Hyperemesis Gravidarum – Between a Rock and a Hard Place [Guest Post]

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Hyperemesis Gravidarum

Note: The thoughts expressed here are of guest blogger Caitlin Dean only.

Pregnant and throwing up? No doubt you’ll have heard one or all of the following snippets of wisdom from family, friends and complete strangers:

“Sickness is a good sign, it means the pregnancy is strong”

“It’s normal to be sick in pregnancy, you just have to get on with it”

“The baby will be fine, it takes what it needs from you”

When it comes to regular morning sickness, as experienced by around 80% of pregnant women, all those things hold threads of truth[1]. “Morning sickness”, or as it’s better termed, pregnancy sickness as it is rarely confined to the mornings, is associated with a decreased risk of early miscarriage, but that is not to say you definitely won’t miscarry. It can come as a particularly harsh shock to lose your baby after weeks of sickness made bearable by this association. Sickness is indeed a normal part of pregnancy for the vast majority of women and for them it’s manageable and over within a few weeks. But for around 1.5% of pregnant women [2] sickness escalated well beyond the realms of “normal”, these are women who have a serious complication of pregnancy called hyperemesis gravidarum (HG), literally meaning – extreme (hyper) sickness (emesis) of pregnancy (gravidarum).

For women who have hyperemesis, getting on with it simply isn’t an option. The nausea is crippling and can feel like your whole body has been poisoned. The vomiting can be near on continuous while you’re awake with episodes anywhere from 5 to 50 times a day. It’s not unusual to start vomiting blood or burst blood vessels with the strain. It’s hardly a wonder then that, after just a couple of days of this, women start to lose weight and become dehydrated. And, at that point, the idea that “baby will be fine” becomes a nonsense[3, 4].

That’s not to say baby will be harmed by it… the jury is out on that one still, as evidence of the long term effects of starvation in early pregnancy and the impact of mom coming under huge amounts of stress is discovered[5]. But, unless effective treatment is forthcoming from knowledgable health professionals, for 10-20% of women, termination becomes the only option – and in those cases baby certainly isn’t fine[6, 7].

In addition to the incorrect notion that baby will be just fine is the rather derogatory disregard for the women’s health… even if we could guarantee that the baby will “act like a parasite and take what it needs”, why should women forego safe and effective treatments at the expense of her own physical and mental health? You’re not selfish if you need to take medication for a serious condition in pregnancy – but you might be a martyr if you don’t!

So – the fact you are suffering at all is the rock, but what is the hard place?

If you are a woman who has taken medication in pregnancy for any reason, you are likely to have come across the following snippets of wisdom from the above mentioned general public and, maybe, your healthcare providers too:

“Nothing is safe to take in pregnancy”

“You can’t take medication in pregnancy as your baby can’t consent”

“Medications cause birth defects”

And in those few words, muttered by well meaning, concerned people they have wedged you firmly between a rock and a hard place for the duration of your pregnancy and beyond.

But, is it true? Well, there are medications out there which absolutely must not be taken in pregnancy. Thalidomide, for example, is the most famous. It was wonderfully effective for nausea and vomiting and a lot of other pregnancy discomforts, but caused devastating side effects in those babies who survived. There are a number of other medications which shouldn’t be used in pregnancy and many more which we do not know the safety of yet. However, there are a number of drugs, particularly anti-emetics, which have been used for decades now with no evidence of major malformations being caused by them. Generally, those with the most evidence of safety are prescribed first and, then, if the condition isn’t controlled, further medications can be used. There are about 4 steps in total, starting with the anti-histamines first, then the phenothiazine type drugs andmetoclopramide. If they fail, ondansetron (Zofran) tends to be effective and has been used for nearly 20 years now. If that fails, steroids can be used to get symptoms under control[8-11].

What about long term effects and minor malformations that aren’t easily recognized at birth? As we established early on, not getting symptoms under control early also carries risks… studies about the impact of the Dutch famine have found starvation in early pregnancy to have an impact on the offspring in mid-life[5].

Unfortunately, for women with hyperemesis, it is not as simple as thinking “oh, I will have a totally natural pregnancy and not take any medication and eat healthily”… they have to weigh up two risks for which we don’t have full information on: the risk of taking medication in pregnancy versus the risk of being dehydrated and malnourished in early pregnancy.

