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Nausea and vomiting in pregnancy is extremely common. Mual dan muntah dalam kehamilan sangat umum. Hyperemesis gravidarum (HEG) is the most severe form of nausea and vomiting in pregnancy. Hiperemesis gravidarum (HEG) adalah bentuk yang paling parah mual dan muntah dalam kehamilan. A continuous spectrum of the severity of nausea and vomiting ranges from the nausea and vomiting that occurs in most pregnancies to the severe disorder of hyperemesis gravidarum. Sebuah spektrum kontinu dari keparahan mual dan muntah berkisar dari mual dan muntah yang terjadi pada kehamilan yang paling terhadap gangguan parah hiperemesis gravidarum.

Studies estimate that nausea and vomiting occurs in 50-90% of pregnancies. Studi memperkirakan bahwa mual dan muntah terjadi pada 50-90% dari kehamilan. The nausea and vomiting associated with pregnancy usually begins by 9-10 weeks of gestation, peaks at 11-13 weeks, and resolves in most cases by 12-14 weeks. Mual dan muntah berhubungan dengan kehamilan biasanya dimulai dengan 90-10 minggu kehamilan, puncak di 11-13 minggu, dan menyelesaikan dalam banyak kasus oleh 12-14 minggu. In 1-10% of pregnancies, symptoms may continue beyond 20-22 weeks. 1 , 2 Dalam 1-10% dari kehamilan, gejala dapat berlanjut setelah 20-22 minggu. 1 , 2

Normal nausea and vomiting may be an evolutionary protective mechanism—it may protect the pregnant woman and her embryo from harmful substances in food, such as pathogenic microorganisms in meat products and toxins in plants, with the effect being maximal during embryogenesis (the most vulnerable period of pregnancy). Normal mual dan muntah dapat menjadi pelindung mekanisme evolusi-mungkin melindungi wanita hamil dan embrio-nya dari zat-zat berbahaya dalam makanan, seperti mikroorganisme patogen pada produk daging dan racun dalam tanaman, dengan efek yang maksimal selama embriogenesis (masa paling rentan kehamilan). This is supported by studies showing that women who had nausea and vomiting were less likely to have miscarriages and stillbirth. 3 , 4 Hal ini didukung oleh penelitian yang menunjukkan bahwa wanita yang mual dan muntah kurang mungkin mengalami keguguran dan kelahiran mati. 3 , 4

Hyperemesis gravidarum is characterized by persistent nausea and vomiting associated with ketosis and weight loss (>5% of prepregnancy weight). Hiperemesis gravidarum ditandai dengan mual dan muntah terus-menerus berhubungan dengan ketosis dan penurunan berat badan (> 5% dari berat sebelum hamil). Hyperemesis gravidarum may cause volume depletion, electrolytes and acid-base imbalances, nutritional deficiencies, and even death. Hiperemesis gravidarum dapat menyebabkan deplesi volume, ketidakseimbangan elektrolit dan asam-basa, kekurangan gizi, dan bahkan kematian. Severe hyperemesis requiring hospital admission occurs in 0.3-2% of pregnancies. 5 Hiperemesis berat yang membutuhkan masuk ke rumah sakit terjadi pada 0,3-2% kehamilan. 5
Pathophysiology Patofisiologi

The physiologic basis of hyperemesis gravidarum is controversial. Dasar fisiologis dari hiperemesis gravidarum adalah kontroversial. Hyperemesis gravidarum appears to occur as a complex interaction of biological, psychological, and sociocultural factors. Hiperemesis gravidarum tampaknya terjadi sebagai interaksi kompleks faktor biologis, psikologis, dan sosial budaya. The following theories have been proposed: Teori-teori berikut telah diusulkan:

Hormonal changes Perubahan hormonal

Women with hyperemesis gravidarum often have high hCG levels that cause transient hyperthyroidism. Wanita dengan hiperemesis gravidarum sering memiliki kadar hCG yang tinggi yang menyebabkan hipertiroidisme sementara. hCG can physiologically stimulate the thyroid gland thyroid-stimulating hormone (TSH) receptor. fisiologis hCG dapat merangsang hormon kelenjar thyroid-stimulating tiroid (TSH) reseptor. hCG levels peak in the first trimester. hCG level puncak pada trimester pertama. Some women with hyperemesis gravidarum appear to have clinical hyperthyroidism. Beberapa wanita dengan hiperemesis gravidarum tampak telah hipertiroidisme klinis. However, in a larger portion (50-70%), TSH is transiently suppressed and the free thyroxine (T4) index is elevated (40-73%) with no clinical signs of hyperthyroidism, circulating thyroid antibodies, or enlargement of the thyroid. Namun, dalam porsi yang lebih besar (50-70%), TSH adalah transiently ditekan dan tiroksin bebas (T4) indeks yang ditinggikan (40-73%) dan tidak ada tanda klinis hipertiroidisme, beredar antibodi tiroid, atau pembesaran tiroid. In transient hyperthyroidism of hyperemesis gravidarum, thyroid function normalizes by the middle of the second trimester without antithyroid treatment. Dalam hipertiroidisme transien gravidarum hiperemesis, fungsi tiroid menormalisir oleh tengah trimester kedua tanpa pengobatan antitiroid.Clinically overt hyperthyroidism and thyroid antibodies are usually absent. 4 , 6 , 7 , 5 Klinis jelas dan antibodi tiroid hipertiroidisme biasanya tidak ada. 4 , 6 , 7 , 5

A report on a unique family with recurrent gestational hyperthyroidism associated with hyperemesis gravidarum showed a mutation in the extracellular domain of the TSH receptor that made it responsive to normal levels of hCG. Sebuah laporan pada sebuah keluarga yang unik dengan hipertiroidisme kehamilan berulang yang terkait dengan hiperemesis gravidarum menunjukkan mutasi dalam domain ekstraselular dari reseptor TSH yang membuat responsif ke tingkat normal hCG. Thus, cases of hyperemesis gravidarum with a normal hCG may be due to varying hCG isotypes. 8 , 9 Dengan demikian, kasus hiperemesis gravidarum dengan hCG normal dapat disebabkan oleh berbagai isotypes hCG. 8 , 9

