Hyperemesis Gravidarum is one of the most debilitating issues that can affect you during your pregnancy. It can occur at any stage but most commonly occurs during the first trimesters. For 90% of women, it disappears by 14 weeks gestation, and only occasionally is relentless throughout the pregnancy. It occurs more frequently in the evenings (which makes you wonder why it was ever called morning sickness!) and can change significantly based on the type of quantity of food you eat. Most women gain more weight during this time as they crave large amounts of salt laden carbohydrates, but a few women can vomit so much they lose weight, both from calorie depletion and dehydration. This can be a major concern and should be aggressively treated as serious consequences can occur.
The serious side of morning sickness
Hyperemesis Gravidarum (HG) is a condition of markedly excessive vomiting that occurs in approximately 1% of pregnancies. Vomiting can occur more than 50 times per day and is resistant to conventional therapies. It is associated with severe water and electrolyte disturbances, concentrated urine, excessive salivation, headaches, constipation and tears in the oesophagus. The enormous impact on work, social circumstances and mood need to be assessed and managed carefully.
Risk factors include a previous pregnancy with HG, a strong family history, poor social support and social isolation, and multiple pregnancies. Close monitoring of weight loss can determine degree of dehydration and calorie deficit. Blood tests and possible intravenous rehydration may be required. Recently both actress Amy Schumer and Catherine, Duchess of Cambridge were admitted to hospital for rehydration in the setting of HG. Prolonged HG can be associated with kidney, liver and brain changes caused by the chronic dehydration, electrolyte and certain vitamin deficiencies. Miscarriage is not a frequent complication of HG. Though, depression can develop from the chronic illness state and support from family and friends is of great importance.
Treatment for HG
Dietary choices usually swing towards salty carbohydrates in most women and other savoury foods. Eating early in the morning can often assist with it, along with frequent small meals. Even if you can’t face much food in the evening, effective snacking and a few small meals earlier in the day can be enough. Aim to sip clear fluids constantly, with plain water being preferable, but soda water or flat lemonade an alternative. If you are consuming less than 500ml per day and you are getting dark urine, then medical assessment is necessary.
Some women find vitamin B6 tablets or ginger can help with the sickness and a variety of preparations are available to buy that are easy to consume. Acupuncture has also been effective in some women, but may require repeated treatments over weeks. Wrist bands for pressure points have been tried in milder cases.
Medication as treatment
Most medication that is utilised for pregnancy nausea are not always licensed for this use. Drug manufacturers are usually reluctant to specifically approve a drug for pregnancy, and most pregnant women are not willing to go into research trials. However, a lot of data has been collected on the safety of many drugs in pregnancy and proven safety in longer term medication is reliable.
Different medication may suit different women but starting with a simpler, more readily available medication makes sense. Over the counter pharmacy medication such as Cyclizine or Doxylamine are effective in mild to moderation cases of nausea and vomiting, and are the most widely utilised and research in the U.S.A. Doxylamine has a sedative effect which can be of benefit at night and help prevent morning nausea.
Metaclopramide (Maxalon) and Domperidone (Motilium) are available on prescription, but have been utilised in pregnancy for nearly 30 years and help enormously if nausea and vomiting is more sever.
For resistant vomiting and nausea, ondansetron (Zofran) is a powerful medication that has been extensively monitored for safety in pregnancy. It may cause constipation as a side effect, but it assists the vast majority of women and has become one of the most widely utilised medicines in pregnancy. It is non-sedating, and available as mouth wafers if required.
Where HG is intractable oral or intravenous steroids can be a powerful anti-nausea treatment. Prednisolone tablets have a long history of being utilised in pregnancy and may be the most effective treatment we have for severe HG. Early research suggested that there may be a slight increased risk for the baby to develop a cleft palate, but subsequent large studies have found this to not be the case. Since utilising oral prednisolone tablets in these severe cases, the amount of severely dehydrated women has markedly reduced, and the need for intravenous hydration has been almost eliminated. The developing mood changes and subsequent depression also frequently improves. Taking these tablets for a number of weeks may be required, and some other side effects may need to be checked, but in these sever cases the benefits remain very strong.
Speak to your obstetrician about HG
If you have had severe HG in the past, aggressive treatment in a future pregnancy should be able to control things to a satisfactory level and you should not be too fearful of having another pregnancy if you wish. Take the opportunity to talk to an obstetrician before you conceive to have a better knowledge of your options and plan treatments that are acceptable for you.
