vomiting of pregnancy
Introduction
Introduction to pregnancy vomiting Vomitingofpregnancy refers to pregnant women often have food choices during early pregnancy, loss of appetite, mild nausea and vomiting, dizziness, and burnout. It is called early pregnancy reaction. It usually starts around 40 days after menopause, and the reaction disappears within 12 weeks of pregnancy. The work has little impact and no special treatment is required. A small number of pregnant women have frequent vomiting, can not eat, leading to weight loss, dehydration, acid and alkali balance disorders, as well as water, electrolyte metabolism disorders, severe life-threatening. The incidence rate is 0.1% to 2%, and more common in the first pregnant women, more common in early pregnancy, very few symptoms are serious, sustainable to middle and late pregnancy, the prognosis is poor, perniciousvomiting refers to extremely serious pregnancy spit The patient may die due to acidosis, electrolyte imbalance, liver and kidney failure. basic knowledge The proportion of illness: 90% (this symptom is usually common in women during pregnancy, the general incidence rate is above 90%) Susceptible population: pregnant women Mode of infection: non-infectious Complications: esophageal rupture abdominal pain shock nystagmus coma pulmonary edema fetal growth restriction
Cause
Causes of pregnancy vomiting
Endocrine factors (25%):
(1) Increased levels of chorionic gonadotropin (HCG): It is currently believed that hyperemesis in pregnancy is associated with a sharp increase in HCG levels in pregnant women's blood, because on the one hand, the occurrence and disappearance of early pregnancy reactions coincides with the elevated HCG levels in pregnant women; On the one hand, in multiple pregnancies, the HCG value of hydatidiform mole patients is significantly increased, and the rate of pregnancy vomiting is also increased. After the termination of pregnancy, vomiting disappears, but the severity of the disease is not necessarily positively correlated with blood HCG levels.
(2) Thyroid function changes: 60% of patients with hyperemesis of pregnancy have transient hyperthyroidism, and elevated thyroid hormone is due to the increase of HCG concentration to stimulate thyroid secretion; on the other hand, the thyroid secretes an HCG allosteric body and Stimulating thyroid activity, the severity of vomiting in patients is significantly associated with free thyroid hormone and thyrotropin levels.
Neurological factors (20%):
On the one hand, the excitability of the cerebral cortex increases and the inhibition of the subcortical center decreases in early pregnancy, which causes various autonomic dysfunctions in the hypothalamus, causing hyperemesis in pregnancy; on the other hand, the uterus increases with pregnancy during pregnancy. Intrauterine receptors are stimulated and transmitted to the brain's center to cause radioactive reactions, causing nausea and vomiting.
Other factors (25%):
(1) Vitamin deficiency: especially vitamin B6 deficiency can lead to hyperemesis in pregnancy. (2) Allergic reactions: Several histamine receptor subtypes have been found to be associated with vomiting, and clinical antihistamines are effective in treating vomiting. (3) Increased Helicobacter pylori: Compared with asymptomatic pregnant women, the serum IgG concentration of anti-Helicobacter pylori in patients with hyperemesis of pregnancy increased.
Mental and social factors (20%):
Fear of pregnancy, nervousness, emotional instability, strong dependence and low social status, pregnant women with poor economic conditions are prone to pregnancy spit.
Pathogenesis
1. The plasma chorionic gonadotropin (HCG) level caused by pregnancy is rapidly increasing
In view of the development and disappearance of early pregnancy reaction such as nausea and vomiting, it coincides with the increase and decrease of HCG value in pregnant women's blood. In the case of trophoblastic disease, multiple pregnancy, the blood HCG value of pregnant women is significantly higher, and the degree of vomiting is also heavier. The incidence of hyperemesis in pregnancy increases, but once the pregnancy is terminated (even when the symptoms of severe vomiting are the heaviest), the symptoms disappear immediately. Therefore, it is currently recognized that hyperemesis in pregnancy is closely related to the increase of blood HCG levels, but the severity of symptoms varies greatly. Large, and not necessarily proportional to HCG content, Goodwin et al (1994) reported that the total plasma HCG and -HCG subunits in patients with hyperemesis were significantly higher than those without vomiting, and now the plasma concentration of HCG is too high. High or rising too fast has been recognized as a major factor in the onset of hyperemesis in pregnancy. The fact that gestational trophoblastic disease and twin pregnancies are complicated by pregnancy spit is also consistent with this theory.
2. Hyperthyroidism or thyroid irritation
Women with hyperemesis of pregnancy are associated with "subclinical hyperthyroidism" or "biochemical hyperthyroidism" (increased biochemical markers of thyroid function). There are many documents in the literature. Leunen et al reported that 23% of pregnant women with vomiting in hospitals showed thyroid gland. Excited, this hyperthyroidism (hyperthyroidism) is different from general hyperthyroidism. First, the patient does not have classic symptoms and signs of hyperthyroidism, but the biochemical indicators of thyroid function are elevated (so people call it "biochemical hyperthyroidism"). There is no thyroid antibody, unlike autoimmune hyperthyroidism.
