Nausea and vomiting affects around 80% of pregnant women to a greater or lesser degree making it the most common medical condition in pregnancy (Gadsby and Barnie-Adshead, 2011). Around 30% of women will be severely affected; however, only 1–1.5% of pregnant women will be admitted to hospital with extreme nausea and vomiting, known as hyperemesis gravidarum (Gadsby and Barnie-Adshead, 2011). With 729 674 live births in the UK in 2012, admissions for hyperemesis gravidarum (HG) are significant at nearly 11 000 across the UK (Office for National Statistics (ONS), 2013). Furthermore, the rate for therapeutic termination for HG is estimated to be 10% in the UK, accounting for further morbidity and admissions (Poursharif et al, 2007; Pregnancy Sickness Support, 2013). In the financial year of 2003/04, the cost for admission for HG in England was estimated to be at £36 481 745 (Gadsby and Barnie-Adshead, 2011). It is the most common reason for hospitalisation in early pregnancy and the second most common reason throughout pregnancy—preterm labour being the first (Goodwin, 2008).
HG is a severe and potentially life-threatening condition, which can have a profound effect on the sufferer's health and wellbeing. Clinical manifestations of HG include weight-loss of 5% or more of pre-pregnancy weight, ketosis and/or a urine output of <500 ml in 24 hours. Electrolyte imbalance can occur and if left untreated, and further complications can follow. HG is considered an appropriate diagnosis when symptoms are severe and persistent enough that they reduce a woman's quality of life, affect her ability to conduct acts of daily living and prevent her from eating and drinking (Dean and Gadsby, 2013).
A woman's psychological wellbeing can be negatively affected by HG. She may experience feelings of depression, relationship difficulties and she may feel she is a less effective parent or have concern for the health of her unborn child (Swallow et al, 2004). HG can last until birth (Fejzo et al, 2009) and when poorly managed in the second trimester and beyond, physiological complications may include oesophageal tears, placental dysfunction disorders such as pre-eclampsia (Bolin et al, 2013) and, the potentially fatal complication, Wernicke's encephalopathy (D'Abbicco et al, 2011).
In addition to physiological and psychological complications there can be further difficulties for families who experience financial difficulty due to time off work and increased need for child care while the mother is incapacitated with HG (Gadsby and Barnie-Adshead, 2011).
Recurrence of hyperemesis gravidarum
Unlike with the majority of pregnancy sickness, which may be experienced by a woman in one pregnancy and not in another, women who have a history of HG have around an 80% chance of suffering again in a subsequent pregnancy (Fejzo et al, 2011; Clark et al, 2012). Of these repeat occurrences, approximately 30% of women will have a similar severity to there first, 26% will have more severe symptoms and 44% report symptoms are less severe (Brecht-Doscher and Jones, 2010). A large online survey by Pregnancy Sickness Support (2013) found that of the women whose symptoms were less severe in subsequent pregnancies, 50% reported that this was due to better treatment in their previous pregnancy. Therefore, it is important women with a history of HG are seen early and encouraged to plan their medical and personal management prior to pregnancy. In the same survey, 53% of respondents said that their family size had been limited by recurrence of HG (Pregnancy Sickness Support, 2013).
Maltepe and Koran (2013a) found a significant reduction in the severity of HG symptoms in subsequent pregnancies when treatment was started preemptively compared to controls whose treatment started after the onset of symptoms. The principle of early treatment is similar to that of motion sickness treatment (which is started prior to commencing travel) and, similarly, in oncology prophylactic antiemetics are administered to prevent acute and delayed chemotherapy-induced nausea and vomiting (Jordan et al, 2007).
For a significant number of women, nausea and vomiting symptoms can start before a missed period (Gadsby and Barnie-Adshead, 2011) and for over half of women with HG, onset is sudden with rapid deterioration to severe and debilitating symptoms (Pregnancy Sickness Support, 2013). For this reason, planning and preparation prior to pregnancy is better than waiting until sickness is experienced. Health professionals need to be aware of the importance of early intervention and prescribing in advance of symptom onset. Furthermore, midwives seeing women at the end of pregnancies affected by HG, or post-partum, can counsel them on the importance of early preparation and treatment for subsequent pregnancies and provide information about accessing early prenatal appointments for women with a history of HG (Brecht-Doscher and Jones, 2010).
Developing a pre-emptive care plan
An effective and complete holistic care plan should include all the factors in Box 1. Women with HG commonly report feelings of being ‘out of control’ adding to their distress, along with fear and an inability to advocate for themselves and difficulty communicating with their health care providers (Swallow et al, 2004; Sykes et al, 2013) so having a thorough plan in place may increase a woman's autonomy over her situation. Kripalani et al (2014) found that careful and thorough discharge planning from hospital can reduce readmission rates.