A positive correlation between the serum hCG elevation level and free T4 levels has been found, and the severity of nausea appears to be related to the degree of thyroid stimulation. Sebuah korelasi positif antara tingkat serum hCG elevasi dan tingkat T4 bebas telah ditemukan, dan beratnya mual tampaknya terkait dengan tingkat stimulasi tiroid. hCG may not be independently involved in the etiology of hyperemesis gravidarum but may be indirectly involved by its ability to stimulate the thyroid. hCG mungkin tidak independen terlibat dalam penyebab hiperemesis gravidarum tetapi mungkin tidak langsung terlibat dengan kemampuannya untuk merangsang tiroid. For these patients, hCG levels were linked to increased levels of immunoglobulin M, complement, and lymphocytes. Untuk pasien ini, tingkat hCG terkait dengan tingkat peningkatan M imunoglobulin, komplemen, dan limfosit. Thus, an immune process may be responsible for increased circulating hCG or isoforms of hCG with a higher activity for the thyroid. Dengan demikian, proses kekebalan mungkin bertanggung jawab untuk hCG yang beredar meningkat atau isoform hCG dengan aktivitas yang lebih tinggi untuk tiroid. Critics of this theory note that (1) nausea and vomiting are not usual symptoms of hyperthyroidism, (2) signs of biochemical hyperthyroidism are not universal in cases of hyperemesis gravidarum, and (3) some studies have failed to correlate the severity of symptoms with biochemical abnormalities. 10 , 11 , 12 Kritik ini catatan teori bahwa (1) mual dan muntah adalah gejala tidak biasa hipertiroidisme, (2) tanda-tanda hipertiroidisme biokimia tidak universal dalam kasus hiperemesis gravidarum, dan (3) beberapa studi telah gagal untuk mengkorelasikan tingkat keparahan gejala dengan kelainan biokimia. 10 , 11 , 12

Some studies link high estradiol levels to the severity of nausea and vomiting in patients who are pregnant, while others find no correlation between estrogen levels and the severity of nausea and vomiting in pregnant women. Beberapa studi tingkat link estradiol tinggi untuk tingkat keparahan mual dan muntah pada pasien yang sedang hamil, sementara yang lain tidak menemukan korelasi antara tingkat estrogen dan beratnya mual dan muntah pada wanita hamil. Previous intolerance to oral contraceptives is associated with nausea and vomiting in pregnancy. intoleransi Sebelumnya kontrasepsi oral berhubungan dengan mual dan muntah dalam kehamilan. Progesterone also peaks in the first trimester and decreases smooth muscle activity; however, studies have failed to show any connection between progesterone levels and symptoms of nausea and vomiting in pregnant women. Progesteron juga puncak pada trimester pertama dan penurunan aktivitas otot polos, namun, studi telah gagal untuk menunjukkan hubungan antara tingkat progesteron dan gejala mual dan muntah pada wanita hamil. Lagiou et al studied prospectively 209 women with nausea and vomiting who showed that estradiol levels were positively correlated while prolactin levels were inversely associated with nausea and vomiting in pregnancy and no correlation existed with estriol, progesterone, or sex-hormone binding globulin. 13 Lagiou et al mempelajari prospektif 209 wanita dengan mual dan muntah yang menunjukkan bahwa kadar estradiol yang berkorelasi positif sementara kadar prolaktin adalah terbalik terkait dengan mual dan muntah dalam kehamilan dan tidak ada korelasi dengan progesteron, atau mengikat hormon seks-globulin, estriol. 13

Gastrointestinal dysfunction Disfungsi gastrointestinal

The stomach pacemaker causes rhythmic peristaltic contractions of the stomach. Alat pacu jantung menyebabkan perut itu kontraksi peristaltik ritmis lambung. Abnormal myoelectric activity may cause a variety of gastric dysrhythmias, including tachygastrias and bradygastrias. Aktivitas Abnormal myoelectric dapat menyebabkan berbagai disritmia lambung, termasuk tachygastrias dan bradygastrias. Gastric dysrhythmias have been associated with morning sickness. disritmia lambung telah dikaitkan dengan morning sickness. The presence of dysrhythmias was associated with nausea while normal myoelectrical activity was present in the absence of nausea. Kehadiran disritmia dikaitkan dengan mual sementara aktivitas myoelectrical normal hadir dalam ketiadaan mual. Mechanisms that cause gastric dysrhythmias include elevated estrogen or progesterone levels, thyroid disorders, abnormalities in vagal and sympathetic tone, and vasopressin secretion in response to intravascular volume perturbation. Mekanisme yang menyebabkan disritmia lambung termasuk estrogen tinggi atau tingkat progesteron, gangguan tiroid, kelainan dalam nada vagal dan simpatik, dan sekresi vasopresin dalam menanggapi perturbasi volume intravascular. Many of these factors are present in early pregnancy. Banyak faktor-faktor ini hadir pada awal kehamilan.These pathophysiologic factors are hypothesized to be more severe or the gastrointestinal tract more sensitive to the neural/humoral changes in those who develop hyperemesis gravidarum. 14 Faktor-faktor pathophysiologic yang diduga lebih parah atau saluran pencernaan lebih sensitif terhadap perubahan saraf humoral / pada mereka yang mengembangkan gravidarum hiperemesis. 14

