Hyperemesis Gravidarum: Severe Nausea and Vomiting during Pregnancy

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HG can be a debilitating condition and patients may become depressed and/or anxious due to the severity of their symptoms. Patients may feel that there is no end in sight during their first episode and have feelings of helplessness given the uncertainty of when it will resolve. It can be particularly distressing for women and their families who have experienced a previous pregnancy loss, as they struggle to find the strength to endure the symptoms knowing they have a subsequent pregnancy loss in the past. Their underlying fears of potential adverse effects this pregnancy experience may have on pregnancy outcome can be quite distressing. Many patients are unable to work and require significant practical and emotional support from family members and friends. Due to the often abrupt onset and severity of the symptoms, patients may require frequent visits to urgent care or the emergency room for care. In some cases, hospitalization may be necessary.

Hyperemesis gravidarum (HG) is a severe and prolonged form of nausea and/or vomiting during pregnancy. It is generally described as unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids. If severe and inadequately treated, it is associated with significant adverse maternal and fetal outcomes. The severity of nausea and vomiting can cause the patient to be malnourished, dehydrated, and may result in the production of ketones. It is estimated that HG affects about 0.5-2% of pregnant women. Unfortunately, due to underreporting of the illness, the prevalence is not well understood.

Definition and Overview

HG can result in weight loss, dehydration, vitamin deficiencies, and a hospital admission. It can have a psychological impact including increased stress, anxiety, and depression. Some women have experienced post-traumatic stress disorder from suffering with HG. Additionally, women have terminated wanted pregnancies due to the severity of symptoms and lack of effective medical treatments. The impact on the patient’s family, including young children, can also be significant. HG can result in increased sick leave from paid employment for the patient and partners’ employment to care for the patient and/or children. Inadequate treatment of HG can result in increased costs to the health system, for example, multiple general practitioner visits, emergency department admissions with no resolution of symptoms, tests, and hospital admissions. HG can also impact the baby’s health, and the long-term outcome on the child is currently an area of ongoing research. With the potential adverse outcomes of HG, it is important for clinicians to have a good understanding of the diagnosis and management of HG to provide optimal care for these patients.

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting in pregnancy. It is generally described as unrelenting, excessive pregnancy-related nausea and/or vomiting that prevents adequate intake of food and fluids. If severe and/or inadequately treated, HG can result in inadequate nutrition for both mother and fetus. Though the cause is often unknown, the understanding of the cause of HG has evolved over time and is becoming better understood through evidence-based medicine. Jahren et al suggest the differences in normal pregnancy-related nausea and vomiting (NVP) versus HG are becoming more apparent with advances in understanding the pathophysiology of HG. It is important to differentiate normal NVP from HG; NVP is a common experience in pregnancy which is generally self-limiting and resolves by 12-20 weeks gestation. HG is a separate diagnosis which requires more intensive treatment and possibly hospitalization.

Causes and Risk Factors

Problems with nausea and vomiting in pregnancy are experienced by up to 80% of gravidas in early pregnancy. It can cause a great deal of distress and discomfort as well as having an adverse effect on the quality of life during what is a challenging time for the woman. HG is a severe form of NVP, defined as pregnancy-related vomiting accompanied by dehydration, ketonuria and weight loss of more than 5% of body weight. It is estimated to affect 0.3-2.0% of pregnancies and is more common in Western societies probably due to the low parity in these populations. Although the symptoms resolve for most women by around 20 weeks gestation, a significant number of women will continue to have symptoms throughout the second trimester and an unfortunate 20% will continue to have symptoms until delivery. The etiology of NVP and HG is not well understood. It is likely to be multifactorial, involving both genetic and environmental factors. Nausea and vomiting are known to be influenced by serum concentrations of certain hormones. As a result of this, much of the research has focused on the role of hormones in NVP and HG. Estrogen is thought to play a significant role as the timing of onset and resolution of symptoms indicates a strong association with serum HCG and levels of estrogen and Thyroid Hormone (TSH) are elevated in NVP/HG. The fact that monozygotic twin pregnancies have been shown to have a higher concordance for HG than dizygotic twins or singleton pregnancies also supports a theory of genetic predisposition with regards to hormonal responsiveness. Another hormone thought to play a part in NVP/HG is Thyroid Releasing Hormone (TRH). In a non-pregnant state, TRH stimulates the release of Thyroid Hormone as well as the production and release of Prolactin from the Anterior Pituitary. High levels of Prolactin are associated with a decrease in dopamine which can result in an anti-emetic effect. However, stimulation of the posterior pituitary by TRH produces vasopressin and it is suggested that when high levels of estrogen also cause increased production of TRH, this can cause an excess of vasopressin which can stimulate the CTZ in a similar way to the effects of high levels of HCG. This would then cause increased Nausea and Vomiting. An understanding of the exact cause of hormone changes in NVP/HG may lead to possible future hormone treatments. High levels of HCG have also been shown to have a direct thyrotropic effect and it is suggested that it is this dual effect on TRH and the thyroid gland that causes the raised levels of TSH seen in pregnancy with NVP/HG.

