When It's Not NVP
Nausea and vomiting are two of the most common symptoms in early pregnancy, but women should not always assume this is due to normal Nausea and Vomiting of Pregnancy (NVP), especially if severe and/or accompanied by abdominal or pelvic pain.
Nausea and vomiting early in pregnancy can be symptoms of other pregnancy-related conditions, as well as non-obstetric conditions (called a differential diagnosis). Molar pregnancies very often present with severe nausea and vomiting in the first trimester, while ectopic pregnancy can sometimes present with these symptoms (mostly abdominal pain).
Women experiencing severe nausea, vomiting, and/or abdominal pain early in pregnancy need to call their health care provider (HCP) for an appointment, or visit an emergency department if severe.
The HCP will perform a physical assessment, an ultrasound exam, and take a detailed history to rule out other possible causes. Of most importance, if other possible conditions are ruled out and NVP is diagnosed, the woman and her HCP can discuss a management plan for controlling her symptoms.
Background
Although less common, pregnant women can experience health complications resulting in nausea and vomiting in early pregnancy that is not the result of normal pregnancy-related changes.
These symptoms can be mistaken for Nausea and Vomiting of Pregnancy (NVP), thereby delaying possible diagnosis of molar pregnancy, ectopic pregnancy, appendicitis, gallstones, or bladder/kidney infection.
It is advised that women visit their HCP as early as possible in their pregnancy if they are suffering from nausea and vomiting. Although it is very likely they are experiencing NVP, it is important to rule out other causes. Further, once NVP is diagnosed, this helps open the door of communication between a woman and her HCP regarding a management plan for her NVP symptoms.
Note: It is especially important for women who start nausea and vomiting AFTER 9 weeks of pregnancy (as this makes NVP less likely), or in women with continued nausea and vomiting into the second trimester, to get evaluated. Although it is common for NVP to last through 16 to 20 weeks, it is good practice to be assessed by an HCP due to continued symptoms.
Early Pregnancy-Related
Women who present with nausea and vomiting in the first trimester of pregnancy are more than likely suffering from NVP. However, if nausea and vomiting also present with abdominal tenderness, pain, or fever, an HCP will perform an ultrasound/lab tests to rule out:
Molar pregnancy: Molar pregnancy occurs when abnormal trophoblastic tissue grows into the uterus after implantation; part of a rare category of diseases known as Gestational Trophoblast Disease. This condition presents with nausea and vomiting early in pregnancy and must be treated immediately.
Ectopic pregnancy: Ectopic pregnancy occurs when a fertilized egg implants in the Fallopian tube or other reproductive structure that is not the uterus. This condition is considered a gynecological emergency because if left undiagnosed and untreated, the developing embryo can cause the Fallopian tube to rupture, which is life-threatening and requires surgery. The most common symptoms are abdominal pain and bleeding, but nausea/vomiting can also be present.
Thyroid disorders: Pregnancy causes significant stimulation to the endocrine system due to the increase in hormones necessary for successful fetal growth and development. Therefore, some pregnant women can develop hypothyroidism or hyperthyroidism, which can present with nausea and vomiting. An HCP can request lab work for diagnosis; both conditions are easily and safely treated during pregnancy.
Multiple pregnancy: Although technically still NVP, confirming multiples early in pregnancy not only provides an explanation and potential diagnosis of severe NVP or Hyperemesis Gravidarum (HG), but can prepare women for twins (or higher). Earlier recognition also gives women and their HCPs time to discuss an NVP management plan in the event symptoms get worse.
Non-Pregnancy-Related
The differential diagnosis for NVP (non-obstetric causes of nausea/vomiting that could coincidentally occur in the first trimester or later) include:
Gastroenteritis (stomach bug/virus)
Hepatitis
Peptic ulcer
Gastroesophageal reflux disease (GERD, severe acid reflux)
Urinary tract infection that has spread to the kidneys
Appendicitis, gallstones, and urinary tract infections are three of the most common non-obstetric causes of nausea and vomiting during pregnancy; most of these conditions also present with abdominal or pelvic pain:
Appendicitis: Appendicitis is inflammation of the appendix, a pouch located at the end of the colon on the right, lower part of the abdomen. It is the most common cause of non-obstetric pain in pregnant women, occurring in approximately 1 in 1,000 to 1,500 pregnancies. There is no evidence pregnancy specifically makes this condition more common.
