A complete history taking and physical examination are important in the evaluation of pregnant

women with persistent vomiting. Nausea and vomiting in early pregnancy is usually self limited
condition, but when the condition becomes more severe, the potentially serious causes need to be
ruled out. To exclude the differential diagnosis, the following parameters should be investigated
including: onset of nausea and vomiting (nearly all the cases begin before nine weeks of
gestation), attendant symptoms, underlying chronic diseases, or in very rare cases, hereditary
diseases.1
Nausea and vomiting during pregnancy has very few attendant symptoms other than fatigue
exhaustion, and indisposition. Pyrexia, gastric pain, headache or neurological signs point to other
causes, such as: Wernickes encephalopathy. Clinical symptom of flank pain may suggest
urogenital causes, such as uremia, pyelonephritis, and nephrolithiasis. 2 Thyroid function is
physiologically altered during pregnancy, including stimulation by Human Chorionic
Gonadotropin (HCG); the most likely endocrine factor for the development of hyperemesis
gravidarum. In the case of elevated thyroid hormones, it is important to distinguish between
Transient Hyperthyroidism of Hyperemesis Gravidarum (THHG) and primary thyroid disease.
THHG is known to be self-limited. It may persist until 18 weeks of gestation and no need further
treatment.2 Metabolic ketoacidosis and ketonaemia (actone-like breath) may occur with
occasional pyrexia and hepatic symptoms (such as: jaundice). In this case, laboratory
investigations should be done, including hematocrit, electrolytes, as well as urinary status
(presence or absence ketone bodies, specific weight, pH).2,3
In another case, some gastrointestinal causes may also manifest in nausea and vomiting with the
addition of abdominal pain. Epigastric pain and hematemesis should be specifically enquired
about, which may suggest peptic ulcer. If the pain is in the lower abdominal with fever
accompanying, it may suggest appendicitis. Further examination, such as ultrasonography may
be helpful in ruling out gastrointestinal disorders (including gall bladder and liver disorders).1,2,3
Multiple pregnancies have been associated with hyperemesis gravidarum. Thus, ultrasound may
be done to relieve maternal anxiety regarding her pregnancy viability status. In addition,
ultrasonography may also be performed to exclude trophoblastic disorders and neoplasms.2,3

Figure 1. Differential Diagnosis of Hyperemesis Gravidarum

1. Quinlan JD and Hill DA. Nausea and vomiting of pregnancy. American Family
Physician. 2003;68(1):121-8.
2. Jueckstock JK, Kaestner R, Mylonas I. Managing hyperemesis gravidarum: a multimodal
challenge. BMC Medicine. 2010;8:46.
3. Sonkusare S. Hyperemesis gravidarum. In: A Textbook of Gynecology for LessResourced Locations. London: Sapiens Publishing. 2012.