|Mild hyperemesis gravidarum (no metabolic derangement)|
|Classification and external resources|
Morning sickness, also called nausea gravidarum, nausea, vomiting of pregnancy (emesis gravidarum or NVP), or pregnancy sickness is a pregnancy discomfort that affects more than half of all pregnant women. Sometimes symptoms are present in the early hours of the morning and reduce as the day progresses. However, in spite of its common name, it can occur at any time of the day. For most women it may stop around the 12th week of pregnancy.
Related to increased estrogen levels, a similar form of nausea is also seen in some women who use hormonal contraception or hormone replacement therapy. The nausea can be mild or induce actual vomiting, however, not severe enough to cause metabolic derangement. In more severe cases, vomiting may cause dehydration, weight loss, alkalosis and hypokalemia. This condition is known as hyperemesis gravidarum and occurs in about 1% of all pregnancies. Nausea and vomiting can be one of the first signs of pregnancy and usually begin around the 6th week of pregnancy (counting gestational age from 14 days before conception).
Proximate causes of pregnancy sickness include:
- An increase in salivation during the first trimester, that is often bitter tasting (Ptyalism), is then ingested during the mothers sleep. This can upset the stomach enough to cause the morning nausea.
- An increase in the circulating level of the hormone estrogen. However, there is no consistent evidence of differences in estrogen levels and levels of bilirubin between women that experience sickness and those that do not.
- Low blood sugar (hypoglycemia) due to the placenta's draining energy from the mother, though studies have not confirmed this except for in Type I diabetic expectant mothers.
- An increase in progesterone relaxes the muscles in the uterus, which prevents early childbirth, but may also relax the stomach and intestines, leading to excess stomach acids and gastroesophageal reflux disease.
- An increase in human chorionic gonadotropin. It is probably not the human chorionic gonadotropin itself that causes the nausea. More likely, it is the human chorionic gonadotropin stimulating the maternal ovaries to secrete estrogen, which in turn causes the nausea.
- An increase in sensitivity to odors, which overstimulates normal nausea triggers.
- An increase in bilirubin levels due to increased liver enzymes.
Note that Gastroesophageal reflux disease can also be caused by pregnancy, and may result in nausea and vomiting.
Morning sickness as a defense mechanism
Morning sickness is understood as an evolved trait that protects the fetus against toxins ingested by the mother.  Many plants contain chemical toxins that serve as a deterrent to being eaten. Adult humans, like other animals, have defenses against plant toxins, including extensive arrays of detoxification enzymes manufactured by the liver and the surface tissues of various other organs. In the fetus, these defenses are not yet fully developed, and even small doses of plant toxins that have negligible effects on the adult can be harmful or lethal to the embryo. Pregnancy sickness causes women to experience nausea when exposed to the smell or taste of foods that are likely to contain toxins injurious to the fetus, even though they may be harmless to her.
- Morning sickness is very common among pregnant women, which argues in favor of its being a functional adaptation and against the idea that it is a pathology.
- Fetal vulnerability to toxins peaks at around 3 months, which is also the time of peak susceptibility to morning sickness.
- There is a good correlation between toxin concentrations in foods, and the tastes and odors that cause revulsion.
In addition to protecting the fetus, morning sickness may also protect the mother. A pregnant woman's immune system is suppressed during pregnancy, presumably to reduce the chances of rejecting tissues of her own offspring. Because of this, animal products containing parasites and harmful bacteria can be especially dangerous to pregnant women. There is evidence that morning sickness is often triggered by animal products including meat and fish.
If morning sickness is a defense mechanism against the ingestion of toxins, the prescribing of anti-nausea medication to pregnant women may have the undesired side effect of causing birth defects or miscarriages by encouraging harmful dietary choices. On the other hand, many domestic vegetables have been purposely bred to have lower levels of toxins than in the distant past, and so the level of threat to the embryo may not be as high as it was when the defense mechanism first evolved.
There is no evidence to demonstrate the effectiveness of home treatments and a lack of high quality evidence generally regarding the treatment of morning sickness.
A number of antiemetics are effective and safe in pregnancy including: pyridoxine/doxylamine, antihistamines (such as diphenhydramine), and phenothiazines (such as promethazine). With respect to effectiveness it is unknown if one is superior to another. In the United States and Canada, the doxylamine-pyridoxine combination (as Diclegis in US and Diclectin in Canada) is the only approved Pregnancy Category "A" prescription treatment for nausea and vomiting of pregnancy.
Ondansetron may be beneficial however there are some concerns regarding an association with cleft palate, and there is little high quality data. Metoclopramide is also used and relatively well tolerated. Evidence for the use of corticosteroids is weak.
Thalidomide was originally developed and prescribed as a cure for morning sickness in West Germany, but its use was discontinued when it was found to cause birth defects. The United States Food and Drug Administration never approved thalidomide for use as a cure for morning sickness.
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