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Nausea and vomiting of pregnancy (NVP) is considered a “normal” part of pregnancy, with every woman experiencing a myriad of symptoms to varying degrees for a period of time starting in early pregnancy. In the more severe cases, hyperemesis gravidarum (HG) can develop, often requiring a prolonged hospital admission with pharmacotherapeutic management. As a result, early recognition and implementation of a management strategy is crucial. These strategies consist of more conservative measures like dietary and lifestyle modifications, to oral pharmacotherapy in an outpatient setting or intravenous pharmacotherapy in the inpatient setting. Once a treatment plan is implemented, counseling regarding adherence is essential in order to prevent progression or relapse of symptoms.

Reflux is another common problem that may precede the onset of pregnancy, begin with the onset of NVP, or worsen as the pregnancy progresses. Like NVP, the normal physiologic changes of pregnancy contribute to its development and often make management difficult. Unlike NVP, symptoms may persist well into the second or third trimesters due to the enlarging uterus and displacement of the intra-abdominal organs and lower esophageal sphincter. Comanagement of NVP and reflux is often necessary in order to maximize treatment benefit. The aim of this chapter is to present the clinical presentation; diagnosis and management strategies of NVP, HG, and reflux; and the more infrequent occurrence of ptyalism in pregnancy.


NVP and HG

Nausea and vomiting of pregnancy (NVP) is a very common medical condition in pregnancy that often goes underdiagnosed and/or undertreated. The symptoms of NVP occur in 50% to 90% of pregnancies, with approximately 50% to 55% of patients having both nausea and vomiting and 25% with nausea alone.1,2,3,4,5,6,7 Despite the fact that NVP is often referred to as “morning sickness,” symptoms can occur at any time of the day, last for varying periods of time and vary from day to day. The usual onset of NVP is between 4 and 9 weeks gestational age, with maximal symptoms at 12 to 15 weeks, and resolution by 20 weeks gestational age.1,4,8 There are a small percentage of pregnant women (approximately 9%-20%), however, who experience symptoms beyond 20 weeks gestational age and into the late second and third trimesters or until delivery8,9 (Figure 21-1). Conservative measures are successful at treating symptoms in most cases, with NVP following a benign and typical clinical course. However, some women will require multiple visits to the ER, provider’s office or labor and delivery triage with inpatient admission for the more severe cases of NVP.

FIGURE 21-1.

Clinical presentation of nausea and vomiting in pregnancy.

Although the physical examination in patients with NVP is typically benign and ...

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