Symptoms and Diagnosis

Symptoms usually begin between the fourth and sixth week of pregnancy and may subside at around the 20th week of pregnancy. Several characteristics of this condition are:

1. Severe nausea and vomiting – This symptom is the most common characteristic and usually presents early in the morning. Vomiting may be so severe that it leads to: – 3.5% – 5% loss of pre-pregnancy body weight or greater – Dehydration

2. Food aversions/aversions to certain smells

3. Early satiety

4. Persistent Osmetol aversions with or without weight loss.

5. Vitamin deficiencies

6. Other symptoms and how they affect the patient:

a. Depression – Two-thirds of patients report high levels of anxiety or depression

b. Post-Traumatic Stress Syndrome

c. Job disability/loss

d. Financial stress

e. Antiemetic (medication to stop vomiting) and IV therapy requirements

f. Feelings of incompetence in inability to cope with pregnancy

Symptoms questioning the diagnosis of Hyperemesis Gravidarum:

1. Feelings of hunger, but inability to eat due to nausea

2. Gastro-esophageal reflux

3. Hyperthyroidism

4. Peptic Ulcer Disease

5. Gallbladder Disease

6. Depression

Treatment Options

Since odor triggers, changes in weather, and stress can also affect the severity of symptoms, it may be useful to keep a diary tracking symptoms and possible triggers, so that adjustments can be made. Acupressure or Sea-Bands and hypnosis have helped some women to reduce nausea and vomiting. TCM (Traditional Chinese Medicine) dietary and herbal therapy has also helped a few women, but many herbs are contraindicated in pregnancy, so consult with a licensed professional. Alternative therapies such as reflexology, aromatherapy, or massage can sometimes reduce stress and improve overall well-being, but may worsen nausea if strong odors are involved. Biofeedback techniques can help in identifying and controlling physical reactions to stress. All alternative therapies are best used under the guidance of a licensed professional, and it is important to be well informed of any potential risks.

Simple changes to diet, rest, and activity may help control the severity of HG. Because what helps varies from person to person, it is best to identify the triggers of your symptoms and then make the necessary adjustments. A food diary may be helpful for identifying food triggers. Eating small frequent meals high in protein and low in carbohydrates may help to stabilize blood sugar levels. Fluids should be consumed slowly and in small amounts with meals or in-between meals. An oral rehydration solution may be easier to tolerate than water or ice cubes. Consumption of prenatal vitamins and fatty acids may also support general well-being. With regard to rest and activity, finding the right balance may take time and may need frequent adjustments. Complete bed rest may not be much more beneficial than light activity. The key is to avoid overexertion and stressful situations.

Lifestyle Changes and Home Remedies

Vitamin B6 has been shown to be an effective treatment for nausea and vomiting in pregnancy and a recent study has indicated that Diclegis, a prescription medication containing Vitamin B6 and an antihistamine, is more effective than placebo in treating nausea and vomiting in pregnancy with no apparent increased risk of harm to the fetus. Other antihistamines have been found to be effective in treating nausea and vomiting in pregnancy and are considered safe. Antiemetic drugs such as Ondansetron have been shown to be effective in treating nausea and vomiting in pregnancy and are deemed safe in the limited studies which have been done. Corticosteroids have also been used to treat hyperemesis but due to their potential for harmful side effects, it is suggested they be used as a last resort.

