The patient was a 29-year-old married, pregnant woman at 14 + 2 weeks gestational age (WGA) who presented to the hospital emergency department seeking treatment for recurrent nausea and vomiting.
Upon arrival at the emergency department the patient was triaged into care and intravenous (IV) access was secured. Blood and urine laboratory tests, including complete blood count, chemistry panel, liver function tests, urine drug screen, urinalysis, and venous blood gas were conducted and found to be consistent with mild hyperemesis, without indicators of severe medical illness (Table 1). Physical examination was notable for a nontender gravid abdomen with intact bowel sounds and dry mucus membranes but was otherwise unremarkable. Bedside ultrasound demonstrated an intact intrauterine pregnancy with normal-range fetal heart tones. The patient received a 2 L bolus of IV fluid repletion, 4 mg of IV ondansetron, and 50 mg of IV ranitidine. The patient endorsed resolution of her nausea and was discharged from the emergency department.
The patient presented to the emergency department again within minutes of discharge, newly disclosing suicidality related to the intractable nature of her nausea and vomiting. She subsequently underwent evaluation by the hospital's consultation-liaison psychiatry team.
During the psychiatric interview the patient clarified her psychosocial circumstances, noting that she was traveling to secure the financial assistance of her (estranged) husband to aid in facilitating elective termination of pregnancy, an intervention to which her family of origin was opposed. Her obstetric history was notable for seven pregnancies including the current. Her first pregnancy resulted in an early spontaneous abortion. Her next two pregnancies culminated in delivery at 34 + 2 WGA and 37 WGA, respectively, and both were complicated by severe nausea and vomiting localized to the first trimester of gestation. Due to the intensity of these symptoms, the patient's next three pregnancies were electively terminated at less than 10 WGA. The patient's two living children were healthy at the time of the patient's presentation to the emergency department. Given her intention to terminate her current pregnancy, she had not acquired any manner of prenatal care by the time of her current presentation to the hospital.
The patient reported a psychiatric history of anxiety, depression, and posttraumatic stress disorder (PTSD). She contextualized her PTSD to an incident where she witnessed, in close proximity, a murder via firearm. She had a history of brief psychiatric hospitalization for depression and suicidality. Pharmacologically, past treatments included sertraline, bupropion, and prazosin. At the time of her current presentation, she had not seen a mental health professional for several years.
Regarding her symptomology, the patient endorsed predominantly depressive spectrum symptoms including sleep disturbance, anergia, anorexia, suicidal thoughts, sadness, psychomotor retardation, and guilt related to her intention to terminate her current pregnancy. She additionally endorsed paroxysmal anxiety and nightmares with posttraumatic themes. There were no suggestions of mania or psychosis. Her affect was dysthymic, tearful, and restrictive. Her sense of guilt was exacerbated by relationship stressors, specifically as the recipient of her husband's blame for her inability to carry pregnancies to term due to hyperemesis gravidarum (HG). Historically, she recounted scant depressive disturbances in mood outside the gravid state. The patient was admitted to the inpatient psychiatric ward for further management.
The patient endorsed predominantly depressive symptomatology, including insomnia, anergia, anorexia, thoughts of suicide, and psychomotor retardation, lasting approximately 8 days and representing a change from baseline functioning. Her mental status examination was tearful, dysthymic, and restrictive. As her symptoms did not yet meet temporal criteria for a major depressive episode, her differential diagnosis included other specified depressive disorder, adjustment disorder with depressed mood as a reaction to her medical condition and psychosocial circumstances, and depressive disorder due to another medical condition. On the basis of the clear contextualization of her depression to symptoms of HG and resolution of depression with better control of her nausea and vomiting, her final diagnosis was adjustment disorder with depressed mood.
The hospital obstetrics and gynecologic service was consulted to assist in the patient's care. She was subsequently initiated on scheduled nightly and as-needed pyridoxine/doxylamine, oral ondansetron as a second-line treatment, and rectal/oral promethazine as a third-line intervention. Oral medications proved to be sufficient for symptom control, with compliance to scheduled doxylamine/pyridoxine at night and regular use of the as-needed second-line 4 mg of ondansetron every 8 hours. Medications were well tolerated with no adverse effects. In addition to this regimen for management of nausea and vomiting, her dysregulated sleep, which was felt to be multifactorial in nature, was targeted with 5 mg of zolpidem nightly. Zolpidem was selected in collaboration with the patient and the obstetrics/gynecology team, with due consideration of that medication's risk profile in pregnancy.
With institution of these measures, the patient's affect brightened markedly by hospital day 3. Her baseline nausea was tolerable rather than overwhelming. She now planned to carry her pregnancy to completion and intended to return to her home of origin for ongoing familial support. She consented to routine prenatal testing procedures. She was instructed to follow-up with an ambulatory care center local to her home of origin for intermittent IV fluid repletion and antiemetic medications as appropriate to the severity of her symptoms.