That is never going to be an easy decision to make, which is why more research and help with understanding the level of risks for the various options is so important. For some people, the decision will be easier than for others… if you are at the point of considering termination, clearly trying medication first seems logical. We know none of the medications currently used for hyperemesis cause noticeable problems for the infant, unlike termination! But, what if you’re not at that point, what if your sickness is bad, but not that bad? At what point do you bite the bullet?

Chances are, if you are thinking that your symptoms are so bad that you might need to take medication, then they probably are. If you are not managing to eat and drink normally and the nausea is so bad that you can’t work or look after your home, then you probably need to think about treatment. It’s reasonable to try self-help strategies like resting and eating little and often, but if they are not working or you are getting worse, then medication may be the best option. There is mounting evidence that starting treatment early, before you reach the point of needing to go to hospital for an IV drip, can help to prevent full blown HG and the risks that come with it[8, 12].

It’s also important to get support. If you are in the USA then get in touch with the Hyperemesis Education and Research (HER) Foundation, who have volunteers across the USA and indeed the world to support you. They also carry details for “HG friendly” doctors who will be able to provide you with good care and support, so that you make informed choices about your treatment.

If you are in the UK, then please get in touch with Pregnancy Sickness Support (PSS). They have a helpline you can phone for information about treatment and services in the UK and a network of volunteers across the country who provide one-to-one support. Both organizations also have active online forums where you can get safe support. Facebook has a number of HG groups, but they are not moderated by trained volunteers, so you need to be careful with what you read there.

Finally, I have a blog called Spewing Mummy and a book called Hyperemesis Gravidarum – The Definitive Guide, which has pretty much everything I can possibly tell you about HG and how to survive it. My children’s book “How to be an HG Hero” is for young children to understand why mommy is sick during pregnancy and aims to answer their questions and offer helpful suggestions for a positive experience.

So remember – you don’t need to suffer alone between the rock and the hard place… there is help and support if you look upwards.

About the Author:

caitlin

Caitlin Dean is a 3 time survivor of HG, registered nurse and the chairperson for UK Charity Pregnancy Sickness Support. Involved in research and writing for the medical and lay press, Caitlin spearheads the movement to improve care and treatment for the condition in the UK. She writes the popular blog Spewing Mummy, representing the voice of HG, and has a sheep farm in Cornwall with her husband and 3 kids. Follow her on Twitter.

References

  1. Gadsby, R. and A. Barnie-Adshead, Nausea and vomiting of pregnancy – A literature review. Pregnancy Sickness Support [online], 2011.
  2. Einarson, T.R., C. Piwko, and G. Koren, Quantifying the global rates of nausea and vomiting of pregnancy: a meta analysis. J Popul Ther Clin Pharmacol, 2013. 20(2): p. e171-83.
  3. Mullin, P.M., 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): p. 200-204.
  4. Bolin, M., et al., Hyperemesis gravidarum and risks of placental dysfunction disorders: a population-based cohort study. Bjog-an International Journal of Obstetrics and Gynaecology, 2013.
  5. Painter, R.C., T.J. Roseboom, and O.P. Bleker, Prenatal exposure to the Dutch famine and disease in later life: An overview. Reproductive Toxicology, 2005. 20(3): p. 345-352.
  6. Poursharif, B., et al., Elective pregnancy termination in a large cohort of women with hyperemesis gravidarum. Contraception, 2007. 76(6): p. 451-455.
  7. Dean, C. and C. Murphy, 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 B.P.A. Service, Editors. 2015.
  8. Dean, C., Helping women prepare for hyperemesis gravidarum. British Journal of Midwifery, 2014. 22(12): p. 847-852 6p.
  9. Taylor, R., Successful management of hyperemesis gravidarum using steroid therapy. QJM, 1996. 89(2): p. 103-7.
  10. Al-Ozairi, E., J.J.S. Waugh, and R. Taylor, Termination is not the treatment of choice for severe hyperemesis gravidarum: Successful management using prednisolone. Obstetric Medicine, 2009. 2(1): p. 34-37.
  11. Jarvis, S. and C. Nelson-Piercy, Management of nausea and vomiting in pregnancy. British Medical Journal, 2011. 342.
  12. Koren, G. and C. Maltepe, Preemptive Diclectin therapy for the management of nausea and vomiting of pregnancy and hyperemesis gravidarum. American Journal of Obstetrics and Gynecology, 2013. 208(1): p. S20-S20.
Guest Post
Our guest bloggers come from all walks of life to share their expertise and experience from the worlds of Pregnancy and Lactation. If you wish to submit a blog post for consideration, please write to hello@pregistry.com.

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