Hyperemesis Gravidarum (HG)
Hyperemesis Gravidarum (HG) is a severe form of Nausea and Vomiting during Pregnancy (NVP). HG affects around 1-1.5% of all pregnant women 1 and is much more serious than the typical symptoms that the majority of women experience. Generally HG is suggested when the symptoms become so severe the woman is admitted to hospital for IV hydration. However other indicators can include weight loss of more than 5% of the pre-pregnancy weight, dehydration, ketonuria and electrolyte imbalance2.
What are the risk factors associated with HG?
Since the introduction of IV hydration, HG is rarely the life threatening illness it once was, although deaths from complications associated with HG have been reported as recently as 2015 3, 4. Adequate treatment (including IV hydration and the prescription of antiemetic medication) is therefore essential to alleviate suffering and avoid the complications caused by vitamin deficiencies and electrolyte imbalances. Major concerns in women with severe vomiting include Wernicke’s Encephalopathy, thyrotoxicosis and hypokalemia 3.
It is a common misconception that women with HG have no greater risk of adverse outcomes than those without such severe vomiting. However recent research has shown that if symptoms are not sufficiently treated so as to prevent severe weight loss and malnutrition adverse foetal outcomes can include placental abruption, pre-eclampsia and small for gestational weight babies 5. Long term foetal outcomes can include increased risk of psychological and behavioural disorders 6 and long term cardiometabolic problems 7.
A woman suffering from HG may also be at increased risk of antenatal depression, postnatal depression and post-traumatic stress disorder 8, 9. Social impacts include financial strain from time off work, inability to care for dependents and relationship problems10.
What treatment options are available?
In addition to IV hydration, there are several antiemetic medications that may be prescribed by a GP or consultant. These include cyclizine, promethazine, prochlorperazine, metoclopramide, ondansetron and even steroids. Though none of these are licensed for use during pregnancy, they have been used for decades during pregnancy with no evidence of adverse effects 11. With regards to efficiency there is far less data. Recent Cochran reviews have attempted to assess which treatments are most effective but the lack of consistency in outcome measures, trail design and definition of HG has rendered results inconclusive 12. However, many experts argue that because HG is likely to be multi-factorial in origin, women respond to different drugs and have different levels of tolerance to the side effects experienced treatment should be tailored to the women using a stepwise approach until symptoms are controlled 13.
Gaining appropriate treatment is crucial for the wellbeing of women suffering from HG. Some women feel so unable to continue with such severe symptoms that they feel their only option is to terminate the pregnancy. Many of these women end a much wanted pregnancy and so it is vital that all treatment options have been discussed with the woman before any decision is made 4.
Professional counselling should also be offered to women with severe symptoms.
Can alternative therapies help?
While many women who experience regular “morning sickness” may find that Complementary and Alternative Medicines (CAM) may help with symptom management, for women with HG it is important that conventional treatment is not delayed by exploration of CAM. The national helpline run by Pregnancy Sickness Support speak to hundreds of women every year with hyperemesis, Karen Lodge, who answers the helpline says “Almost everyone I speak to has already tried ginger, acupressure, aromatherapy and the various other self-help techniques available before they even visit their GP or see their midwife. Information about self-help and CAM options are widely available and therefore healthcare professionals can confidently assume that women already know about them”. While there has been some evidence for ginger to ease nausea and vomiting a recent large scale survey of women’s experience of ginger for HG found that in 50% of women it actually made symptoms worse and cause pain and discomfort. Furthermore they found that when healthcare professionals suggested it to women who had a diagnosis of HG it had a profoundly negative impact on their mental wellbeing 14.
What role can midwives play?
As the symptoms of HG typically begin during the first trimester, a woman suffering from it is likely to have had considerable contact with her GP before ever meeting her midwife at the booking appointment. But the midwifery team involved in her care can still play a key role in her treatment.
If the woman is admitted to hospital, it is important to offer empathy and understanding. HG is far more than typical NVP symptoms and the woman may be feeling totally isolated and alone. For many women this may be their first bout of serious ill health in their lives and at a time that they were hoping to be joyous and exciting. Many women mention the lack of care given and how they have been expected to ‘pull themselves together’ or settle into the hospital routine on a busy ward even though the various different stimuli may all act as triggers for the sickness. A recent literature review found that the historic stigma of HG caused by notions of psychodynamic aetiology persists today and negatively impacts the care they receive 15. That said, awareness of HG is improving at a phenomenal speed and services such as HG Day Units are opening up across the UK with women giving excellent feedback on the care they are receiving in many areas.