Medicines and alternative therapies should be tried only with the guidance of a practitioner you trust. As research on their effects is limited, it is better to make recommendations on treatment based on empirical evidence. At this time there is no evidence specifically related to the use of medication in HG, however there is evidence to suggest that some treatments may be helpful in reducing symptoms of nausea and vomiting.

The following guidelines are generally geared toward coping with morning sickness, but are just as appropriate in reducing the symptoms of hyperemesis. They are listed in order of invasiveness.

Medications and Therapies

Another anti-emetic which is often prescribed as a first line before Zofran is Cyclizine (Marizine) or prochlorperazine (Stemetil). These have mixed results with many sufferers finding they don’t work at all and quite a few reporting that they make their symptoms worse. Anti-emetics can often cause significant constipation, so it is often necessary to take a stool softener and laxatives.

Anti-emetics Anti-emetics are the obvious choice of medication for something whose main symptom is severe nausea and vomiting! They work to block a certain neurotransmitter in the brain, which causes the vomiting reflex. There are a few different anti-emetics available and new research is constantly taking place developing new and more effective anti-emetics. The most commonly prescribed anti-emetic is Ondansetron (Zofran) which has been found to be very effective in alleviating nausea and decreasing the vomiting episodes. It is available in a few different forms: orally disintegrating tablets, which if goes through insurance can be massively expensive, and regular oral tablets. It has also been available in intravenous form, although the use of intravenous Zofran in recent years has been discouraged due to research showing it can prolong the Q-T interval in the heart.

There are several different medications and therapies available for HG sufferers, and finding the right one to combat each individual case of HG involves trials of different medications and perhaps a combination of a few to find the right fit.

Hospitalization and Intravenous Fluids

The level of care increases with the severity of symptoms, and hyperemetic women often need continuous support until the end of the pregnancy. Weight loss and nutritional supplementation may be necessary. Admission to hospital is indicated for severe cases where women are dehydrated and vomiting to the extent that ketosis is apparent. Admission may also be necessary if the woman is unable to manage symptoms at home, or is becoming dehydrated and losing weight. Admission to hospital will provide a break from the responsibilities of everyday life, and enable the woman to rest in a supportive environment until symptoms subside. The aims of treating dehydration and ketosis are to correct fluid and electrolyte imbalances, and starvation ketosis, giving only enough dextrose to prevent further ketosis and promote re-feeding. The re-feeding process must be carefully managed to avoid exacerbating nausea and vomiting. Intravenous fluids must be given if the woman is unable to tolerate oral fluids, or symptoms are severe with signs of dehydration and poor oral intake. Antiemetic therapy may also be given in severe cases to promote tolerance of oral fluid and food, although it is usually more effective with mild to moderate nausea and vomiting.

Complications and Long-Term Effects

Although hyperemesis gravidarum resolves after the first trimester for most women, some women will continue to have severe symptoms until delivery. Weight loss during pregnancy can have significant negative effects on birth weight and can result in small for gestational age (SGA) infants. SGA infants are at an increased risk of perinatal mortality and morbidity, growth and developmental disturbances, and chronic health conditions in later life. The results of studies examining the relationship between hyperemesis gravidarum and prematurity have been conflicting. A number of studies have shown an increased risk of preterm delivery associated with hyperemesis gravidarum, but it is unclear whether this is due to prematurity of the underlying pregnancy or indicated preterm delivery. Neonatal outcomes of prematurity and low birth weight are significant considering the increased risk of developmental delay associated with lower birth weight infants. These infants are also at higher risk for certain adult health conditions, such as heart disease, high blood pressure and diabetes. Given the potential effects of hyperemesis gravidarum on the neonate, it is important to understand how HG affects pregnancy duration and birth weight.

Nutritional Deficiencies and Weight Loss

Weight loss is another concern in pregnancy, and weight loss occurring in pregnancy is a strong predictor of poor pregnancy outcome (Mannisto et al., 2010). There is significant correlation found between the severity of NVP and lower gestational weight gain (McCarthy FP et al., 2011) and between hyperemesis gravidarum and low birth weight (Gazmararian et al., 2002). Maternal malnutrition can have serious implications for the growing fetus. The fetus will adapt to malnutrition by slowing its metabolic rate and reducing its growth to conserve resources in attempts to survive adverse intrauterine conditions. This can lead to infants being born small for gestational age and with developmental and health problems in the short and long term. An association between maternal hyperemesis and developmental problems in the offspring has been shown in a number of studies (McCarthy FP et al., 2011; Munch et al., 2004; Vikanes et al., 2013). One of proposed mechanism for developmental problems is through effects of vitamin B6 deficiencies on the fetus. A case controlled study found that infants born to mothers who had HG had smaller head circumferences and at 4.5 years of age had reduced hand-eye coordination and in a parallel study, maternal B6 deficiencies were found to be higher in cases compared to control mothers (Vikanes et al., 2013; Sahakian et al., 1991).