Hepatic dysfunction Disfungsi hepatik

Liver disease, usually consisting of mild serum transaminase elevation, occurs in almost 50% of patients with hyperemesis gravidarum. Penyakit hati, biasanya terdiri dari elevasi serum transaminase ringan, terjadi pada hampir 50% dari pasien dengan hiperemesis gravidarum.Impairment of mitochondrial fatty acid oxidation (FAO) has been hypothesized to play a role in the pathogenesis of maternal liver disease associated with hyperemesis gravidarum. Penurunan asam lemak oksidasi mitokondria (FAO) telah diduga berperan dalam patogenesis penyakit hati ibu terkait dengan hiperemesis gravidarum. It has been suggested that women heterozygous for FAO defects develop hyperemesis gravidarum associated with liver disease while carrying fetuses with FAO defects due to accumulation of fatty acids in the placenta and subsequent generation of reactive oxygen species. Ia telah mengemukakan bahwa wanita heterozigot untuk kerusakan FAO mengembangkan gravidarum hiperemesis terkait dengan penyakit hati sambil membawa janin dengan cacat FAO akibat akumulasi asam lemak dalam plasenta dan generasi berikutnya spesies oksigen reaktif. Alternatively, it is possible that starvation leading to peripheral lipolysis and increased load of fatty acids in maternal-fetal circulation, combined with reduced capacity of the mitochondria to oxidize fatty acids in mothers heterozygous for FAO defects, can also cause hyperemesis gravidarum and liver injury while carrying nonaffected fetuses. Atau, mungkin yang kelaparan menuju perifer dan peningkatan lipolisis load asam lemak di sirkulasi ibu-janin, dikombinasikan dengan pengurangan kapasitas mitokondria untuk mengoksidasi asam lemak pada ibu heterozigot bagi FAO kerusakan, juga dapat menyebabkan gravidarum hiperemesis dan luka hati saat membawa janin nonaffected.

Lipid alterations Perubahan lipid

Jarnfelt-Samsioe et al found higher levels of triglycerides, total cholesterol, and phospholipids in women with hyperemesis gravidarum compared with matched, nonvomiting, pregnant and nonpregnant controls. Jarnfelt-Samsioe et al menemukan tingkat yang lebih tinggi trigliserida, total kolesterol, dan fosfolipid pada wanita dengan hiperemesis gravidarum dibandingkan dengan yang cocok, nonvomiting, kontrol hamil dan tidak hamil. This may be related to the abnormalities in hepatic function in pregnant women. Hal ini mungkin terkait dengan kelainan fungsi hati pada wanita hamil. However, Ustun et al found decreased levels of total cholesterol, LDL cholesterol, apoA and apoB in women with hyperemesis gravidarum compared with controls. 15 , 16 Namun, dkk Ustun ditemukan penurunan tingkat kolesterol total, kolesterol LDL, apoA dan apoB pada wanita dengan hiperemesis gravidarum dibandingkan dengan kontrol. 15 , 16

Infection Infeksi

Helicobacter pylori is a bacterium found in the stomach that may aggravate nausea and vomiting in pregnancy. Helicobacter pylori adalah bakteri yang ditemukan di dalam perut yang dapat memperburuk mual dan muntah dalam kehamilan. Studies have found conflicting evidence of the role of H pylori in hyperemesis gravidarum. Penelitian telah menemukan bukti yang bertentangan tentang peran H pylori di gravidarum hiperemesis. Recent studies in the United States have not shown association with hyperemesis gravidarum. Penelitian terbaru di Amerika Serikat tidak menunjukkan hubungan dengan hiperemesis gravidarum. However, persistent nausea and vomiting beyond the second trimester may be due to an active peptic ulcer caused by H pylori infection. 17 , 18 Namun, mual dan muntah persisten luar trimester kedua mungkin disebabkan oleh ulkus peptikum aktif yang disebabkan oleh infeksi H pylori. 17 , 18

Vestibular and olfaction Vestibular dan Penciuman

Hyperacuity of the olfactory system may be a contributing factor to nausea and vomiting during pregnancy. Hyperacuity sistem penciuman dapat menjadi faktor untuk mual dan muntah selama kehamilan. Many pregnant women report the smell of cooking food, particularly meats, as triggers to nausea. Banyak ibu hamil laporan bau memasak makanan, khususnya daging, sebagai pemicu untuk mual. Striking similarities between hyperemesis gravidarum and motion sickness suggest that unmasking of subclinical vestibular disorders may account for some cases of hyperemesis gravidarum. 19 , 20 Kesamaan mencolok antara gravidarum hiperemesis dan mabuk menunjukkan bahwa gangguan vestibular unmasking subklinis mungkin account untuk beberapa kasus hiperemesis gravidarum. 19 , 20

Biochemical research Penelitian biokimia

Hyperemesis gravidarum is associated with overactivation of sympathetic nerves and enhanced production of tumor necrosis factor (TNF)-alpha. 21 Increased adenosine levels have also been noted; since adenosine is an established suppressor of excessive sympathetic nerves activation and cytokine production, the increase in plasma adenosine in hyperemesis gravidarum may be modulatory. 22 Trophoblast-derived cytokines have been reported to induce secretion of hCG. Hiperemesis gravidarum dikaitkan dengan overactivation saraf simpatik dan produksi yang disempurnakan tumor nekrosis faktor (TNF)-alpha. 21 Peningkatan tingkat adenosin juga telah mencatat; sejak adenosin adalah penekan mapan aktivasi saraf simpatik yang berlebihan dan produksi sitokin, peningkatan plasma adenosin dalam hiperemesis gravidarum dapat modulatory. 22 -berasal sitokin trofoblas telah dilaporkan untuk menginduksi sekresi hCG.

Immunoglobulins C3 and C4 and lymphocyte counts are significantly higher in women with hyperemesis gravidarum. Imunoglobulin menghitung C3 dan C4 dan limfosit secara signifikan lebih tinggi pada wanita dengan hiperemesis gravidarum. T-helper 1/T-helper 2 balance is decreased in women with hyperemesis gravidarum, which results in increased humoral immunity. T-helper 2 1/T-helper saldo menurun pada wanita dengan hiperemesis gravidarum, yang menghasilkan kekebalan humoral meningkat. Increased fetal DNA has been found in the maternal plasma of women with hyperemesis gravidarum, and the increased DNA is speculated to be derived from trophoblasts that have been destroyed by the hyperactive maternal immune system. Peningkatan DNA janin telah ditemukan dalam plasma ibu dari wanita dengan hiperemesis gravidarum, dan DNA yang meningkat berspekulasi akan berasal dari trophoblasts yang telah dihancurkan oleh sistem kekebalan tubuh ibu hiperaktif. Thus, hyperemesis gravidarum may be mediated by immunologic aberrations in pregnancy. 23 , 24 , 25 , 26 Dengan demikian, hiperemesis gravidarum ini dimediasi oleh penyimpangan kekebalan pada kehamilan. 23 , 24 , 25 , 26

