Skip to main content

Cannabinoid hyperemesis syndrome in the pregnant patient: clinical case and literature review

Abstract

Background

Cannabis use is on the rise. Several cases of cannabinoid hyperemesis syndrome, secondary to chronic cannabis intoxication, have been described worldwide, but few cases have described this entity in pregnant women.

Case presentation

We describe a 29-year-old pregnant patient that had consumed cannabis and experienced uncontrolled vomiting. The use of hot baths, the rapid improvement in symptoms, and results of complementary examinations suggested a diagnosis of cannabinoid hyperemesis syndrome. The patient could return home, and she continued her pregnancy and childbirth without peculiarities.

Conclusion

Cannabinoid hyperemesis syndrome should be considered in the differential diagnosis of vomiting in pregnancy. Consumption of cannabis must be systematically included in the anamnesis. However, it seems to be somewhat unacceptable socially or medically. Consumption must be stopped to manage symptoms.

Background

Cannabinoid hyperemesis syndrome is a recent clinical entity [1] involving nausea and vomiting in chronic cannabis users. The syndrome is also frequently associated with abdominal pain and compulsive showers or hot baths, which can attenuate the symptomatology [1, 2].

The diagnosis of cannabinoid hyperemesis syndrome is based on the exclusion of other causes, and the disappearance of symptoms once cannabis consumption is terminated [2]. The diagnosis and treatment of cannabinoid hyperemesis syndrome presents a challenge to the clinician. We describe a rare case of a pregnant woman that was likely to have cannabinoid syndrome. We will review the cases published to date and the current therapeutic options and discuss the peculiarity of pregnancy. Finally, we emphasize the notion that this syndrome should not be ignored, when assessing other causes of vomiting during pregnancy, such as hyperemesis gravidarum.

Case presentation

A 29-year-old patient in her first pregnancy, at 29-week and 1-day gestation, visited the emergency room for uncontrollable vomiting and epigastric pain. She reported no health problems, but she smoked tobacco and cannabis. She had consumed 2 g per week for 6 years. She did not have any known allergies. She reported a decline in symptoms when taking a hot bath. The cardiopulmonary clinical examination was unremarkable. Abdominal palpation showed epigastric pain without guarding or rebound. The patient had a body temperature of 35.9 °C and displayed stable hemodynamics.

Further examinations revealed normal CBC but leukocytosis with WBC of 14.7 with a left shift. An abdominal ultrasound showed no detectable pathology. Obstetrically, she had a normal ultrasound, normal cardio-fetal monitoring.

She was treated with acetaminophen (1000 mg), tramadol (50 mg), metoclopramide (10 mg), and butylhyoscine bromide (10 mg). Based on the strong suspicion of cannabinoid hyperemesis syndrome and her clinical improvement in the emergency department, the details of this entity were explained to the patient, and she returned home.

The pregnancy was uncomplicated, and she gave birth at 39 weeks 6/7 to a healthy 2650-g newborn. She was discharged home with her infant uneventfully on postpartum day 3.

Discussion

The classic clinical picture of cannabinoid hyperemesis syndrome is as follows: chronic, intensive use of cannabis, episodes of uncontrollable vomiting, and abdominal pain. A symptomatological and temporary improvement in symptoms is noted when taking a bath or hot shower. Finally, the syndrome ceases when the patient ceases cannabis use and resumes when they do not.

Cannabis use is increasing worldwide [3]. Accordingly, the number of published cases of cannabinoid hyperemesis syndrome has increased, and the pathology is of interest in various related specialties, including pediatrics [4] and forensic pathology [5]. Although the cause of the syndrome is being discussed continually and remains to be formally clarified, a few known factors are notable. First, Δ-9-tetrahydrocannabinol (THC) is a CB1 receptor agonist, and it is assumed that deregulation of the receptor could cause nausea.