Physical preparation
Low pre-pregnancy weight is associated with an increase in hospital admission for HG (Rochelson et al, 2003) and a high pre-pregnancy weight is also associated with an increase in nausea and vomiting symptoms (Gadsby and Barnie-Adshead, 2011). Therefore women should be advised to aim for a health body weight prior to pregnancy. In her role in the charity, the author is commonly asked by women if they should aim to have ‘a little bit of weight to loose’ when beginning pregnancy. From her experience, suggesting mothers aim at higher end of a healthy body mass index (BMI) of 23–24.9 kg/m2 is a welcome goal for women to allow for inevitable weight loss without causing extra worry for the mother.
In addition to folic acid, women with a history of HG can be advised to take a supplement of vitamin B6 (pyridoxine), 10 mg four times per day (Maltepe and Koren, 2013a). Vitamin B6 has been associated with reduced nausea and vomiting in pregnancy (Lee, 2011). Because a lack of vitamin supplementation prior to 6 weeks gestation has the highest correlation with vomiting, supplementation needs to be started before pregnancy (Brecht-Doscher and Jones, 2010). Furthermore, in the author's experience, inability to take pregnancy vitamins once vomiting has started can be a source of stress and worry for the pregnant woman with HG, reassuring women that the most protective effects of folic acid are achieved by days 26-28 of the pregnancy may help to reduce the anxiety she may be experiencing.
Basic lifestyle changes made before pregnancy may make continuing them into early pregnancy more manageable. Maltepe and Koren (2013b) recommends counselling women to start eating small frequent meals with a source of protein before pregnancy in order make maintaining the self-help technique more effective (Table 1).
| Instead of | Try |
|---|---|
| Two slices of toast for breakfast | One slice at breakfast and the second 1 hour later |
| Not snacking until lunch | Add a high protein snack mid-morning |
| One sandwich at lunch time | Have half as an early lunch and the other half 1 hour later |
| Not snacking until dinner | Add a high protein snack mid-afternoon |
| Eating a large meal in the evening | Have a lighter meal early evening and a snack later in the evening and before bed |
Prophylactic medication
Maltepe and Koren (2013a) conducted a randomised control trial for pre-emptive treatment of nausea and vomiting of pregnancy and found that starting treatment prior to symptom onset had a significant positive effect on the overall severity and duration of HG symptoms. While treatment plans need to be addressed individually, it is appropriate to start with the treatments that have the most data for safety and effectiveness and move on from that as required. Therefore starting with antihistamine such as cyclizine or promethazine is appropriate (Bottomley and Bourne, 2009; Ebrahimi et al, 2010).
National Institute for Health and Care Excellence (NICE) do not have specific guidelines for the treatment of HG; however, they do recommend antihistamine treatment for commonly experienced NVP (NICE, 2008). Furthermore their Clinical Knowledge Summary Management Scenario (NICE, 2013) recommends early treatment with cyclizine or promethazine, which can prevent deterioration and complications.
Criteria to assess deterioration
Symptom tolerance is unique for each woman and her circumstances, for example, a woman who has full time child care and plenty of support may be less willing to take medication than a women who has small children at home all day and who has no support, or who cannot afford to take time away from work. Furthermore, it is important to note the impact that nausea, alone or with retching, can have on a woman's physical and mental health (Davis, 2010).
In addition to deciding on criteria indicating deterioration, it is important to discuss a method of monitoring the criteria, such as patient reporting. Women can be taught to monitor their own fluid balance and/or conduct keto-analysis at home and this can enable a woman to feel she has more control over her life and symptoms (Dean, 2014) (Table 2).
| Symptom | Method of monitoring |
|---|---|
| Vomiting >5 per day | Patient reporting |
| Weight loss >5% of pre-pregnancy weight | Patient reporting/weighing by GP/nurse/midwife |
| Fluid intake <500 ml per day | sPatient reporting |
| Urine output <500 ml per day | Patient reporting |
| Nausea/vomiting preventing reasonable level of functioning | Patient reporting |
| Ketosis | Urinalysis by patient or health professional |
Clinical tools such as the Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) (Koren et al, 2002) can also be used for assessment. This validated scale consists of three questions regarding vomiting, retching and episodes of nausea which, when answered by the sufferer, renders a score between 3 and 15 depending on the severity of symptoms. A score of 6 or less is considered mild nausea and vomiting, a score of 7–12—moderately severe, and a score of 13 or more—severe. The benefit of this tool is it allows quick and easy assessment of the morbidity caused nausea and/or retching without associated vomiting. It also can be used for assessing the effectiveness of the treatments or deterioration requiring further treatment.
Further treatment options if required
There are a number of treatment options considered safe and effective for HG and it is important they are used in severe cases to control symptoms effectively (Lane, 2007). The treatment ladder (Figure 1), has been devised has been devised by the author and colleagues at Pregnancy Sickness Support, combining the Jarvis and Nelson-Peircy (2011) recommendations and Lane (2007) tailored approach to treatment, into an accessible visual tool. It also incorporates the Al-Ozairi et al (2009) recommendations for steroid therapy for nonresponsive, severe HG. Assessment of symptoms should occur between each step of the ladder.
