Evidence-Based Reviews

‘Morning sickness’ in pregnancy loses psychogenic stigma

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Evidence refutes past beliefs, supports organic causes and psychological sequelae.


 

References

Nausea and vomiting in pregnancy (NVP) is a misunderstood disorder associated with stress, anxiety, and depression. Prejudice toward women is thought to have guided the historical psychoanalytic concept of NVP as psychogenic, but this view is being replaced by newer biologic theories.

This article examines the evidence for psychological and organic causes of NVP to inform psychiatrists treating pregnant patients. We review guidelines for pharmacologic treatment of NVP and discuss potentially useful psychotherapies and alternative approaches.

Definitive cause unknown

“Morning sickness” affects 50% to 80% of pregnant women, occurring so commonly that NVP is often considered normal.1,2 Approximately 0.5% to 2% of women experience the most severe NVP—hyperemesis gravidarum (HG)3—characterized by intractable vomiting, weight loss, and electrolyte imbalance that can lead to hospitalization.

Without modern supportive care, HG can be lethal; although Charlotte Brontë’s death certificate states she died of “phthisis” (tuberculosis), the author of Jane Eyre is popularly believed to have succumbed to HG.4,5

The search for effective NVP treatments has been disappointing, partly because no cause has been identified. After other conditions that may lead to nausea and vomiting are ruled out (Table 1), NVP medical management is supportive. Correcting dehydration and encouraging dietary and lifestyle changes (Table 2)6 are important adjuncts to step-wise pharmacologic treatment recommended by the American College of Obstetrics and Gynecology (Algorithm).7

Algorithm Pharmacologic treatment of nausea and vomiting in pregnancy*


Source: Adapted and reprinted with permission from Canadian Family Physician. Levichek Z, Atanackovic G, Oepkes D, et al. Nausea and vomiting of pregnancy. Evidence-based treatment algorithm. Can Fam Physician 2002;48:267-77Table 1

Medical causes of nausea and vomiting in pregnancy

Possible causeHow to rule it out
AppendicitisHistory; do physical, order imaging
HepatitisJaundice; order liver function tests, antibody studies, imaging
PancreatitisHistory of alcohol use, abdominal pain; check amylase and lipase level
Gastrointestinal obstructionHistory of surgeries; order imaging
Peptic ulcer diseaseHistory; order upper GI series/endoscopy
Thyroid diseaseThyroid function tests
Urinary tract infectionUrinalysis, culture-sensitivity
Trophoblastic diseaseCheck hCG,* order ultrasound
* Elevated human chorionic gonadotropin (hCG) has shown evidence of an association with NVP20

Table 2

Advice for patients: Strategies to manage NVP

Correct dehydration
Drink small amount of fluids frequently
Dietary changes
Eat frequent, small meals
Avoid high-fat foods
Snack before getting out of bed and before going to sleep
Don’t force yourself to eat
Use candy and salty snacks to combat nausea
Avoid strong odors and scents; try cold foods, which may have less odor than hot foods
Take advantage of good days or good hours of the day for eating
Lifestyle changes
Get out of bed slowly
Lie down when nauseated
Avoid stressful situations
NVP: nausea and vomiting in pregnancy
Source: Reference 6

Prejudice vs evidence

Psychological factors. Historically, psychological factors have been blamed for NVP, but support comes from a few poorly designed studies or case reports.3,4

Psychoanalytically, pregnancy and childbirth are significant events in a woman’s life and a rich environment for conflict that could lead to physical expression of symptoms. Freud believed pregnancy and childbirth involve the unconscious substitution of the penis with the child.8 Later writers viewed motherhood as woman’s most powerful wish and the primary organizer of her sexual drive and personality.8

NVP has been considered a conversion or somatization disorder in which symptoms are a “hysterical” expression of unconscious conflict. A psychoanalytic view contends that women who experience NVP are ambivalent about the pregnancy and seek to reject it.1,9 Vomiting, in this view, represents an oral abortion attempt.10 Others claim NVP is a rejection of femininity3 or that symptoms in women with overly attached maternal relationships mask unconscious aggressive feelings toward their mothers.11

Robertson11 proposed an association between NVP and a woman’s view of sexual experiences and her ability to achieve orgasm. He interviewed 100 women and found that 40 of 57 with NVP had “disturbed sexual functioning” or were “frigid” (defined as experiencing coitus as undesirable and unaccompanied by orgasm).

Higgins12 in 1887 proposed that the cause of NVP “is sexual intercourse, the husband too eager for it and the wife too adverse.” Additionally, NVP and HG have been associated with infantile, childish, immature, and hysterical personalities.12-14

Psychiatric comorbidities. Attempts have been made to associate NVP with other psychiatric disorders such as depression, bipolar disorder, schizophrenia, and anxiety disorders, including posttraumatic stress disorder (PTSD). No definitive association has been found between NVP and depressive illness, bipolar disorder, or schizophrenia15 or the use of antidepressants before or during early pregnancy.16 Studies reporting an association with depression have not established a cause-effect relationship.17

Seng18 reported increased NVP risk in women with PTSD. High levels of stress, anxiety, and depression found in women with NVP are thought to result from—rather than cause—NVP’s physical symptoms, however.3,19,20

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