More than half of pregnant women experience nausea and vomiting. Hyperemesis gravidarum, which affects only 0.3 to 1% of pregnant women, is defined as persistent vomiting, more than 5% weight loss, ketonuria, and electrolyte abnormalities (particularly hypokalemia). The physiopathology remains unclear, but it is linked to hormonal activity and the production of human chorionic gonadotropin [6, 7].

We conducted a literature search to identify clinical cases of cannabinoid hyperemesis syndrome in pregnant patients. We employed the search terms “Cannabinoid,” “Hyperemesis,” andPregnancyin PubMed andGoogleScholar. We identified five clinical cases [8,9,10,11,12] and extracted their characteristics (detailed in the appendix tables) (Tables 1 and 2).

Table 1 Published cases of cannabinoid hyperemesis syndrome in pregnant women
Table 2 Demographic characteristics

Unlike studies in non-pregnant individuals [2], the low number of studies in pregnant patients makes it difficult to perform statistical analyses. On the other hand, there are similarities between non-pregnant and pregnant individuals. Most individuals with cannabinoid hyperemesis syndrome have consumed cannabis for years, mostly daily, and the symptoms tend to improve after taking a shower or hot bath. However, cannabinoid hyperemesis syndrome is particularly complex in pregnant women. Women that use cannabis during pregnancy are more likely to experience severe nausea than those that do not [13]. Nevertheless, and paradoxically, antiemetic effects have been attributed to cannabis, in both the general population [14] and pregnant women [15]. Some authors have recommended cannabis for treating hyperemesis gravidarum [16]. One hypothesis suggested that endocannabinoids played a role in the latter pathology. However, that hypothesis was refuted in a prospective study that did not find any changes in plasma endocannabinoid levels in patients with gravidarum hyperemesis [17].

Cannabis use is increasing among pregnant women [18]. However, it seems to be somewhat unacceptable socially or medically. This stigma might lead them to hide it when taking of a comprehensive patient history. This possibility was reinforced by the absence of a link between symptomatology and cannabis use [8]. The prevalence of cannabis use in parturition is likely to be generally underestimated [19]. Some patients diagnosed with classical nausea and vomiting during pregnancy or even gravidarum hyperemesis might actually have cannabinoid hyperemesis syndrome. These entities might be differentiated clinically by the sensitivity of hyperemesis gravidarum to certain antiemetic drugs [20, 21].

Potentially beneficial therapies for treating common cannabinoid hyperemesis syndrome, such as lorazepam [22] and haloperidol [23], are contraindicated in parturient women [24]. Capsaicin cream is not recommended in pregnant women. However, its usefulness could be discussed, in light of its supposed safety. Capsaicin treatment requires low dosages, and it does not cross the placental barrier [25]. Similarly, ondansetron [26] appears to have some efficacy. Although ondansetron is not recommended in the first trimester of pregnancy, its use might be permissible thereafter [24]. Metoclopramide, which can be used throughout pregnancy, has been used to treat cannabinoid hyperemesis syndrome and showed some efficacy.

This case study serves to remind physicians of the need to insist on recounting cannabis use when taking of the comprehensive patient history, particularly in parturient women with vomiting. Fortunately, the compulsive use of hot baths or showers seems specific to this clinical entity [2] and can help discriminate cannabinoid hyperemesis syndrome from other diseases.

There is a need for prospective studies that aim to determine the proportion of this syndrome among a parturient sample with vomiting and characterize potential differences in this subpopulation.

Randomized, controlled therapeutic trials should also be conducted to find a functional treatment for symptoms. On the one hand, an effective treatment could obviate the potential consequences of drugs of equivocal safety. On the other hand, an effective treatment is needed to avoid serious consequences of uncontrollable vomiting, which range from pneumomediastinum [27] to death [5] and acute renal insufficiency [28].

Availability of data and materials

Please contact author for data requests.

Abbreviations

CBC:

Complete blood count

WBC:

White blood cell

References

  1. 1.