Psychological issues Masalah psikologis

Physiological changes associated with pregnancy interact with each woman's psychologic state and cultural values. perubahan fisiologis yang berhubungan dengan kehamilan berinteraksi dengan keadaan psikologis setiap wanita dan nilai-nilai budaya. Psychologic responses may interact with and exacerbate the physiology of nausea and vomiting during pregnancy. tanggapan psikologi dapat berinteraksi dengan dan memperburuk fisiologi mual dan muntah selama kehamilan.Nonetheless, hyperemesis gravidarum is typically the cause of, as opposed to the result of, psychologic stress. Meskipun demikian, hiperemesis gravidarum biasanya penyebab, dibandingkan dengan hasil, stres psikologis. In very unusual instances, cases of hyperemesis gravidarum could represent psychiatric illness, including conversion or somatization disorder or major depression . 27 , 28 , 29 Dalam kasus yang tidak biasa, kasus hiperemesis gravidarum dapat mewakili penyakit jiwa, termasuk konversi atau somatisasi gangguan atau utama depresi . 27 , 28 , 29
Frequency Frekuensi
United States Amerika Serikat

Of all pregnancies, 0.3-2% are affected by hyperemesis gravidarum (approximately 5 per 1000 pregnancies). Dari semua kehamilan, 0,3-2% dipengaruhi oleh hiperemesis gravidarum (sekitar 5 per 1000 kehamilan).
International Internasional

Hyperemesis gravidarum appears to be more common in westernized industrialized societies and urban areas than rural areas. Hiperemesis gravidarum tampaknya lebih umum dalam masyarakat industri kebarat-baratan dan daerah perkotaan dari daerah pedesaan.
Mortality/Morbidity Mortalitas / Morbiditas

Hyperemesis gravidarum was a significant cause of maternal death before 1940. In Great Britain, mortality decreased from 159 deaths per million births from 1931-1940 to 3 deaths per million births from 1951-1960. Hiperemesis gravidarum adalah penyebab besar kematian ibu sebelum 1940. Di Great Britain, kematian menurun dari 159 kematian per juta kelahiran 1.931-1.940 sampai 3 kematian per juta kelahiran 1.951-1.960. Charlotte Brontë is thought to have died of hyperemesis gravidarum in 1855. Charlotte Brontë diperkirakan telah meninggal karena hiperemesis gravidarum pada tahun 1855. In the United States, 7 deaths from hyperemesis gravidarum were reported in the 1930s. Di Amerika Serikat, 7 kematian dari hiperemesis gravidarum dilaporkan pada 1930-an. Today, although hyperemesis gravidarum is still associated with significant morbidity, it is still a rare cause of maternal mortality. Hari ini, meskipun gravidarum hiperemesis masih terkait dengan morbiditas yang signifikan, masih langka penyebab kematian ibu.

* Many hours of productive work are lost because of nausea and vomiting during pregnancy. Banyak jam kerja produktif yang hilang karena mual dan muntah selama kehamilan. Nearly 50% of employed women believe that their work is affected, and up to 25% require time off from work. Hampir 50% wanita bekerja percaya bahwa pekerjaan mereka terganggu, dan sampai dengan 25% membutuhkan waktu off dari kerja.
* Hyperemesis gravidarum is a debilitating illness that can cause severe suffering, which profoundly affects both patients and their families. Hiperemesis gravidarum adalah penyakit melemahkan yang dapat menyebabkan penderitaan yang parah, yang sangat mempengaruhi baik pasien dan keluarga mereka. In about half of the women there is an adverse effect on spousal relationships, and 55% have feelings of depression. Di sekitar setengah dari wanita ada efek yang merugikan pada hubungan suami-istri, dan 55% memiliki perasaan depresi. In one study of 140 women with hyperemesis gravidarum, 27% required multiple hospitalizations. Dalam salah satu penelitian terhadap 140 wanita dengan hiperemesis gravidarum, 27% diperlukan beberapa rumah sakit. The financial burden of hyperemesis gravidarum on the American health system has been estimated as approximately $130 million dollars per year, excluding physician fees. Beban keuangan gravidarum hiperemesis pada sistem kesehatan Amerika telah diperkirakan sekitar $ 130.000.000 dolar per tahun, tidak termasuk biaya dokter.
* Women with hyperemesis gravidarum who have a low pregnancy weight gain (<15.4> Wanita dengan hiperemesis gravidarum yang memiliki berat badan kehamilan rendah (<£ 15,4 atau 7 kg) telah meningkatkan risiko untuk memberikan neonatus berat lahir rendah, memberikan neonatus yang kecil untuk usia kehamilan, kelahiran prematur, dan skor Apgar 5 menit kurang daripada 7.

Race Ras

No clear racial predominance is noted for hyperemesis gravidarum. Tidak ada dominasi ras jelas dicatat untuk gravidarum hiperemesis.

* Hyperemesis gravidarum is less common in American Indian and Eskimo populations. Hiperemesis gravidarum kurang umum dalam American Indian dan Eskimo populasi.
* Hyperemesis gravidarum is less common in African and some Asian populations (but not industrialized Japan). Hiperemesis gravidarum kurang umum di Afrika dan beberapa populasi Asia (tetapi tidak industri Jepang).

Sex Seks

Hyperemesis gravidarum affects females. Hiperemesis gravidarum mempengaruhi perempuan.
Age Usia

The risk of hyperemesis gravidarum appears to decrease with advanced maternal age. Risiko gravidarum hiperemesis muncul menurun, dengan ibu usia lanjut.
Clinical Klinis
History Sejarah