With each increase in medication, symptoms should be reassessed to evaluate effectiveness of the treatment, and adjusted accordingly. Side effects should also be balanced with treatment benefits; the PUQE score can be useful for this.
Women, their families and health professionals tend to overestimate the teratogenic effect of antiemetics, which leads to them being under used in the management of HG (Koren and Levichek, 2002). By discussing the various options in advance of pregnancy both the health care team and the woman can feel confident approaching the pregnancy in a pro-active way. The health care provider will know that the woman is taking treatment for which she has provided informed consent and the women herself will have had the opportunity to explore the pros and cons of the regimen and ask any questions about the treatment.
Defining the criteria for admission to hospital
Criteria for admission to hospital can be decided on in advance of the pregnancy. This can help women feel more in control of their situation (Dean, 2014), as once a woman is sick she may find advocating for herself more difficult (Sykes et al, 2013). Routes for ward admission can be arranged in advance, for example, via GP referral to a preferred hospital or via direct access to the ward. Many city hospitals, such as Birmingham Women's Hospital, now offer HG clinics, which provide iv fluids in a day care setting. In some areas of the UK, particularly the South West, iv at home services are becoming increasingly available for women with HG. Knowing what is available prior to pregnancy can ensure local services are used in the most effective manner. Furthermore, by giving women access to timely rehydration services the overall length of hospital admission may be reduced (Dean, 2014).
Psychosocial management
An holistic pre-emptive care plan for a woman with a history of HG should address both the medical interventions to be used to control the severity of symptoms and the psychosocial measures to be implemented to lessen the impact of the condition on her and her family's lives. Psychosocial morbidity is common for women with HG, with secondary depression and/or anxiety developing in nearly half of HG cases (Tan et al, 2010) and in a large scale survey by Poursharif et al (2008) 83% of women with HG reported a negative impact on their psychosocial wellbeing. HG has been found to increase the risk of post traumatic stress disorder (Christodoulou-Smith et al, 2011). Factors such as the suffocation sensation that comes with unrelenting retching and vomiting can be traumatic and may trigger symptoms such as flashbacks, intrusive images, nightmares, numbness, depression, and a tendency to feel withdrawn. As these can continue for some time after the birth, there may still be trauma from a previous pregnancy that should be addressed during the planning of a subsequent pregnancy. If perinatal mental health services are available in the area, then referral to this may be valuable (Dean, 2014).
Psychosocial factors, such as the inability to care for family, significantly contribute to decisions to terminate pregnancies complicated by HG (Poursharif et al, 2007); therefore, encouraging women to consider how they will prepare for this in advance may reduce this. Factors to consider include child care, household chores and self-care. Families should anticipate the need for rest and potential hospitalisations. Further reasons cited by Poursharif et al (2007) for termination include inability to work for extended periods. Therefore signposting to information about sick leave rights and employment laws could reduce this impact (Brecht-Doscher and Jones, 2010). Further information about employment rights and pregnancy sickness can be accessed via the UK charity Pregnancy Sickness Support (Box 2).
Most women, particularly those entering second HG pregnancies are aware of the complementary and alternative therapy (CAM) options for pregnancy sickness (O'Hara, 2013). If they wish to try using CAM techniques again then ensuring they are evidence-based and considered safe for pregnancy can form part of the planning process (Tiran, 2014).
Many women with HG feel very isolated (Sykes and Swallow, 2013). The Pregnancy Sickness Support network is a peer support system, which can significantly reduce the isolation women experience. Women who are currently suffering HG are matched with women who have suffered themselves, ideally from the local area, although this is not always possible. Women are supported via phone, text message or email and sometimes via face-to-face meetings at hospital or home. Volunteers are fully trained and provided with supervision and support. The network is run by an employed coordinator and although women cannot currently be matched until they are pregnant they are able to access the forum to talk to other women also planning pregnancy, and they can contact the charity for further information. An internal review of the impact of their support network found that the most commonly reported benefit was a reduction in isolation (Pregnancy Sickness Support, 2014). Midwives can refer consenting women to this service during pregnancy.
Conclusion
Women with a history of HG are at high risk of experiencing similar symptom severity in subsequent pregnancies. It is wise, therefore, to develop a management plan in advance, particularly as women often find communication and advocacy more difficult once they are symptomatic. Pre-emptive treatment could reduce the overall severity of symptoms but prescriptions need to be issued prior to a positive pregnancy test. Planning should address not just treatment plans but psychosocial factors, which may prove difficult during the pregnancy. By planning in advance of the pregnancy the symptoms may be better controlled, local services better used, and women may feel more in control. This can have a positive impact on pregnancy outcomes and postnatal maternal health.