Hyperemesis Gravidarum

Hyperemesis Gravidarum (Pregnancy Morning Sickness)

 

What is hyperemesis gravidarum?

Nausea and vomiting in early pregnancy are very common. When the nausea and sickness become excessive and persistent to the extent that the woman is unable to keep food or liquid down, it is then called ‘hyperemesis gravidarum’.

It may start as early as the 6th week of pregnancy, persist for several weeks and usually improve by 12th to 14th week. Very rarely, it may continue throughout the pregnancy.

It can be a serious condition without treatment due to the lack of nutrition for the mother and the developing pregnancy.

 

What are the causes?

Definite causes are unknown. There may, however, be links to the normal hormonal changes in pregnancy and changes in thyroid hormone levels.

Emotional factors and a family history may also have a role in the development of hyperemesis gravidarum. Twin pregnancies may also increase the chance of hyperemesis gravidarum. An abnormal form of pregnancy, called ‘molar pregnancy’, may also be associated with excessive sickness.

Hyperemesis gravidarum may happen again in future pregnancies, although this is not a fixed rule.

 

What are the signs and symptoms?

These include:

  • Prolonged and severe nausea and vomiting (more than three or four times a day).
  • Inability to keep down food or water.
  • Weight loss.
  • Excessive tiredness and dizziness.
  • Passing more concentrated and lower volume of urine than usual.
  • Experiencing headaches and rarely confusion.
  • Dizziness and fainting.
  • Blood is seen sometimes in the vomit.
  • Inability to swallow saliva.
  • Skin becoming pale and dry.

 

What problems can occur as a result of severe nausea and vomiting?

  • Women who become severely unwell as a result of hyperemesis gravidarum are at risk of the following:
  • Vitamin deficiencies.
  • Malnutrition and weight loss.
  • Severe dehydration can put women at risk of deep vein thrombosis – clot in the leg and pulmonary embolism (clot in the lung).
  • Low levels of electrolytes can affect heart rhythm and cause generalised weakness.
  • Severe vomiting can sometimes cause small tears in the gullet.
  • Psychological problems can occur as a result of having to cope with constant nausea.

 

When should women with nausea and vomiting seek help?

Any woman who is experiencing severe symptoms of nausea and vomiting in pregnancy, and who are unable to keep down fluids, should be seen and assessed by a doctor.

 

What is the aim of treatment for Hyperemesis Gravidarum?

The aim is to:

  • Correct dehydration.
  • Break the cycle of vomiting that leads to dehydration.
  • Stop medication such as iron supplements that can make the sickness worse.
  • Ensure there is no other medical problem that could be causing the nausea and vomiting.

 

How will the severe nausea and vomiting be treated?

Fluid replacement to correct dehydration:

  • Fluids are given intravenously directly in to the circulation.
  • Electrolytes such as potassium and sodium can also be replaced by this method.

Anti-sickness medication:

  • There are several anti-sickness medications that can be used on their own or in combination.
  • None of the anti-sickness tablets commonly used in pregnancy are known to have ill effects for the baby.
  • Initially we will administer the anti-sickness medication as an injection but once you feel better you can take this medication orally and it would be prescribed to take home with you.

Vitamin Therapy:

  • Initially vitamin B can be given intravenously (through a drip) but once you are feeling better vitamin B and folic acid can be taken orally.

 

Why do we test the urine of patients with severe nausea and vomiting every day?

Urine is tested for the presence of ketones. When we are eating and drinking normally the body processes the food that we eat and turns it into sugar. In women with Hyperemesis Gravidarum, severe vomiting and dehydration mean that the body is not taking in food normally and therefore has to look for alternative supplies of sugar. Ketones are a waste product of this process.

The presence of ketones in the urine in early pregnancy gives us an indication of the severity of dehydration in patients with Hyperemesis Gravidarum.

Other Investigations that may be carried out:

Blood tests for electrolyte imbalance and a sample of urine will be taken to rule out the possibility of urinary infection that may make the sickness worse.

If you have not had an ultrasound scan, one will be arranged to confirm that the pregnancy is normal and to ascertain the number of babies.

Alternative treatments that you can try:

If you’re finding it hard to cope with morning sickness, there are some natural treatments and drug treatments you can try. Research has found that the ones we list below can help.

Ginger is a natural remedy and one of the most widely used treatments for nausea and vomiting. It is a spicy root used to flavour food such as gingerbread, biscuits, and stir-fried vegetables. It’s also found in drinks such as ginger tea, ginger ale, and ginger beer.

Wearing an acupressure wristband over a certain place on your forearm (called the P6 point) may help to reduce nausea and vomiting.

 

How will I know I am getting better?

You will know you are getting better once you are able to eat and drink and your symptoms have improved and you no longer have

ketones (ketones are toxic (poisonous) acidic chemicals) in your urine.

Advice on discharge from hospital.

You will be discharged home with oral medication to help control the nausea and vomiting. We recommend that you continue to take the medication regularly and to see your GP when the medication runs out.

However, there are many things you can do to help yourself:

  • Eating little and often (for example, every two to three hours).
  • Eating dry crackers or toast.
  • Eating ginger biscuits.
  • Avoiding very rich, spicy, or fatty foods.
  • Eating a little when you wake up before brushing the teeth and taking time to get out of bed.
  • Drinking lots of liquid (but avoiding alcohol and caffeine).
  • Sitting down after eating.
  • Moving slowly and avoiding sudden movements.
  • Getting some fresh air and exercise daily.

 

How will I know I am getting better?

You will know you are getting better once you are able to eat and drink and your symptoms have improved and you no longer have

ketones (ketones are toxic (poisonous) acidic chemicals) in your urine.

Advice on discharge from hospital.

You will be discharged home with oral medication to help control the nausea and vomiting. We recommend that you continue to take the medication regularly and to see your GP when the medication runs out.

However, there are many things you can do to help yourself:

  • Eating little and often (for example, every two to three hours).
  • Eating dry crackers or toast.
  • Eating ginger biscuits.
  • Avoiding very rich, spicy, or fatty foods.
  • Eating a little when you wake up before brushing the teeth and taking time to get out of bed.
  • Drinking lots of liquid (but avoiding alcohol and caffeine).
  • Sitting down after eating.
  • Moving slowly and avoiding sudden movements.
  • Getting some fresh air and exercise daily.

 

What will happen to me?

The good news is that morning sickness usually gets better after the first three months of pregnancy. But for some women it can go on longer. About 1 in 10 women still feel sick after 20 weeks of pregnancy.

Dr. Najlaa Al Tamimi

  • Specialist Obstetrician & Gynecologist
  • MBChB, MRCOG, DGO