* The defining symptoms of hyperemesis gravidarum are gastrointestinal in nature and include nausea and vomiting. Gejala mendefinisikan hiperemesis gravidarum adalah gastrointestinal dalam alam dan mencakup mual dan muntah.
* Other common symptoms include ptyalism (excessive salivation), fatigue, weakness, and dizziness. gejala umum lainnya termasuk ptyalism (air liur yang berlebihan), kelelahan, kelemahan, dan pusing.
* Patients may experience the following: Pasien mungkin akan mengalami hal berikut:
o Sleep disturbance Gangguan tidur
o Hyperolfaction Hyperolfaction
o Dysgeusia Dysgeusia
o Decreased gustatory discernment Penurunan ketajaman gustatory
o Depression Depresi
o Anxiety Kegelisahan
o Irritability Sifat lekas marah
o Mood changes Perubahan mood
o Decreased concentration Penurunan konsentrasi
* When obtaining history from the patient, discuss present symptoms. Ketika sejarah memperoleh dari pasien, membahas gejala ini. Obtain information pertaining to the timing, onset, severity, pattern, and alleviating and exacerbating factors (eg, relationship to meals, medications, prenatal vitamins, stress, other triggers). Dapatkan informasi mengenai waktu, onset, keparahan, pola, dan mengurangi dan memperburuk faktor (misalnya, hubungan dengan makanan, obat, vitamin prenatal, stres, lain pemicu).
* A thorough review of systems for any symptoms that might suggest other gastrointestinal, renal, endocrine, and central nervous system disorders is vital. Tinjauan menyeluruh sistem untuk gejala yang mungkin menunjukkan lain gastrointestinal, ginjal, endokrin, dan gangguan sistem saraf pusat sangat penting.
* Review past medical history, placing emphasis on past medical conditions, surgeries, medications, allergies, adverse drug reactions, family history, social history (including support system), employment, habits, and diet. Review riwayat medis masa lalu, menempatkan penekanan pada kondisi-kondisi medis masa lalu, operasi, obat, alergi, reaksi obat merugikan, sejarah keluarga, sejarah sosial (termasuk dukungan sistem), pekerjaan, kebiasaan, dan diet.
* Obtaining a thorough gynecologic history of symptoms, such as vaginal bleeding or spotting, past pregnancies, past use of oral contraceptives, and response to oral contraceptives used, is important. Mendapatkan sejarah ginekologi menyeluruh gejala, seperti pendarahan vagina atau spotting, kehamilan masa lalu, penggunaan kontrasepsi oral masa lalu, dan respons terhadap kontrasepsi oral yang digunakan, adalah penting.

Physical Fisik

* The physical examination is usually unremarkable in patients with hyperemesis gravidarum. Pemeriksaan fisik biasanya biasa-biasa saja pada pasien dengan hiperemesis gravidarum.
* The physical examination findings may be more helpful if the patient has unusual complaints suggestive of other disorders (eg, bleeding, abdominal pain). Temuan Pemeriksaan fisik mungkin lebih membantu jika pasien memiliki keluhan yang tidak biasa sugestif dari gangguan lain (misalnya, perdarahan, sakit perut).
* Pay attention to the vital signs, including standing and lying blood pressure and pulse, volume status (eg, mucous membrane condition, skin turgor, neck veins, mental status), general appearance (eg, nutrition, weight), thyroid examination findings, abdominal examination findings, cardiac examination findings, and neurologic examination findings. Perhatikan tanda-tanda vital, termasuk berdiri dan berbaring tekanan darah dan denyut nadi, status volume (misalnya, kondisi membran mukosa, turgor kulit, urat leher, status mental), penampilan umum (misalnya, nutrisi, berat), temuan pemeriksaan tiroid, perut temuan pemeriksaan, temuan pemeriksaan jantung, dan temuan pemeriksaan neurologis.

Causes Penyebab

In a review of 1,301 cases of hyperemesis gravidarum from Canada, Fell et al showed that medical complications of hyperthyroid disorders, psychiatric illness, previous molar disease, gastrointestinal disorders, pregestational diabetes, and asthma were significantly independent risk factors for hyperemesis gravidarum, whereas maternal smoking and maternal age older than 30 years decreased the risk. Dalam review 1.301 kasus hiperemesis gravidarum dari Kanada, Fell et al menunjukkan bahwa komplikasi medis dari gangguan hipertiroid, penyakit jiwa, penyakit molar sebelumnya, gangguan pencernaan, diabetes pregestational, dan asma secara signifikan faktor risiko independen untuk gravidarum hiperemesis, sedangkan ibu merokok dan usia ibu lebih tua dari 30 tahun mengalami penurunan risiko. Pregnancies with female fetuses and multiple fetuses were also at increased risk. 30 , 31 Kehamilan dengan janin janin perempuan dan juga meningkatkan risiko. 30 , 31

In some studies, women from low to middle socioeconomic class, women with lower levels of education, women with previous pregnancies with nausea and vomiting, women in their first pregnancy, and women with previous intolerance to oral contraceptives more commonly experience nausea and vomiting during pregnancy. Dalam beberapa penelitian, perempuan dari kelas sosial ekonomi rendah sampai menengah, perempuan dengan tingkat pendidikan yang lebih rendah, wanita dengan kehamilan sebelumnya dengan mual dan muntah, wanita dalam kehamilan pertama mereka, dan wanita dengan intoleransi sebelumnya untuk kontrasepsi oral lebih sering mengalami mual dan muntah selama kehamilan . Nausea and vomiting during pregnancy is also more common with multiple-gestation pregnancies. Mual dan muntah selama kehamilan juga lebih umum dengan beberapa kehamilan-kehamilan.

Other factors that have been proposed include ethnicity, occupational status, fetal anomalies, increased body weight, nausea and vomiting in a prior pregnancy, history of infertility, interpregnancy interval, corpus luteum in right ovary, and prior intolerance to oral contraceptives. Faktor lain yang telah diajukan termasuk etnis, status pekerjaan, anomali janin, peningkatan berat badan, mual dan muntah pada kehamilan sebelumnya, riwayat infertilitas, interval interpregnancy, korpus luteum di ovarium kanan, dan intoleransi sebelum kontrasepsi oral.

* Risk factors for hyperemesis gravidarum may include the following: Faktor risiko untuk gravidarum hiperemesis dapat mencakup sebagai berikut:
o Previous pregnancies with hyperemesis gravidarum Sebelumnya kehamilan dengan hiperemesis gravidarum
o Greater body weight Greater berat badan
o Multiple gestations Beberapa kehamilan
o Trophoblastic disease Penyakit trofoblas
o Nulliparity Nulliparity
* Cigarette smoking is associated with a decreased risk for hyperemesis gravidarum. Rokok merokok berhubungan dengan penurunan risiko untuk gravidarum hiperemesis.

