Hyperemesis gravidarum

Pregnancy is a time of significant physical and emotional changes for women, and while some discomfort is expected, certain conditions can greatly impact a woman's quality of life. One such condition is hyperemesis gravidarum, a severe form of morning sickness that affects a small percentage of pregnant women. It is essential for expectant mothers to be aware of this condition, its symptoms, and when to seek medical attention to prevent potential complications.

What is Hyperemesis gravidarum?

Hyperemesis gravidarum (HG) is a condition in pregnancy where you have severe and constant nausea and vomiting. It can cause weight loss and dehydration. HG is sometimes known as extreme morning sickness.

Hyperemesis gravidarum (HG) usually starts in the first trimester of pregnancy, around six weeks in. It can last for weeks, months, or even until birth. The symptoms can be very strong and may stop you from doing your daily activities.

Common symptoms of hyperemesis gravidarum:

• Severe nausea
• Vomiting more than three times a day
• Losing more than 5% of your pre-pregnancy weight
• Being unable to keep food or drinks down
• Dehydration
• Dizziness or feeling lightheaded
• Urinating less than usual
• Extreme tiredness
• Fainting
• Headaches

Less common symptoms:

• Low blood pressure
• Fast heart rate
• Dry skin
• Confusion
• Yellowing of the skin (jaundice) due to liver problems
• A rare brain disorder called Wernicke-Korsakoff syndrome

The exact causes of hyperemesis gravidarum are unknown, but it is likely due to the rise in pregnancy hormones. One key hormone is HCG (human chorionic gonadotropin), which your body produces in high amounts during pregnancy. HCG levels are highest around the 10th week of pregnancy, which is when symptoms are usually the worst. Another hormone, estrogen, also increases during pregnancy and may contribute to nausea and vomiting.

While any pregnant woman can develop hyperemesis gravidarum, certain factors may increase your risk, including:

• A previous history of HG in past pregnancies
• Carrying twins or multiples
• Having a genetic predisposition, particularly if your mother or sister suffered from HG (suggesting the condition may run in families)
• Being prone to motion sickness
• Having a history of migraine headaches, menstrual pain, sensitivity to oral contraceptives, allergies, high blood pressure, kidney disease, or liver problems

Preventing hyperemesis gravidarum (HG) with complete certainty is not currently possible. Although there are no known methods to entirely prevent HG, some steps can be taken to potentially reduce its severity or prepare for its impact. Women who have experienced HG in a previous pregnancy have an estimated 89% chance of recurrence. Taking a multivitamin containing vitamin B6 before getting pregnant may help reduce the severity of symptoms. Early, pre-emptive use of vitamin B6 supplements and first-line medications has shown effectiveness in preventing the deterioration of HG symptoms. Maintaining a healthy diet rich in nutrient-dense foods and ensuring adequate levels of essential vitamins like thiamine (B1) may also help mitigate the severity of HG. Lifestyle changes, such as eating small, frequent meals high in protein and avoiding spicy, fatty, or oily foods, can be beneficial. However, it is crucial to note that these measures do not guarantee the prevention of HG but can assist in managing and reducing its impact. If you suspect symptoms of HG or have a history of it, consult your healthcare provider promptly.

Diagnosing hyperemesis gravidarum (HG) involves a combination of clinical evaluation, medical history, and physical examination. The healthcare provider will assess the severity of the patient's symptoms, such as severe morning sickness that impairs their ability to eat and drink normally, affecting daily activities. These hyperemesis gravidarum symptoms typically begin between the 4th and 6th week of pregnancy and can persist throughout the first trimester or longer. Blood and urine tests may be ordered to check for dehydration, electrolyte imbalances, and ketonuria, although the presence of ketonuria is no longer considered a necessary criterion for diagnosis. The provider may also perform tests to rule out other causes of nausea and vomiting, such as gastrointestinal illnesses or urinary tract infections. An ultrasound may be used to determine if the patient is carrying multiple fetuses or has other conditions like trophoblastic disease, which can also cause HG. Once diagnosed, appropriate hyperemesis gravidarum treatment can be initiated to manage the condition and alleviate the debilitating morning sickness in pregnancy.

Managing moderate to severe cases of nausea and vomiting requires medical intervention. Below are key treatment approaches incorporating medications:

1. Prescription Medication

• Doxylamine + Vitamin B6 (Pyridoxine) is often the first-line treatment, helping to reduce nausea and vomiting.
• If symptoms persist, stronger medications such as Promethazine, Metoclopramide, or Ondansetron may be required.

These medications can be administered orally, via injection, or through an IV, depending on the severity of symptoms.

2. IV Fluids

• In cases of dehydration, intravenous (IV) fluids help restore fluid balance and essential nutrients.

3. Tube Feeding

• Severe cases may require nutritional support via a feeding tube inserted through the nose (nasogastric tube) or stomach (gastrostomy tube) during hospitalisation.

4. IV Nutrition (Total Parenteral Nutrition – TPN)

• In extreme cases, nutrients are delivered directly into the bloodstream through an IV, allowing the digestive system to rest and recover.

4. Considerations During Pregnancy

• Some medications carry risks during pregnancy, so it is crucial to consult a doctor before starting any treatment.

Early medical intervention and proper hydration are essential to managing severe nausea and vomiting effectively.

Consulting a healthcare provider as soon as possible is essential if symptoms of hyperemesis gravidarum are suspected or if there is a history of HG in previous pregnancies. Symptoms that warrant a doctor's consultation include persistent and severe nausea and vomiting that interferes with daily activities and nutrition, weight loss exceeding 5% of pre-pregnancy weight, dehydration indicated by excessive thirst or decreased urine output, electrolyte imbalances identified through blood tests, and psychological distress or significant impact on daily life due to symptoms. If you have a history of HG, discussing your previous experiences and developing a care plan with your healthcare provider before becoming pregnant is advisable. This plan should include pre-emptive treatments such as vitamin B6 supplements and first-line medications for morning sickness. Ensure that your healthcare provider understands your medical history and is prepared to support you with a cohesive hyperemesis gravidarum treatment plan. If symptoms of HG start during pregnancy, seek medical attention promptly, as early treatment can help manage symptoms and prevent complications such as malnutrition, dehydration, and electrolyte imbalances.

• Hyperemesis gravidarum (HG) is a severe form of morning sickness that affects approximately 0.5-2% of pregnant women.

• Symptoms of HG include persistent and severe nausea and vomiting, weight loss, dehydration, and electrolyte imbalances.

• While the exact cause of HG is unknown, it is believed to be related to hormonal changes during pregnancy.

• Treatment for HG may include dietary changes, medications, and in severe cases, hospitalization for intravenous fluids and nutrition.

• Although preventing HG with certainty is not currently possible, steps such as taking a multivitamin containing vitamin B6 before pregnancy and maintaining a healthy diet may help reduce the severity of symptoms.

• If symptoms of HG are suspected or there is a history of HG in previous pregnancies, it is essential to consult a healthcare provider promptly for proper diagnosis and treatment.