    Allen JH, de Moore GM, Heddle R, Twartz JC. Cannabinoid hyperemesis: cyclical hyperemesis in association with chronic cannabis abuse. Gut. 2004. https://doi.org/10.1136/gut.2003.036350.

  2. 2.

    Simonetto DA, Oxentenko AS, Herman ML, Szostek JH. Cannabinoid hyperemesis: a case series of 98 patients. Mayo Clin Proc. 2012. https://doi.org/10.1016/j.mayocp.2011.10.005.

  3. 3.

    INCB. World drug report 2014, http://www.incb.org/documents/Publications/AnnualReports/AR2018/Annual_Report/Annual_Report_2018_F.pdf. Accessed April 1, 2020.

  4. 4.

    Desjardins N, Stheneur C. Cannabinoid hyperemesis syndrome: a review of the literature. Arch Pediatr. https://doi.org/10.1016/j.arcped.2016.01.016.

  5. 5.

    Nourbakhsh M, Miller A, Gofton J, Jones G, Adeagbo B. Cannabinoid Hyperemesis Syndrome: Reports of Fatal Cases. J Forensic Sci. 2019. https://doi.org/10.1111/1556-4029.13819.

  6. 6.

    Goodwin TM. Hyperemesis gravidarum. Clin Obstet Gynecol. 1998. https://doi.org/10.1097/00003081-199809000-00014.

  7. 7.

    Niebyl JR. Nausea and vomiting in pregnancy. N Engl J Med. 2010. https://doi.org/10.1056/NEJMcp1003896.

  8. 8.

    Schmid SM, Lapaire O, Huang DJ, Jürgens FE, Güth U. Cannabinoid hyperemesis syndrome: an underreported entity causing nausea and vomiting of pregnancy. Arch Gynecol Obstet. 2011. https://doi.org/10.1007/s00404-010-1811-8.

  9. 9.

    Alaniz VI, Liss J, Metz TD, Stickrath E. Cannabinoid hyperemesis syndrome: a cause of refractory nausea and vomiting in pregnancy. Obstet Gynecol. 2015. https://doi.org/10.1097/AOG.0000000000000595.

  10. 10.

    Andrews KH, Bracero LA. Cannabinoid hyperemesis syndrome during pregnancy: a case report. J Reprod Med. 2015;60(9-10):430–2.

    PubMed  PubMed Central  Google Scholar 

  11. 11.

    Manning Meurer M, Chakrala K, et al. A case of cannabinoid hyperemesis syndrome with Heliobacter pylori and preeclampsia during pregnancy. Subst Abus. 2018. https://doi.org/10.1080/08897077.2017.1356790.

  12. 12.

    Kim HG, Moon J, Dixon H, et al. Recurrent nausea and vomiting in a pregnant woman with chronic marijuana use. Case Rep Obstet Gynecol. 2018. https://doi.org/10.1155/2018/9746062.

  13. 13.

    Roberson EK, Patrick WK, Hurwitz EL. Marijuana use and maternal experiences of severe nausea during pregnancy in Hawai'i. Hawaii J Med Public Health. 2014;73(9):283–7.

    PubMed  PubMed Central  Google Scholar 

  14. 14.

    Carlini EA. The good and the bad effects of (-) trans-delta-9-tetrahydrocannabinol (Delta 9-THC) on humans. Toxicon. 2004;44(4):461–7.

    CAS  Article  PubMed  Google Scholar 

  15. 15.

    Westfall RE, Janssen PA, Lucas P, et al. Survey of medicinal cannabis use among childbearing women: patterns of its use in pregnancy and retroactive self-assessment of its efficacy against 'morning sickness'. Complement Ther Clin Pract. 2006;12(1):27–33.

    Article  PubMed  Google Scholar 

  16. 16.

    Russo E. Cannabis treatments in obstetrics and gynecology: a historical review. J Cannabis Therapeut. https://doi.org/10.1300/J175v02v03_02.