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sumber: http://emedicine.medscape.com/article/254751-overview

Jumlah kematian akibat kanker global diperkirakan meningkat 45% 2007-2030 (7.900.000-11.500.000 kematian), sebagian dipengaruhi oleh peningkatan dan populasi global penuaan. The estimated rise takes into account expected slight declines in death rates for some cancers in high resource countries. Kenaikan memperhitungkan diperkirakan sedikit menurun diharapkan dalam angka kematian untuk beberapa kanker di negara-negara sumber daya tinggi. New cases of cancer in the same period are estimated to jump from 11.3 million in 2007 to 15.5 million in 2030. kasus baru kanker pada periode yang sama diperkirakan melompat dari 11,3 juta pada tahun 2007-2030 15.500.000 dalam.

Jumlah Penderita Kanker Payudara Di Dunia Menurut WHO tahun 2020

World Cancer Report provides clear evidence that action on smoking, diet and infections can prevent one third of cancers, another third can be cured

3 April 2003 | GENEVA -- Cancer rates could further increase by 50% to 15 million new cases in the year 2020, according to the World Cancer Report, the most comprehensive global examination of the disease to date. However, the report also provides clear evidence that healthy lifestyles and public health action by governments and health practitioners could stem this trend, and prevent as many as one third of cancers worldwide.

In the year 2000, malignant tumours were responsible for 12 per cent of the nearly 56 million deaths worldwide from all causes. In many countries, more than a quarter of deaths are attributable to cancer. In 2000, 5.3 million men and 4.7 million women developed a malignant tumour and altogether 6.2 million died from the disease. The report also reveals that cancer has emerged as a major public health problem in developing countries, matching its effect in industrialized nations.

“The World Cancer Report tells us that cancer rates are set to increase at an alarming rate globally. We can make a difference by taking action today. We have the opportunity to stem this increase. This report calls on Governments, health practitioners and the general public to take urgent action. Action now can prevent one third of cancers, cure another third, and provide good, palliative care to the remaining third who need it, "said Dr. Paul Kleihues, Director of the International Agency for Research on Cancer (IARC) and co-editor of the World Cancer Report.

The World Cancer Report is a concise manual describing the global burden, the causes of cancer, major types of malignancies, early detection and treatment. The 351-page global report is issued by IARC, which is part of the World Health Organization (WHO).

Dr Gro Harlem Brundtland, Director-General of WHO, states: “The report provides a basis for public health action and assists us in our goal to reduce the morbidity and mortality from cancer, and to improve the quality of life of cancer patients and their families, everywhere in the world,”

Examples of areas where action can make a difference to stemming the increase of cancer rates and preventing a third of cases are:

* Reduction of tobacco consumption. It remains the most important avoidable cancer risk. In the 20th century, approximately 100 million people died world-wide from tobacco-associated diseases
* A healthy lifestyle and diet can help. Frequent consumption of fruit and vegetables and physical activity can make a difference.
* Early detection through screening, particularly for cervical and breast cancers, allow for prevention and successful cure.

The predicted sharp increase in new cases – from 10 million new cases globally in 2000, to 15 million in 2020 - will mainly be due to steadily ageing populations in both developed and developing countries and also to current trends in smoking prevalence and the growing adoption of unhealthy lifestyles.

“Governments, physicians, and health educators at all levels could do much more to help people change their behaviour to avoid preventable cancers,” says Bernard W. Stewart, Ph.D., co-editor of the report, Director of Cancer Services, and Professor, Faculty of Medicine, University of New South Wales, Australia. “If the knowledge, technology and control strategies outlined in the World Cancer Report were applied globally, we would make major advances in preventing and treating cancers over the next twenty years and beyond.”

From a global perspective, there is strong justification for focusing cancer prevention activities particularly on two main cancer-causing factors - tobacco and diet. We also need to continue efforts to curb infections which cause cancers,” said Dr Rafael Bengoa, Director, Management of Non-communicable disease at WHO. “These factors were responsible for 43 per cent of all cancer deaths in 2000, that is 2.7 million fatalities, and 40 per cent of all new cases, that is four million new cancer cases.”

As part of an effort to stem this trend, WHO is engaged in efforts to stem both tobacco use, and to improve diet, nutrition and physical activity. Tobacco consumption remains the most important avoidable cancer risk. The report reviews and recommends a number of strategies to reduce global tobacco consumption, requiring the coordinated involvement of government and community health organizations, health care professionals and individuals. The groundbreaking public health treaty - the Framework Convention on Tobacco Control - which the Member States of WHO have agreed to submit to the World Health Assembly in May 2003, represents a powerful tool to ensure that such strategies are implemented.

WHO is also engaged in preparing a Global Strategy on Diet, Physical Activity and Health, under a May 2002 mandate from Member States to address the growing global burden of chronic diseases, including cancers, cardiovascular diseases, diabetes and obesity. WHO is consulting widely with Member States, other UN agencies, the private sector and civil society on the strategy, which will be presented to the World Health Assembly in May 2004. The strategy will contain recommendations for governments on nutrition and physical activity goals and population-based interventions to reduce the prevalence of chronic disease including cancer.
The World Cancer Report – The major findings

Tobacco, the case for primary prevention
Tobacco consumption remains the most important avoidable cancer risk. In the 20th century, approximately 100 million people died world-wide from tobacco-associated diseases (cancer, chronic lung disease, cardiovascular disease and stroke). Half of regular smokers are killed by the habit. One quarter of smokers will die prematurely during middle age (35 to 69 years).

The lung cancer risk for regular smokers as compared to non-smokers (relative risk, RR) is between 20 and 30 fold. In countries with a high smoking prevalence and where many women have smoked cigarettes throughout adult life, roughly 90 per cent of lung cancers in both men and women are attributable to cigarette smoking. For bladder and renal pelvis, the RR is five-six but this means that more than 50 per cent of cases are caused by smoking.