Whether in a hospital or clinic setting, the midwife can offer welcome knowledge and understanding on the severity of the sickness experienced. One of the main things to note is that the term “morning sickness” is both inaccurate and trivialises the condition. Many women with NVP and HG experience at least two episodes per day and some mention that the symptoms are worse later in the day when tiredness affects them. Therefore, asking about a woman’s specific symptoms and noting how much they are affecting her life can give a clear indication of the help she needs. The Motherisk Program in Canada created a Pregnancy Unique Quantification of Emesis (PUQE) scale which asks women to monitor how many hours they feel ill, how often they actually vomit, and how often they have dry-retched over a 24 hour period to evaluate the severity of their symptoms 16. This could be a useful tool for midwives to adopt, particularly for NVP, however it is important to note that it may be inaccurate or insensitive at the HG end of the spectrum.
It may also help the woman to maintain a diary of symptoms. This may help her determine when the symptoms are at their minimum and hence the better time to try food and drink. A diary can downloaded from the Pregnancy Sickness Support website and there is a page about HG in the Mums section of the MAMA Academy site which includes information and coping strategies.
It is important to remember that such severe symptoms are often unresponsive to the normal suggestions for NVP. Advising a woman with HG to ‘eat little and often’, ‘try ginger’ or ‘eat a dry cracker before getting out of bed’ will only upset her if she has been unable to keep even the smallest amount of liquid down each day. Instead it is best to ask her what she can tolerate, check before mentioning food (in case this is a trigger for her sickness) and advise her to eat and drink whatever she can tolerate, whenever she can tolerate it. However, women suffering from NVP and HG also often have a greater sensitivity to smells, and it may help women to avoid odours in the house, especially those involved in the preparation of food.
Knowledge of HG and the treatment options available would be highly valuable in the care of women with severe symptoms and may help reassure them that treatment is available and that they need not suffer in silence. This is where the midwife could play a vital role, providing the information a woman needs to make choices that are right for her. Advocacy is a key role of the midwife for all of her women and this can be particularly important for women with HG who may find advocating for themselves difficult or almost impossible 17.
Unlike the more typical NVP, women suffering from HG will often experience symptoms throughout the second and even third trimesters, often only gaining relief once the baby is born. As contact with the midwifery team increases as the pregnancy progresses, they can offer continuity of care by always asking about the symptoms experienced, both physical and emotional.
Finally it is important to note that many women suffering from severe NVP never gain a diagnosis of HG and struggle to gain appropriate care and treatment despite many visits to the GP and/or midwife. In fact Jarvis notes that approximately 35% of pregnant women will suffer from symptoms that are of clinical relevance. Therefore there is a clear need to offer support and guidance to any woman suffering from unusually severe symptoms as they may feel invalidated through the lack of diagnosis.
What are the NICE guidelines for HG?
The NICE guidelines only make recommendations for NVP and include ginger, P6 acupressure and antihistamines for NVP, but make no specific recommendations for HG. However, they do provide a Clinical Knowledge Summary which outlines the various drug therapies which is based on the widely accepted Javis and Nelson-Pericy Paper 11.
The NICE guidelines specifically states:
“Women, their partners and their families should always be treated with kindness, respect and dignity. The views, beliefs and values of the woman, her partner and her family in relation to her care and that of her baby should be sought and respected at all times.
“Women should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals […]Good communication between healthcare professionals and women is essential. It should be supported by evidence-based, written information tailored to the woman’s needs […] Every opportunity should be taken to provide the woman and her partner or other relevant family members with the information and support they need.”
What other guidelines are available?
Numerous hospitals have their own guidelines for HG and in 2016 the Royal Colleage of Obstetricians and Gynecologists are launching their first edition of Greentop Guidelines for NVP and HG which will hopefully have a huge impact on the treatment for the condition. The guidelines have been developed in conjunction with the patient advocacy charity Pregnancy Sickness Support (PSS) and have been praised for having the patients voice ingrained throughout the guideline.
Additionally, PSS provide GP guidelines which they helped to develop in Nottingham and have been adopted into practice there as of last year.
What other support can be offered to women?