Hershman et al (1999) believe that HCG has the effect of stimulating thyroid activity. In early pregnancy, when HCG level is high, it affects thyroid function. In hyperembolic gestation or trophoblastic tumor, excessive HCG secretion can cause hyperthyroidism, usually only thyroid function. Patients with abnormalities and rare clinical manifestations, Nader et al (1996) reported that a woman had three consecutive single-pregnancy episodes of pregnancy, and two of them were found to have temporary hyperthyroidism during biopsy (biochemical indicators), suggesting that HCG can be induced. Hyperthyroidism, they believe that it may be trophoblastic synthesis of HCG to make thyroid gland hyperplasia, or HCG can change some tissue properties in the mother, so that it can produce a molecule that can greatly promote thyroid proliferative activity, Tareen et al (1995) It also showed that the level of plasma thyroxine (T4) was significantly increased and the level of TSH was significantly decreased in women with hyperemesis. Correlation analysis showed that T4 was positively correlated with HCG in the hyperemesis of pregnancy, while thyrotropin (TSH) was negatively correlated with HCG. In addition to reporting the same results as Tareen, Leylek et al. (1999) further reported serum IgG, IgM, complement C3, and complement C4 in the immune parameters of the case group. The blood lymphocyte count was significantly higher than that of the control group, and the IgG, -HCG, and IgM in the hyperemesis of hyperthyroidism were significantly higher than those in the hyperembolic group without hyperthyroidism. This result suggests hyperemesis of pregnancy (with or without hyperthyroidism). The activity of -HCG and the involvement of the thyroid may be involved in the immune mechanism of the organism.
Panesar et al. (2001) filed an objection, arguing that it is likely that HCG does not participate independently in the etiology of hyperemesis during pregnancy, but may be indirectly involved in the onset of pregnancy vomiting by its ability to stimulate (excite) the thyroid gland.
3. Psychosomatic factors
Psychosomatic factors (Psychosomatic factors) or psychological factors have always been considered as one of the factors of pregnancy vomiting. Clinically, some nervous system dysfunction is observed. Pregnant women with mental stress are more common in pregnancy, indicating that the disease may be In connection with cerebral cortex and subcortical central dysfunction, leading to hypothalamic autonomic dysfunction, Hasler (1999) studied the relationship between serotonin (5-HT) receptor physiology and pregnancy vomiting, and the results showed that 5-HT receptors are distributed in the central nervous system. The nervous system and internal organs, and involved in the onset of hyperemesis in pregnancy, his study found that in the 5-HT receptor subtype, 5-HT4 agonist in patients with nausea and gastric dyspepsia, vomiting before vomiting The nature of the kinase, in contrast, the 5-HT4 antagonist has anti-vomiting activity on experimental models. A study by Leeners et al (2000) showed that psychosomatic factors are indeed associated with hyperemesis in pregnancy, not only related to its pathogenesis, but also to the extent of symptoms and The duration of symptoms is related, and their research also shows that when the psychosomatic factors are considered as a cause of hyperemesis in pregnancy, the treatment results are more isolated from the body. Efficacy results better.
4. Relationship between Helicobacter pylori and hyperemesis in pregnancy
In recent years, studies have found that Helicobacter pylori is closely related to hyperemesis in pregnancy. In 1998, Yoinis et al reported that 2 cases of early pregnancy vomiting patients had oral erythromycin for unrelated reasons, and unexpectedly found that pregnancy vomiting was quickly improved. All the symptoms disappeared, and both of these pregnant women were positive for Helicobacter pylori serological tests, which was consistent with the reports of Helicobacter pylori (Hp) and hyperemesis during pregnancy. Many studies later proved Helicobacter pylori infection is one of the important causes of hyperemesis in pregnancy.
Hayakawa et al (2000) compared the plasma Hp antibody test in 34 cases of hyperemesis and 29 cases of control group, the positive rate of H.pylori IgG antibody in the case group was 47.5%, while the control group was 20.6%, P <0.0005; PCR revealed that the positive rate of H.pylori genome was 61.8%, while that of the control group was 27.6%, P<0.000001, which further confirmed that chronic infection of Helicobacter pylori is an important pathogen of pregnancy vomiting.