The RR for cancers of the oral cavity, oral cavity, pharynx, larynx and squamous cell carcinoma of the oesophagus is greater than six, and three-four for carcinomas of the pancreas. These risk estimates are higher than previously estimated and unfortunately, additional cancer sites with a RR of two-three have been identified as being associated with tobacco smoking, including cancers of the stomach, liver, uterine cervix, kidney (renal cell carcinoma) nasal cavities and sinuses, esophagus (adenocarcinoma) and myeloid leukaemia.

Involuntary (passive) tobacco smoke is carcinogenic and may increase the lung cancer risk by 20 per cent. There is currently no evidence that smoking causes breast, prostate or endometrial cancer of the uterus.

The deadly smoking habit is particularly worrying in Central and Eastern Europe and many developing and newly industrialized countries. The tendency of youth around the world to start smoking at younger and younger ages will predispose them to substantial risks in later life.

While it is best never to start smoking, epidemiological evidence supports the enormous benefits of cessation. The greatest reduction in the number of cancer deaths within the next several decades will be due to those who stop the habit. The greatest effect results from stopping smoking in the early 30s, but a very impressive risk reduction of more than 60per cent is obtained even when the habit is quit after the age of 50 years.

The report reviews and recommends a number of strategies to reduce global tobacco consumption, requiring the coordinated involvement of government and community health organizations, health care professionals and individuals. The groundbreaking public health treaty - the Framework Convention on Tobacco Control represents a powerful tool to ensure that such strategies are implemented.

Infection and cancer: intervention is key
In developing countries, up to 23 per cent of malignancies are caused by infectious agents, including hepatitis B and C virus (liver cancer), human papillomaviruses (cervical and ano-genital cancers), and Helicobacter pylori (stomach cancer). In developed countries, cancers caused by chronic infections only amount to approximately 8 per cent of all malignancies. This discrepancy is particularly evident for cervical cancer. In developed countries with an excellent public health infrastructure and a high compliance of women, early cytological detection of cervical cancer (PAP smear) has led to an impressive reduction of mortality while in other world regions, including Central America, South East Africa and India, incidence and mortality rates are still very high. Today, more than 80 per cent of all cervical cancer deaths occur in developing countries.

Vaccinations could be key to preventing these cancers. HBV vaccination has already been shown to prevent liver cancer in high-incidence countries and it is likely that human papillomavirus (HPV) vaccination will become a reality in 3 to 5 years.

In the gastro-intestinal tract (GIT), any chronic tissue damage with necrosis and regeneration carries an in creased cancer risk, e.g. consumption of very hot beverages (squamous cell carcinoma of the esophagus), gastro-oesophageal reflux (adenocarcinoma of the esophagus), chronic gastritis induced by H. pylori infection (stomach cancer), Crohn’s disease (cancer of the small intestines) and ulcerative colitis (colon cancer).

Poverty, affluence and the global burden of cancer
In developed countries, the probability of being diagnosed with cancer is more than twice as high as in developing countries. However, in rich countries, some 50 per cent of cancer patients die of the disease, while in developing countries, 80 per cent of cancer victims already have late-stage incurable tumors when they are diagnosed, pointing to the need for much better detection programs.

The main reasons for the greater cancer burden of affluent societies are the earlier onset of the tobacco epidemic, the earlier exposure to occupational carcinogens, and the Western nutrition and lifestyle. However, with increasing wealth and industrialization, many countries undergo rapid lifestyle changes that will greatly increase their future disease burden.

“Once considered a “Western” disease, the Report highlights that more than 50 per cent of the world’s cancer burden, in terms of both numbers of cases and deaths, already occurs in developing countries. “Cancer has emerged as a major public health problem in developing countries for the first time, matching its effect in industrialized nations. This is a global problem, and it’s growing. But, we can take steps to slow this growth,” says Paul Kleihues, MD, Director of IARC and co-editor of the World Cancer Report.

The Western lifestyle and its health risks
The Western lifestyle is characterized by a highly caloric diet, rich in fat, refined carbohydrates and animal protein, combined with low physical activity, resulting in an overall energy imbalance. It is associated with a multitude of disease conditions, including obesity, diabetes, cardiovascular disease, arterial hypertension and cancer.

Malignancies typical for affluent societies are cancers of the breast, colon/rectum, uterus (endometrial carcinoma), gallbladder, kidney and adenocarcinoma of the oesophagus. Prostate cancer is also strongly related to the Western lifestyle, but there is an additional ethnic component; black people appear to be at a greater risk than whites and the latter at higher risk than Asian populations. Similar lifestyles are associated with a similar tumour burden. Since they have a common cause, these neoplasms typically go together. There is no region in the world that has a high incidence of breast cancer without a concurrent colon cancer burden.

Obesity is spreading epidemically throughout the world. It visualizes a chronic energy imbalance and is an independent predictor of an increased cancer risk, particularly for carcinomas of the uterine endometrium, kidney and gall bladder.

Together with the independent Expert Report on diet and chronic disease, released in March 2003 by WHO and FAO (Food and Agriculture Organization) the World Cancer Report provides policymakers with the latest information on which to base advice.

Nutrition and cancer – the good news
Stomach cancer is among the most common malignancies worldwide, with some 870,000 cases every year, and 650,000 deaths. About 60 per cent of cases occur in developing countries, with the highest incidence rates coming in Eastern Asia, the Andean regions of South America and Eastern Europe. The good news is that stomach cancer is declining world-wide, in some regions almost dramatically. In Switzerland and neighbouring European countries, the mortality fell by 60 per cent within one generation. If this trend continues, stomach cancer may in some world regions become a rare disease during the next 30 years. The main reason for this welcome development is the invention of the refrigerator, allowing fish and meat preservation without salting. The drop in incidence and mortality rates is therefore particularly impressive in Nordic countries in which fish consumption is traditionally high, e.g. Iceland. In populations that still prefer salty food, e.g. Portugal and Brazil (salted cod, bacalao), Japan and Korea (salted pickles and salad), stomach cancer rates are still high but have also started to decline significantly. An additional factor contributing to this trend is the availability in many countries of fresh fruit and vegetables throughout the year.