Psychological Impact and Emotional Support

Hyperemesis gravidarum (HG) has a multi-faceted negative impact on the quality of life of sufferers. The severity of symptoms can lead to a wide range of emotional responses including feelings of frustration, depression, and in some cases, thoughts of termination or suicide. A study comparing HG sufferers to healthy pregnant women found that HG sufferers had a quality of life score 4 times lower than their healthy counterparts and 5 times lower than the national average. Quality of life was measured according to physical, social, and psychological well-being and level of independence. The psychological effects of HG are as debilitating as the physical effects as women with the condition can feel that their basic purpose of growing new life is compromised and that they are not able to bond with their unborn child. In a study comparing HG pregnant women with non-HG pregnant women on the maternal-fetal attachment scale, it was found that maternal-fetal attachment was significantly lower in the HG group. The study concluded that a significant and negative impact of the maternal-fetal attachment occurs with HG.

Impact on Pregnancy and Fetal Development

There is no increase in the rate of congenital abnormalities in pregnancies complicated by hyperemesis. However, maternal ketonuria has been associated with microcephaly, facial clefting, and vague CNS defects. Because of this and the preliminary evidence of cognitive effects on offspring, it is wise to say hyperemesis gravidarum is probably not a benign condition for the fetus.

Hyperemesis gravidarum results in poor weight gain in pregnancy, often less than five kilograms. The mean birth weight of infants born to women with hyperemesis gravidarum is significantly lower. In a Swedish study by Kallen (1987), mean birth weight was 123 grams lower and the incidence of small for gestational age infants was 9.9% in the hyperemesis group compared with 7.2% in the control group. A large Norwegian study by Vikanes (2013) showed infants of women with hyperemesis were at increased risk of preterm birth (less than 37 weeks) and being small for gestational age. This was particularly marked in women who were underweight before pregnancy, possibly indicating an exacerbation of their poor nutritional state. The long-term significance of this is not known. An American study by Paauw (2002) showed that children born from pregnancies complicated by hyperemesis were at increased risk of developing significant non-psychotic mental disorders in adult life. This needs to be confirmed by other studies but suggests there could be long-term cognitive effects on children born to mothers with hyperemesis.

Coping Strategies and Support

Being sick and taking care of yourself is difficult even when it involves “only” you. Unfortunately, the unsettling truth is that the outcome is the same for everyone – to have their baby and be happy regardless of what it costs them. Whether it be physical discomfort, financial strain, or time lost with those you care about, the greatest gift will be manifested in the birth of your child. Although you are going through something incredibly traumatic with HG, the end result of having a baby and regaining your health is the most powerful force to help you manage. While you are experiencing HG, it will be necessary to make a conscious effort to take care of yourself. Treat yourself with the same tender love and care that you would give to your own child. During this time, it may be appropriate for loved ones to care for you and to lend you support, as you are temporarily in a state of vulnerability that could happen to anyone. Document this experience in a journal or any form of expressive writing. You could handwrite, type or use an online blog to record your story. This can be a great way to use this unremitting time as a personal life-lesson and for others to learn. If you choose to go public with this information, this can also be a very humbling experience for friends to read and gain insight about what you are going through. Last but not least, give yourself credit for what you are enduring. Although the reward is far greater than what you are giving, it is important to acknowledge that you have to be incredibly strong to be able to get through this. This is not a cop-out, but rather a step-up in the discovery of one’s true inner strength and resilience. At the end of this devastatingly trying time, you will come out a better person, a more supportive friend, an even more loving parent, and a stronger apprentice in the school of life.