  17. 17.

    Gebeh AK, Willets JM, Marczylo TH, et al. Plasma anandamide and related n-acylethanolamide levels are not elevated in pregnancies complicated by hyperemesis gravidarum. J Matern Fetal Neonatal Med. 2014. https://doi.org/10.3109/14767058.2013.847413.

  18. 18.

    Keegan J, Parva M, Finnegan M, Gerson A, Belden M. Addiction in pregnancy. J Addict Dis. 2010. https://doi.org/10.1080/10550881003684723.

  19. 19.

    Jaques SC, Kingsbury A, Henshcke P, Chomchai C, Falconer J, Abdelatif ME, et al. Cannabis, the pregnant woman and her child: weeding out the myths. J Perinatol. 2014. https://doi.org/10.1038/jp.2013.180.

  20. 20.

    Fejzo MS, Trovik J, Grooten IJ, Sridharan K, Roseboom TJ, Vikanes A, et al. Nausea and vomiting of pregnancy and hyperemesis gravidarum. Nat Rev Dis Primers. 2019. https://doi.org/10.1038/s41572-019-0110-3.

  21. 21.

    O'Donnell A, McParlin C, Robson SC, Beyer F, Moloney E, Bryant A, et al. Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy: a systematic review and economic assessment. Health Technol Assess. 2016. https://doi.org/10.3310/hta20740.

  22. 22.

    Sun S, Zimmermann AE. Cannabinoid hyperemesis syndrome. Hosp Pharm. 2013. https://doi.org/10.1310/hpj4808-650.

  23. 23.

    Hickey JL, Witsil JC, Mycyk MB. Haloperidol for treatment of cannabinoid hyperemesis syndrome. Am J Emerg Med. 2013. https://doi.org/10.1016/j.ajem.2013.02.021.

  24. 24.

    Reference Center for Teratogens, https//lecrat.fr. Accessed April 1, 2020.

  25. 25.

    Dezieck L, Hafez Z, Conicella A, Blohm E, O’Connor MJ, Schwarz ES, et al. Resolution of cannabis hyperemesis syndrome with topical capsaicin in the emergency department: a case series. Clin Toxicol (Phila). 2017. https://doi.org/10.1080/15563650.2017.1324166.

  26. 26.

    Elkin K, Tai P, Winkel J, Kulkarni M, Sadler D, Truong N, et al. 337 Cannabinoid hyperemesis syndrome: 3-year practice patterns. Ann Emerg Med. 2019. https://doi.org/10.1016/j.annemergmed.2019.08.296.

  27. 27.

    Hernández-Ramos I, Parra-Esquivel P, López-Hernández Á, Burillo-Putze G. Spontaneuos pneumomediastinum secondary to cannabinoid hyperemesis syndrome. An Sist Sanit Navar. 2019. https://doi.org/10.23938/ASSN.0635.

  28. 28.

    Habboushe J, Sedor J. Cannabinoid hyperemesis acute renal failure: a common sequela of cannabinoid hyperemesis syndrome. Am J Emerg Med. 2014. https://doi.org/10.1016/j.ajem.2013.12.013.

Download references

Acknowledgements

Not applicable

Funding

Not applicable

Author information

Affiliations

Authors

Contributions

JF wrote the manuscript. NS corrected the manuscript. HT corrected the manuscript. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Julien Flament.

Ethics declarations

Ethics approval and consent to participate

Not applicable

Consent for publication

The patient give his content for all part of the material referenced here.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Flament, J., Scius, N. & Thonon, H. Cannabinoid hyperemesis syndrome in the pregnant patient: clinical case and literature review. Int J Emerg Med 13, 52 (2020). https://doi.org/10.1186/s12245-020-00311-y

Download citation

Keywords

  • Cannabinoid hyperemesis syndrome
  • Pregnancy
  • Cannabis
  • Vomiting
  • Cyclical vomiting syndrome