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In a pregnant woman, hyperemesis gravidarum has to be distinguished from self-induced vomiting.
A woman of 21 was admitted through the accident and emergency department with severe nausea and vomiting in the eighth week of pregnancy. She was ketotic, with muscle wasting and biochemical sequelae of vomiting. Hyperemesis gravidarum was diagnosed and she was treated with intravenous fluids, antiemetics and thiamine supplements. She was also started on prophylactic anticoagulants. A singleton pregnancy was confirmed on ultrasound scan.
After six weeks in hospital she was discharged, only to be readmitted at 18 weeks with worsening symptoms. Her body mass index at this point was 15 and she was severely undernourished. Total parenteral nutrition was initiated via a right subclavian central line and was continued for seven days. During this time she underwent oesophagogastro-duodenoscopy and was found to have reflux oesophagitis. An abdominal ultrasound showed no abnormality. On questioning, she said she had not dieted before the pregnancy and had never been overweight. There was no previous history of vomiting or eating disorder. She had come to the UK from southern Europe 2 years earlier and spoke little English; there was good family support.
During one of her long inpatient stays, she was observed trying to self-induce vomiting. She agreed to be assessed by a psychiatrist, to whom she admitted making herself sick because she felt there was a lump stuck in the back of her throat. Feelings of anxiety and depression were also expressed, together with concerns about the health of her baby. Fluoxetine 20 mg once daily was prescribed for mixed depression and anxiety. Her symptoms improved although she had to be readmitted at twenty-four and twenty-eight weeks with vomiting. During a remission at thirty-two weeks the fluoxetine was stopped but the sensation of a lump in the throat returned and it had to be restarted. Growth scans of the fetus showed the abdominal circumference to be on the 5th centile throughout the pregnancy. Labour was induced at thirty-seven weeks' gestation and a Ventouse delivery was required for fetal distress. She had a healthy girl weighing 2.7 kg. She was discharged on fluoxetine, with close surveillance from the perinatal mental health team; postnatal depression did not develop.
The importance of recognizing psychiatric disorders in pregnancy has been highlighted in the Confidential Enquiry into Maternal Deaths: 12% of all direct, indirect and late indirect maternal deaths resulted from a psychiatric disorder.1 The permanent sensation of a lump in the throat for which no organic cause can be found is known as globus hystericus. This is believed to be a conversion disorder, whereby psychological anxieties are transformed into physical symptoms. Pregnancy is a period during which women are highly susceptible to conversion disorders.
Very few patients with globus display hysterical personalities and as many as 60% suffer from depression and anxiety.2 Our patient had a primary anxiety disorder which gave rise to the symptom of globus hystericus. She tried to alleviate this symptom by self-inducing vomiting, which caused nutritional deficiency severe enough to require total parenteral nutrition. Self-induced vomiting on this scale would normally alert the clinician to an eating disorder but no evidence of this could be identified in our patient. An important point in diagnosis is that patients with hyperemesis gravidarum usually make every effort to stop the vomiting.
For some women pregnancy is an anxious time, and anxiety predisposes to somatic complaints.3 Language and cultural differences can worsen matters, with poor attendance at antenatal visits and a feeling of isolation and fear. In the present case, inability to communicate without an interpreter may well have exacerbated the symptoms.