Self-Care Tips for Managing Symptoms

Do not immediately start worrying about the weight you think you will lose. Staying hydrated is the most important issue. If you are throwing up and cannot seem to keep anything down, not even water, eat ice chips. Suck on them, and then swallow the water from the ice chips. This is the best way to keep hydrated. Another way to ensure hydration is to buy an at-home IV kit or visit the ER or your doctor’s office for IV hydration. If you are keeping very little down, have a ketones test done to check for starvation and dehydration. This is something that can eventually harm you and your baby. Usually, a prescription is written at this time for some type of anti-nausea medication. Many doctors are leery to prescribe anything during pregnancy, but there are many medications that are safe and effective. I personally have tried a few different ones until finding one that worked. Ideally, you want to stay away from taking medications, especially during the first trimester, but many women suffering from severe morning sickness will have no other option. Ask your doctor for samples if available, so you are not wasting money on a medication that may not work. Keep a food diary and write down the times and food you eat that either triggers vomiting or helps keep it down. This is a good way to figure out a pattern and what food is most tolerable. When feeling well enough to try and eat a meal, eat a couple of saltine crackers 15 minutes before. This seems to help with digestion. High protein snacks before bed help keep the blood sugar up and help not to wake up with severe nausea in the middle of the night. Get plenty of rest and give yourself a break from housework and other duties as much as possible. Stress and fatigue can make nausea worse.

Seeking Professional Help and Support Groups

Many times, when a woman requests help for her form of nausea and vomiting in pregnancy, she is told it is normal and just to get through it. Or she may be told, “Well, you wanted to be pregnant!” Having to fight for relief and understanding can be an added burden during an already difficult time. It is unfair that women with HG must advocate for the medical help they need. Although the severity of their condition warrants medical intervention, it is not uncommon for a woman to suffer unrelenting nausea and vomiting for months before she receives a prescription for antiemetic therapy. Even with medication, many women find it difficult to remain on the therapy as prescribed because managed care plans may refuse to cover the cost, despite the severe nature of the illness and the clear indication for the treatment. Step therapy and high co-pays or deductibles may create an undue burden or delayed access to the proper medication. The prohibitive cost of home health care and IV therapy may also limit a woman’s options. Hopefully, increased awareness and understanding of this debilitating condition will bring about improved treatment and support for women now and in the future. Women with HG often feel very isolated in their struggle to survive the physical and emotional challenges they face each day. It can be helpful to talk to others who have a clear understanding of the situation and who can offer support and empathy. HER Foundation volunteers can provide support and information and share experiences that may help other mothers better cope with HG. To request volunteer support, please email: [email protected]. There are also a number of online support groups where women can find understanding and encouragement from others who have “been there”. Many have found this to be an invaluable resource and a comfort to know they are not alone.

Communicating with Healthcare Providers

Tips for an effective patient-provider relationship: Be open: if you are feeling guilty about the effects of HG on the pregnancy and afraid to voice your concerns, it is important to remember you chose to have a baby, not HG! You did not choose to intentionally harm your unborn child and with help and support from healthcare providers, including midwives, obstetricians, GPs, dietitians, and psychiatrists, you can make the best choices for managing your symptoms and treatments to ensure the best possible outcome. By sharing information and asking questions about the various treatment options, you will be able to make decisions that are right for you. By keeping a diary of your symptoms and possible triggers and sharing this with your healthcare providers, it may help them gain a better understanding of how HG affects you and this could help in planning a more effective treatment plan.

It can be difficult to communicate how HG affects you with healthcare providers, particularly if you are unable to leave the house due to severe nausea and vomiting. When I was between 5-15 weeks pregnant, I was bedridden and housebound. I experienced embarrassing situations when I was unable to get to the toilet in time on a couple of occasions and wet myself. This left me feeling dirty, shame, and embarrassment. I was initially reluctant to tell my GP as I was worried what he would think of me. I bottled it up. It was only when I felt suicidal that I eventually told my GP everything, knowing that I didn’t want to end the pregnancy, but I couldn’t go on feeling that ill. I cried and cried and felt a sense of relief and hope when he prescribed me some anti-emetics. He arranged for me to have rehydration at the hospital every day for a week and referred me to an obstetrician. I felt that by the end of the week, some progress had been made and I was a little clearer in my mind about what I could do to manage this awful sickness.

You can communicate more effectively with healthcare providers by sharing your experiences and symptoms, and working with them to explore possible treatment options.

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