Nausea and vomiting are commonly experienced during pregnancy. HG is a condition associated with intractable worsening of nausea and vomiting causing impaired quality of life and significant sequelae such as electrolyte imbalance, nutritional deficiency, and fluid and weight loss warranting medical intervention.1 Temporally, HG typically occurs in the first trimester with resolution around 20 WGA; however, in 10% of patients the symptoms may persist for the duration of pregnancy.1 HG is estimated to affect about 0.5% of all live births and is the most common indication for hospitalization during the first half of pregnancy.1,2 Volume depletion, metabolic disturbances, and electrolyte disturbances are common complications. Management consists of correction of abnormalities secondary to frequent emesis and anorexia. Numerous etiologies for HG have been proposed, including the hormonal changes of early pregnancy, thyrotoxicosis, serotonin and its role in the vomiting reflex arc, altered gastrointestinal kinetics, infection, hepatic abnormalities, changes to lipid metabolism, autonomic nervous dysfunction, and nutritional deficiencies.3 Psychological factors have likewise been implicated in the etiology, treatment course, and prognosis of HG.3
In the late 19th and early 20th century, psychiatric perspectives on HG were guided predominantly by psychoanalytic theory. Researchers suggested a link between HG and neuroses, postulating that HG embodied a conversion phenomenon such as rejection of femininity or rejection of pregnancy.4 Early studies from this era linked HG to specific personality styles as well as the contemporaneous and now defunct concept of hysteria.4 Long since jettisoned by medical psychiatry for its pejorative implications, hysteria was a diagnostic forerunner of somatization, conversion disorders, and dissociative disorders, all of which are represented in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition.5,6 The notion of HG as a somatization effect has persisted in psychiatric literature on the subject, even calling into question whether HG is a cause or an effect of psychological distress. Multiple contemporary studies have attempted to elucidate the link between HG and mental illness.
Previously identified risk factors for HG requiring antepartum hospital admission include psychiatric illness as well as hyperthyroid disorders, history of molar pregnancy, diabetes, gastrointestinal disorders, and asthma.7 A retrospective analysis of a Canadian cohort of over 150,000 pregnant women showed that psychiatric illness in particular was associated with a relative risk of antepartum admission for HG of 4.1.7 Annagur et al.8 evaluated 47 patients with HG via a DSM-IV–guided psychiatric interview9 and identified an anxiety disorder prevalence of 26% and a mood disorder prevalence of 15% compared with overall anxiety and mood disorder prevalence of 13% among unstratified pregnant and postpartum populations in the United States.8,10 These findings were echoed in a case-control study that identified rates of comorbid mood and anxiety disorders of 15% and 37%, respectively, in HG cases compared to 8% and 12% of non-HG controls, although only the difference in rates of anxiety disorders met thresholds for statistical significance (P = .001).11
Other studies emphasize the important role of psychosocial stress in the psychopathology of HG. An analysis involving retrospective telephonic interview of more than 3,000 women affected by nausea and vomiting of pregnancy showed that psychosocial problems were widespread even when the intensity of reported symptoms was low.12 Among a cohort of 808 patients with HG, 83% endorsed negative psychosocial effects, including socioeconomic losses, attitude changes toward future pregnancy, psychiatric sequelae, and a sense that their symptoms were being minimized by providers.13
There is scant literature investigating the link between HG and suicide risk. A population based-cohort study in Norway investigated the link between HG and long-term mortality outcomes but found no association between HG and death from external causes, including suicide.14 A single case report documents an episode of suicidality in a patient with HG precipitated by the sequelae of antiemetic treatment, specifically the development of akathisia in response to treatment with dopamine antagonists.15
This case documents an account of depressive psychopathology involving suicidality that significantly ameliorated with adequate treatment of HG. Although the patient had a history of past psychiatric diagnoses, these appeared quiescent with the exception of the psychopathology directly related to her obstetric condition. Her psychosocial stressors were complex and interwoven with psychiatric symptomatology. A primary strain on her marriage was her inability to carry pregnancies to term due to the severity of her HG, further exacerbating guilt within her constellation of presenting depressive symptoms. Formation of a robust outpatient treatment plan during hospitalization served to ameliorate the patient's psychosocial stress. She decided against terminating her pregnancy and developed a plan to return to the more supportive familial environment of her home of origin. This decision-making was bolstered by the patient's new understanding of the various treatment options available to her, including the presence of ambulatory care clinics providing IV antiemetics. Although she presented with acute-on-chronic suicidality, the patient did not engage in any self-injurious behaviors or endorse any active suicidality during her hospitalization, and she was provided with a multilayered safety plan at discharge. In this case, misattribution of depression as a cause (rather than an effect) of HG might have resulted in inadequate treatment of nausea and vomiting, prolonging the depressive state and exacerbating suicide risk.