PSS offer a helpline facility Monday to Friday 9am-4.30pm which is available not just for women experiencing symptoms but to their health care professionals too. The Charity’s nurse specialist, Caitlin Dean, can help HCPs to develop care plans and management strategies for complex cases.
The Charity also runs a peer-support system for women suffering in which they can be matched to a volunteer with first-hand experience of the condition and receive regular 1-2-1 support via phone text or email. PSS also run an online forum via their website where women can access support 24/7 from other women and the charity’s volunteers.
For posters, leaflets and other display materials for your clinical area please contact the charity via the helpline or website.
1. Einarson TR, Piwko C, Koren G Quantifying the global rates of nausea and vomiting of pregnancy: a meta analysis, J Popul Ther Clin Pharmacol. 2013, 20, (2), e171-83.
2. Dean C, Gadsby R Severe Nausea and Vomiting in Pregnancy, Nursing in Practice. 2013, March/April, 2.
3. MacGibbon K, Fejzo M, Mullin P Mortality Secondary to Hyperemesis Gravidarum: A Case Report, Women’s Health & Gynecology. 2015, 1, (2), 7.
4. Dean C, Murphy C I could not survive another day: Improving treatment and tackling stigma: lessons from women’s experiences of abortion for severe pregnancy sickness. (Pregnancy Sickness Support and Service, B. P. A. (eds.)). 2015.
5. Bolin M, Akerud H, Cnattingius S, Stephansson O, Wikstrom A Hyperemesis gravidarum and risks of placental dysfunction disorders: a population-based cohort study, Bjog-an International Journal of Obstetrics and Gynaecology. 2013.
6. Mullin PM, Bray A, Schoenberg F, MacGibbon KW, Romero R, Goodwin TM, et al. Prenatal exposure to hyperemesis gravidarum linked to increased risk of psychological and behavioral disorders in adulthood, Journal of Developmental Origins of Health and Disease. 2011, 2, (4), 200-04.
7. Grooten IJ, Painter RC, Pontesilli M, van der Post JA, Mol BW, van Eijsden M, et al. Weight loss in pregnancy and cardiometabolic profile in childhood: findings from a longitudinal birth cohort, Bjog-an International Journal of Obstetrics and Gynaecology. 2015, 122, (12), 1664-73.
8. Swallow BL Nausea and Vomiting in Pregnancy: Psychological and Social Aspects.). Lincoln: University of Lincoln, 2009.
9. Christodoulou-Smith J, Gold JI, Romero R, Goodwin TM, MacGibbon KW, Mullin PM, et al. Posttraumatic stress symptoms following pregnancy complicated by hyperemesis gravidarum, Journal of Maternal-Fetal & Neonatal Medicine. 2011, 24, (11), 1307-11.
10. Gadsby R, Barnie-Adshead A Nausea and vomiting of pregnancy – A literature review, Pregnancy Sickness Support [online]. 2011.
11. Jarvis S, Nelson-Piercy C Management of nausea and vomiting in pregnancy, British Medical Journal. 2011, 342.
12. Boelig RC, Barton SJ, Saccone G, Kelly AJ, Edwards SJ, Berghella V Interventions for treating hyperemesis gravidarum, Cochrane Database Syst Rev. 2016, 5, CD010607.
13. Dean C Helping women prepare for hyperemesis gravidarum, British Journal of Midwifery. 2014, 22, (12), 847-52 6p.
14. Dean CR, O’Hara ME Ginger is ineffective for hyperemesis gravidarum, and causes harm: an internet based survey of sufferers., MIDIRS Midwifery Digest. 2015, 25, (4), 6.
15. Dean C Does the historical stigma of hyperemesis gravidarum impact healthcare professional’s attitudes and treatment towards women with the condition today? A review of recent literature, MIDIRS Midwifery Digest. 2016, 26, (2), 8.
16. Koren G, Boskovic R, Hard M, Maltepe C, Navioz Y, Einarson A Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy, American Journal of Obstetrics and Gynecology. 2002, 186, (5), S228-S31.
17. Dean C A patient experience of hyperemesis gravidarum and how the midwife can support her care, Essentially MIDIRS. 2014, 5, (2), 32-6.
In partnership with Pregnancy Sickness Support.
Visit their website which contains a wealth of other information for use by patients, carers and professionals, including reviews of literature.