Gallstones: In contrast to appendicitis, pregnancy is considered a risk factor for gallstones, hardened deposits of the digestive fluid bile that can form within the gallbladder. Gallstones most likely occur during pregnancy due to progesterone’s affects on gallbladder motility, which causes it to contract more slowly, causing blockage or a buildup up sludge.
Urinary Tract Infection (UTI): Pregnancy is also a risk factor for UTIs, an infection of the urinary tract (bladder, kidneys) due to the presence of bacteria in the urine. UTIs are among the most common medical complications during pregnancy, with an incidence as high as 8% of all pregnant women. A UTI that spreads to the bladder or kidneys is very serious during pregnancy.
One study indicated that in at least one large medical center, nausea and vomiting during pregnancy was the second most common indication for upper endoscopy after upper gastrointestinal bleeding; upper endoscopy can be used to rule out several possible conditions described above.
Late-Onset Nausea and Vomiting
Nausea or vomiting is particularly significant when the onset first presents later in the first trimester or in the second trimester. Sudden appearance of nausea and vomiting after mid-pregnancy may be linked specifically to preeclampsia, ovarian torsion, or acute fatty liver of pregnancy.
Ovarian torsion (OT) occurs when the ovaries twist around the ligaments, tube, or nearby structures either separately or together, and complicates about 1 in 800 pregnancies during any trimester, although peak incidence may occur between 10 and 17 weeks of pregnancy. It is estimated about 10% to 22% of all cases occur during pregnancy. Most women with OT present to the emergency room with severe abdominal pain, nausea, and vomiting.
Preeclampsia is a serious vascular condition during pregnancy that can result in numerous and even life-threatening complications. It can present with high blood pressure, headache, swelling, nausea and vomiting, and vision changes; early diagnosis and treatment can prevent adverse outcomes.
Acute Fatty Liver of Pregnancy is a potentially life-threatening liver disorder of pregnancy that usually occurs in the third trimester or postpartum period. It occurs in approximately 1 in 10,000 to 1 in 15,000 pregnancies and can also present with jaundice and fever. The cause is unknown but it may occur due to an inability of the mother to metabolize fatty acids, which can build up in the bloodstream.
Action
Women experiencing severe nausea, vomiting, and/or abdominal pain early in pregnancy need to call their HCP for an appointment. The HCP will perform a physical assessment, take a detailed history, and likely perform an ultrasound exam to rule out other possible causes. Additionally, if other conditions are ruled out, the woman and HCP can discuss a management plan for her NVP.
Women should also call their HCP immediately if they:
See blood in vomit, which could be red or black
Cannot keep fluids down; experience symptoms of dehydration
Pass only a small amount of urine or urine is a dark color
Have a fever
Have a rapid heart rate
Experience dizziness, faintness, tiredness, or confusion
Women also need to call their HCP if they experience NVP well into the second trimester.
Partners/Support
Partners and family members should learn the Symptoms and Complications of NVP. This will help partners learn and recognize when a woman may be experiencing something else.
When a woman is suffering with moderate to severe nausea and/or vomiting, along with other normal symptoms of early pregnancy, women can be overwhelmed, and may assume much of what they are feeling is simply normal.
However, partners and family members play an important rule in helping a woman assess whether she may be in need of medical care. Although an HCP may determine during the next appointment that she is experiencing normal NVP, partners, women, and the HCP should then take that moment to discuss a management plan moving forward.
Resources
Nausea and Vomiting of Pregnancy (Gastroenterol Clin North Am. 2011 Jun)
Nausea and Vomiting of Pregnancy-What’s New? (Auton Neurosci. 2017 Jan)
Morning Sickness: Nausea and Vomiting of Pregnancy (American College of Obstetricians and Gynecologists)
Nausea and Vomiting of Pregnancy: Committee Opinion 189; January 2018 (American College of Obstetricians and Gynecologists)
Problems of the Digestive System (American College of Obstetricians and Gynecologists)
Acute abdomen and abdominal pain in pregnancy (Royal College of Obstetricians and Gynaecologists)
Stomach Pain in Pregnancy (U.K. National Health Service)