In addition to the above factors related to the onset of the disease, there are several reports on gender factors, saying that the pregnancy in the first trimester of pregnancy, whether hospitalized or not, the proportion of newborn infants is higher, whether the gender is different and the occurrence of pregnancy vomiting The relationship is still unclear. In a nutshell, although the cause of hyperemesis in pregnancy is still not very clear, the results of the past decade have led people to believe that hyperemesis in pregnancy is a multifactorial disease, and the hormonal changes caused by pregnancy are combined. Gastrointestinal dysmotility is the main factor, Helicobacter pylori infection is a predisposing factor for pregnancy vomiting, as Simpsondeng et al (2001) said, the onset of pregnancy vomiting is biological, psychosocial and socioeconomic Caused by compound factors.
Prevention
Pregnancy vomiting prevention
1. Avoid eating time when vomiting is easy;
2, choose your favorite food, eat less meals;
3, eat more vegetables, fruits and other foods rich in vitamins;
4, eat more light and nutritious diet, such as various broths;
5, should avoid high-fat foods;
6. In addition, since the smell during cooking is easy to induce and aggravate vomiting, the patient should avoid it as much as possible before returning to health. At the same time, you should drink more water to replenish the body's lost water due to vomiting.
Complication
Complications of pregnancy vomiting Complications Esophageal rupture, abdominal pain, shock, nystagmus, coma, pulmonary edema, fetal growth restriction
1. Severe vomiting caused by esophageal rupture, mucosal laceration at the junction of esophagus and stomach (Mamory-Weiss syndrome), often occurs after severe vomiting, most believed that vomiting caused reflex pyloric sphincter contraction and severe sinus contraction, plus The tendon and abdominal muscles contract, and the stomach contents act on the gastric cardia and esophageal junction with great impact force and high pressure. At the same time, because the esophagus is in the contractile state, its distal end may have a limited expansion. When the intragastric pressure reaches 13-20 kPa, the mucosal tear can be caused. Since the mucosa cannot expand like the muscular layer, the mucosal tear at the junction of the gastroesophageal junction is caused. In addition to the above mechanical reasons, the local gastric mucosal lesion is also the main cause of the disease. Gastritis caused by various reasons, causing embrittlement of gastric mucosa, weakening of resistance, easy to cause mucosal laceration of the cardia, abdominal pain, most severe abdominal pain after vomiting or vomiting, fixed position, analgesic Can not alleviate deep inhalation or ingestion when swallowing; the amount of hematemesis depends mainly on the size of the mucosal laceration and the size of the blood vessels, and can appear black feces, in severe cases Hemorrhagic shock, and even death.
2. Pregnancy hyperemesis often complicated by temporary hyperthyroidism, which can cause life-threatening complications when the condition is severe.
3. Vitamin B1 is severely deficient and induces Wernick's encephalopathy during pregnancy, resulting in spotted hemorrhage in the gray matter around the midbrain and cerebral aqueduct, cell necrosis and gliosis, cerebellum, thalamic dorsal nucleus, hypothalamic and papillary punctate hemorrhage and necrosis About 10% of patients with malignant vomiting are complicated by the disease. The main features are ophthalmoplegia, tonic ataxia and amnesia. The clinical manifestations are nystagmus, visual impairment, gait and standing posture are affected, and individual stiffness occurs. Or coma, the patient's mortality after treatment is 10%, the untreated mortality rate is as high as 50%, often died of pulmonary edema and respiratory muscle paralysis.
4. Other retinal hemorrhage, liver and kidney damage.
5. For the fetus can lead to fetal growth restriction, and even intrauterine death.
Symptom
Pregnancy vomiting symptoms Common symptoms Menopausal nausea mixed acid-base balance disorder Physiological changes during pregnancy Menopause and galactorrhea Pregnancy signs Weak lips dry and dry skin dry
Disgusting, vomiting
Nausea, salivation and vomiting occurred about 6 weeks after menopause, and gradually increased with pregnancy. After 8 weeks of menopause, it developed frequent vomiting and could not eat. There was bile or coffee-like secretion in the vomit.
2. Water, electrolyte disorder
Severe vomiting and long-term hunger lead to dehydration, electrolyte imbalance, loss of hydrogen, sodium, potassium ions, hypokalemia, obvious weight loss, extreme fatigue, dry lips, dry skin, sunken eyes, reduced urine output, nutrient intake Insufficient weight loss.
3. Acid, alkali balance imbalance
In the case of starvation, the body uses adipose tissue to supply energy, so that the ketone body, an intermediate product of fat metabolism, accumulates, causing metabolic acidosis.
Examine
Examination of pregnancy vomiting
1. Urine examination: The patient's urine specific gravity increases, the urine ketone body is positive, and the protein and cast type may appear in the urine when the renal function is impaired.
2. Blood examination: blood concentration, red blood cell count increased, hematocrit increased, hemoglobin value increased; blood ketone body can be positive, carbon dioxide binding capacity decreased; liver and kidney function impaired blood bilirubin, transaminase, creatinine and urea Nitrogen is elevated.
3. Fundus examination: retinal hemorrhage in severe cases.
4. Electrocardiogram examination: hypokalemia can cause heart rhythm changes and myocardial damage, manifested as abnormal ECG.
