genome-wide association studies (GWAS) and SNP studies of genes
because they are associated with nephrolithiasis, hypotonia, and respi- likely involve in NVP and HG pathogenesis (hCG, hCG receptor, TSHR,
ratory distress in the fetus. In addition, bicarbonate-containing antacids etc).
can also cause maternal and fetal metabolic acidosis and fluid overload
and are not recommended during pregnancy (Law et al., 2010; 8. Conclusions
Mahadevan, 2007).
NVP is probably the most common disorder in pregnancy; it ranges
5.2.6. Corticosteroids in spectrum from mild to its pathologic form HG. NVP significantly re-
duce the quality of life of the pregnant woman and has a large economic
Corticosteroids seem to exert an antiemetic effect on the chemore- impact on patients, caregivers and society, yet this disorder is very often
ceptor trigger zone in the brainstem (Lee and Saha, 2011) and have underestimated.
been used to treat refractory cases of HG demonstrating conflicting re- Although the pathogenesis of NVP remains unclear, it is widely ac-
sults. Two randomized controlled trials of women with HG treated cepted that it is likely to be multifactorial, with a genetic predisposition
with methylprednisolone or promethazine demonstrated that methyl- and a placentally-mediated mechanism characterized by the production
prednisolone had a lower rate of re-hospitalization (Safari et al., 1998) of reproductive hormones. In this context hCG, progesterone and estro-
and at least the same effects than promethazine on reducing the symp- gen seem to play a role in the induction of gastrointestinal dismotility,
toms of HG with fewer drug side-effects (Ziaei et al., 2004). In addition, a that may contribute to the development of NVP. On the other hand,
double-blind study demonstrated a significant reduction in vomiting the bacteria H. pylori may be an important factor for the development
episodes in patients receiving intravenous hydrocortisone (Bondok et of HG possibly by the exacerbation of the hormone-induced changes
al., 2006). On the other hand, a double-blind, placebo-controlled trial in the nerve and electric functioning of the stomach.
demonstrated an improved sense of wellbeing, appetite and increased Currently, the therapy for NVP depends on the severity of the disor-
weight gain in HG patients treated with corticosteroids, although this der and it is focused to improve symptoms while minimizing risks to
treatment did not lead to rapid and complete remission of nausea and mother and fetus. The therapy ranges from dietary changes, intravenous
vomiting (Nelson-Piercy et al., 2001). In addition, a randomized, double- fluid rehydration (including electrolytes, vitamins including thiamin),
blind, placebo-controlled trial found that addition of parenteral and oral pharmacologic treatment, and hospitalization.
corticosteroids to promethazine-metoclopramide treatment for HG did The American College of Obstetrics and Gynecology recommends
not reduce the need for re-hospitalization later in pregnancy (Yost et al., ginger as a nonpharmacologic intervention to treat NVP and a combina-
2003). Finally, a meta-analysis that considered five trials evaluating the tion of oral pyridoxine hydrochloride and doxylamine succinate as the
effectiveness of oral prednisolone, oral methylprednisolone, intravenous first line of pharmacologic treatment for NVP.

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M. Bustos et al. / Autonomic Neuroscience: Basic and Clinical 202 (2017) 62–72 69

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