Cancer prevention: a healthy diet can help!
Epidemiological studies indicate that the frequent consumption of fruit and vegetables may reduce the risk of developing cancers of epithelial origin, including carcinomas of the pharynx, larynx, lung, oesophagus, stomach, colon and cervix. Recent data from the European Prospective Investigation into Cancer and Nutrition (EPIC), suggests that a daily consumption of 500 grams (1.1. lbs.) of fruits and vegetables can decrease incidence of cancers of the digestive tract by up to 25 per cent.

The report also says that given the multi-faceted impact of diet on cancer, many countries should encourage consumption of locally produced vegetables, fruit and agricultural products, and avoid the adoption of Western style dietary habits. IARC says that such actions would have health benefits beyond cancer, since other common non-communicable diseases, notably cardiovascular disease and diabetes, share the same lifestyle-related risk factors.

Early detection – the best strategy second to primary prevention The best possible prevention against cancer remains the avoidance of exposure to cancer-causing agents: this is called primary prevention (eg tobacco, industrial carcinogens, etc).

There is sound evidence that the recent decline in cancer mortality observed in several countries is to a significant extent due to early detection. Responsible for this success are not only improvements in imaging (mammography, magnetic resonance (MR) and computed tomography (CT) imaging), but also a higher degree of disease awareness and educational programmes on typical early symptoms. Most successful so far has been the early detection of cervical cancer by cytology and of breast cancer by mammography. A recent analysis by an IARC Working Group concluded that under trial conditions, mammography screening may reduce breast cancer mortality by 25-30 per cent and that in nation-wide screening programmes a reduction by 20 per cent appears feasible. There is also emerging evidence that prostate cancer screening by assessment of serum PSA levels may result in lower mortality rates but management of early lesions is still very invasive. For colon cancer, colonoscopy is considered the gold standard although its application in population-based screening programmes would require considerable medical resources.

Cancer control strategies
The aim of cancer control is a reduction in both the incidence of the disease and the associated morbidity and mortality, as well as improved life for cancer patients and their families. In addition to substantial opportunities for primary prevention, the World Cancer Report also emphasizes the potential of early detection, treatment and palliative care. It urges all countries to establish comprehensive national cancer control programmes, aimed at reducing the incidence of the disease and improving the quality of life for cancer patients and their families. In developing countries in particular, where a large proportion of cancers are detected late in the course of the disease, efforts to achieve earlier diagnosis and delivery of adequate palliative care and pain relief deserve urgent attention.

Cancer by the Numbers
Lung cancer is the most common cancer worldwide, accounting for 1.2 million new cases annually; followed by cancer of the breast, just over 1 million cases; colorectal, 940,000; stomach, 870,000; liver, 560,000; cervical, 470,000; esophageal, 410,000; head and neck, 390,000; bladder, 330,000; malignant non-Hodgkin lymphomas, 290,000; leukemia, 250,000; prostate and testicular, 250,000; pancreatic, 216,000; ovarian, 190,000; kidney, 190,000; endometrial, 188,000; nervous system, 175,000; melanoma, 133,000; thyroid, 123,000; pharynx, 65,000; and Hodgkin disease, 62,000 cases.

The three leading cancer killers are different than the three most common forms, with lung cancer responsible for 17.8 per cent of all cancer deaths, stomach, 10.4 per cent and liver, 8.8 per cent.

Industrial nations with the highest overall cancer rates include: U.S.A, Italy, Australia, Germany, The Netherlands, Canada and France. Developing countries with the lowest cancer were in Northern Africa Southern and Eastern Asia. (A complete list of cancer rates by countries can be found at http://www-dep.iarc.fr/.

Lung cancer in women
Lung cancer strikes 900,000 men and 330,000 women yearly. Among men, smoking causes more than 80 per cent of lung cancer cases. In women, smoking is the cause of 45 per cent of all lung cancer worldwide, but more than 70 per cent in North America and Northern Europe. In both men and women, the incidence of lung cancer is low before age 40, and increases up to age 70 or 75.

The rise in female smoking prevalence is a major public health concern. In the US, more women die from smoking-induced lung cancer than from breast cancer and in some Nordic countries, including Iceland and Denmark, female lung cancer deaths have begun to outnumber male tobacco victims. Considering that in several European countries up to 50 per cent of young women are now regular smokers, this will cause a disease burden that significantly reduces women’s health in decades to come.

Colon cancer
Cancers of the colon and rectum are rare in developing countries, but are the second most frequent malignancy in affluent societies. More than 940,000 cases occur annually worldwide, and nearly 500,000 die from it each year.

A major cause is a diet rich in fat, refined carbohydrates and animal protein, combined with low physical activity. Genetic susceptibility appears to be involved in less than five per cent of cases. Epidemiological studies suggest that risk can be reduced by decreasing meat consumption (particularly processed meat) and increasing the intake of vegetables and fruit. Migrant populations rapidly reach the higher level of risk of the adopted country, another sign that environmental factors play a major role.

Colonocopy is the most reliable means for early detection. Progressively improved diagnosis and treatment has resulted in a five-year survival rate of 50 per cent.

Key statements

* Tobacco use is the major preventable cause of cancer in the world.
* Molecular genome research will reveal a tremendous amount of information on cancer but it is not clear how easy these discoveries will translate into actual lives saved and may well be restricted to rare cancers.
* As developing countries succeed in achieving lifestyles similar to Europe, North America, Australia, New Zealand and Japan, they will also encounter much higher cancer rates, particularly cancers of the breast, colon, prostate and uterus (endometrial carcinoma).
* Researchers will demonstrate that successful behavioral changes in tobacco, alcohol and diet will prevent far more cancers than the elimination of toxins such as industrial pollution, car exhaust and dioxins;
* The Pap smear for cervical cancer is the single best cancer screening procedure. The medical community must develop a wide spectrum of tests for other cancers and are now evaluating many procedures to determine if they are effective and practical;
* The major differences of cancer between the sexes are the predominance in males with lung, liver, stomach, esophageal and bladder cancer; for the most part, these differences derive from patterns of exposure to the causes of the cancers, to a smaller extent they reflect intrinsic gender differences in susceptibility.
* More than one million cases of breast cancer occur worldwide annually, with some 580,000 cases occurring in developed countries (>300/100,000 population per year) and the remainder in developing countries (usually <1500/100,000>