Diagnosis
Diagnosis of pregnancy vomiting
diagnosis
1. According to the nausea after menopause and menopause for 40 days, the gradual aggravation of vomiting and vomiting, and the signs of early pregnancy in gynecological examination, as well as the increase in urinary HCG and diagnostic ultrasound, the diagnosis is not difficult. But first you must determine if you are pregnant.
2. However, it must be remembered that pregnancy vomiting is a rule of exclusion. In the diagnosis of this disease, in addition to the characteristics of prolonged and severe nausea, vomiting, dehydration, ketosis and weight loss, it should also pay attention to other Disease identification.
3. In patients with hyperemesis of pregnancy, it is also necessary to distinguish between trophoblastic disease and multiple pregnancy through careful examination and auxiliary examination. This is actually not difficult to do. B-mode ultrasound is particularly useful.
4. To determine whether there is chronic Helicobacter pylori infection in the digestive tract, it can be detected by plasma H.pylori antibody, "hose test" or PCR method to detect H.pylori genome.
5. Asakura et al (2000) proposed the determination of reversed T3 (rT3) plasma levels as an indicator of the severity of hyperemesis in pregnancy, and biochemical indicators related to weight loss [free T3, free T4 and unsaturated fatty acids (NEFA)] In the past, NEFA was taken as an indicator of the severity of hyperemesis in pregnancy because of its correlation with the rate of fat dissolution. Asakura et al. found that only rT3 is directly related to weight loss and fat dissolution rate, so it is proposed to measure rT3 plasma. Level to assess the severity of pregnancy spit.
Differential diagnosis
Acute gastroenteritis
Can also cause nausea, vomiting, and even dehydration, but this disease has nothing to do with pregnancy, more than a history of unclean diet, in addition to nausea, vomiting, accompanied by upper abdominal or full abdominal pain and diarrhea, stool examination with white blood cells and pus cells, anti- Symptoms quickly disappear after infection treatment.
2. Acute viral hepatitis
Severe pregnancy vomiting may occur jaundice, liver function damage, but the general serum transaminase increase does not exceed the upper limit of the normal value of 4 times, acute viral hepatitis is not related to pregnancy, often have a history of hepatitis contact, vomiting is not serious, often accompanied by liver Area pain, although loss of appetite, but more can eat, liver function test alanine aminotransferase increased significantly, bilirubin increased, hepatitis B surface antigen positive.
3. Neurofunctional vomiting
The disease is related to eating and mental factors, and has nothing to do with pregnancy. Vomiting occurs more immediately after eating. Vomiting sounds, less spit, mainly water, and can be eaten after vomiting.
Migraine
The disease occurs mostly in adolescence, with paroxysmal half-head headache, with nausea, vomiting, pregnancy can induce the disease, ergot preparation treatment can quickly relieve symptoms.
5. Ulcer disease
Some patients with this disease may have nausea, vomiting, and have nothing to do with pregnancy, often accompanied by abdominal pain, hernia, acid reflux, stomach ulcers often occur 30 minutes to 2 hours after a meal, abdominal pain, duodenal pain occurs in the fasting or at night.
6. Cholecystitis
The disease has nothing to do with pregnancy, mostly after eating greasy food, nausea, vomiting, with persistent upper or upper abdominal cramps, often to the right shoulder radiation, can be accompanied by chills, fever, jaundice, abdominal examination can be swollen and swollen The gallbladder, Murphy sign positive, B-ultrasound examination of gallbladder enlargement, tenderness, rough wall.
7. biliary ascariasis
The disease has nothing to do with pregnancy, in addition to nausea and vomiting, accompanied by paroxysmal or persistent cramps in the lower right of the upper xiphoid xiphoid, the pain is more severe, can be radiated to the shoulder and back, the feces are checked for eggs, and the B-ultrasound is used to check the biliary tract. A locust body with parallel light bands inside.
8. Pregnancy benign intracranial hypertension
The disease is rare, mostly occurs in the first 1-4 months of pregnancy, the cause is unknown, often cause headache, nausea, vomiting, vision loss, diplopia, etc., occasional tinnitus, physical examination showed bilateral optic disc edema, some can have nerve Paralysis, cerebrospinal fluid pressure increased, more than 2.45kPa (250mmH2O), normal cellular components, no abnormalities in ventriculography.
9. Digestive tract malignant tumor
Such as gastric cancer, intestinal cancer and pancreatic cancer, etc., this disease has nothing to do with pregnancy, early can be asymptomatic, some patients have nausea, vomiting, often accompanied by irregular abdominal pain, weight loss, stool with blood or mucus, gastroscopy, X-ray meal Digestive tract examination, barium enema examination, CT examination, etc. can assist in diagnosis.