This case reinforces the primacy of adequate medical treatment in the overall management of HG.
- Verberg MFG, Gillott DJ, Al-Fardan N, Grudzinskas JG. Hyperemesis gravidarum, a literature review. Hum Reprod Update. 2005;11(5):527–539. doi:10.1093/humupd/dmi021 [CrossRef] PMID:16006438
- McCarthy FP, Lutomski JE, Greene RA. Hyperemesis gravidarum: current perspectives. Int J Womens Health. 2014;6:719–725. doi:10.2147/IJWH.S37685 [CrossRef] PMID:25125986
- Eliakim R, Abulafia O, Sherer DM. Hyperemesis gravidarum: a current review. Am J Perinatol. 2000;17(4):207–218. doi:10.1055/s-2000-9424 [CrossRef] PMID:11041443
- Katon WJ, Ries RK, Bokan JA, Kleinman A. Hyperemesis gravidarum: a biopsychosocial perspective. Int J Psychiatry Med. 1980;10(2):151–162. doi:10.2190/BMXF-9PHY-R9KH-MC28 [CrossRef] PMID:7419365
- North CS. The classification of hysteria and related disorders: historical and phenomenological considerations. Behav Sci (Basel). 2015;5(4):496–517. doi:10.3390/bs5040496 [CrossRef] PMID:26561836
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Publishing; 2013.
- Fell DB, Dodds L, Joseph KS, Allen VM, Butler B. Risk factors for hyperemesis gravidarum requiring hospital admission during pregnancy. Obstet Gynecol. 2006;107(2 Pt 1):277–284. doi:10.1097/01.AOG.0000195059.82029.74 [CrossRef] PMID:16449112
- Annagür BB, Tazegül A, Gündüz S. Do psychiatric disorders continue during pregnancy in women with hyperemesis gravidarum: a prospective study. Gen Hosp Psychiatry. 2013;35(5):492–496. doi:10.1016/j.genhosppsych.2013.05.008 [CrossRef] PMID:23810464
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. American Psychiatric Publishing; 1994.
- Vesga-López O, Blanco C, Keyes K, Olfson M, Grant BF, Hasin DS. Psychiatric disorders in pregnant and postpartum women in the United States. Arch Gen Psychiatry. 2008;65(7):805–815. doi:10.1001/archpsyc.65.7.805 [CrossRef] PMID:18606953
- Uguz F, Gezginc K, Kayhan F, Cicek E, Kantarci AH. Is hyperemesis gravidarum associated with mood, anxiety and personality disorders: a case-control study. Gen Hosp Psychiatry. 2012;34(4):398–402. doi:10.1016/j.genhosppsych.2012.03.021 [CrossRef] PMID:22554433
- Mazzotta P, Stewart D, Atanackovic G, Koren G, Magee LA. Psychosocial morbidity among women with nausea and vomiting of pregnancy: prevalence and association with anti-emetic therapy. J Psychosom Obstet Gynaecol. 2000;21(3):129–136. doi:10.3109/01674820009075620 [CrossRef] PMID:11076334
- Poursharif B, Korst LM, Fejzo MS, MacGibbon KW, Romero R, Goodwin TM. The psychosocial burden of hyperemesis gravidarum. J Perinatol. 2008;28(3):176–181. doi:10.1038/sj.jp.7211906 [CrossRef] PMID:18059463
- Fossum S, Vikanes AV, Naess Ø, Vos L, Grotmol T, Halvorsen S. Hyperemesis gravidarum and long-term mortality: a population-based cohort study. BJOG. 2017;124(7):1080–1087. doi:10.1111/1471-0528.14454 [CrossRef] PMID:27981734
- Wright MT. Antiemetics, akathisia, and pregnancy. Psychosomatics. 2007;48(6):461–466. doi:10.1176/appi.psy.48.6.461 [CrossRef] PMID:18071091
|8-Item urine drug screen
||Carbon dioxide 20 mmol/L (normal range 22–32 mmol/L)
Anion gap 20 mmol/L (normal range 6–16 mmol/L)
|Liver function tests
||Within normal limits
||Within normal limits (1.440 mIU/mL)
||Elevated (103,456 mIU/mL)
|Complete blood count
||Mean platelet volume 12.3 fL (normal range, 6.4–10.3 fL)
Proteinuria to 30 mg/dL
Urobilinogen to 4 mg/dL
Mucus on microscopy
Otherwise normal, without a significant number of white or red blood cells on microscopy
|Venous blood gas
||Lactate 1.32 mmol/L