With persistent vomiting after hospitalization, appropriate steps should be taken to exclude possible underlying diseases as a cause of hyperemesis. That said, in one study, endoscopy did not change management in 49 women (Debby, 2008). Other potential causes of vomiting include gastroenteritis, cholecystitis, pancreatitis, hepatitis, peptic ulcer, and pyelonephritis. In addition, severe preeclampsia and fatty liver are more likely after midpregnancy. And although clinical thyrotoxicosis has been implicated as a cause of hyperemesis, it is more likely that abnormally elevated serum thyroxine levels are a surrogate for higher-than-average serum hCG levels (Sun, 2014). This is discussed further in Chapter 5 (p. 100). In our experiences, serum free thyroxine levels normalize quickly with hydration and emesis treatment.
With treatment, most women will have a salutary response and may be sent home with antiemetic therapy. Their readmission rate is 25 to 35 percent in most prospective studies. If associated psychiatric and social factors contribute to the illness, the woman usually improves remarkably while hospitalized (Swallow, 2004). That said, symptoms may relapse in these women, and some go on to develop posttraumatic stress syndrome (Christodoulou-Smith, 2011; McCarthy, 2011). For some women, hyperemesis can be an indication for elective termination (Poursharif, 2007).
In the small percentage of women who continue to have recalcitrant vomiting after intensive therapy, consideration is given for enteral nutrition (p. 1043). Stokke and associates (2015) described successful use of nasojejunal feeding for up to 41 days in 107 such women. Use of sonography to conirm correct placement of the tube has been described (Swartzlander, 2013). Percutaneous endoscopic gastrostomy with a jejunal port has also been reported (Saha, 2009; Schrag, 2007). A randomized trial failed to show any advantages from early enteral feeding (Grooten, 2017).
In our experiences, only a very few women will require parenteral nutrition (Yost, 2003). In a study of 599 women, however, Peled and coworkers (2014) reported that 20 percent required central venous access to be established for nutrition.
Symptomatic reflux is seen in up to 15 percent of nonpregnant individuals (Kahrilas, 2015). he spectrum of sequelae includes esophagitis, stricture, Barrett esophagus, and adenocarcinoma. The main symptom of relux is heartburn, or pyrosis, which is especially common in pregnancy. Its prevalence rose from 26 percent in the irst trimester to 36 percent in the second and 51 percent in the third trimesters (Malfertheiner, 2012). The retrosternal burning sensation stems from esophagitis caused by gastroesophageal relux related to relaxation of the lower esophageal sphincter.