Hyperemesis is a physiological disease, although some persistent myths of a psychological etiology exist which detrimentally delay care for patients. Early, aggressive intervention often results in fewer complications and reduces overall medical costs. As each patient is different, it is most critical that therapies target symptoms and adjust to the response.
Further, each patient will respond differently to treatments, and since the cause is multifactorial, multiple medications may be needed. IV fluids can be given at home in some countries at very low cost and minimal risk. Fluids can also include much-needed vitamins.
Proactive intervention with a consistent treatment plan can decrease both severity and duration of symptoms, not to mention reduce complications. The challenge is finding the treatment that works for each woman.
Secondary Psychosocial Sequelae
Depression is a natural consequence of being confined to home or bed, and unable to perform even simple daily activities or care for one's self. Anxiety often results from the thought of vomiting and retching relentlessly, as well as endless nausea. Many women fear dying and feel guilty that they may lose their unborn child if they don't force feed themselves, despite the inevitable vomiting that follows. Effective treatment is crucial to prevent psychosocial stress.
Patient Comfort Measures
Women with hyperemesis are very miserable and deserve to be treated with great compassion. Extra measures taken to give her comfort are beneficial both physically and psychologically.
- Aggressively treat symptoms to prevent complications and misery.
- Warm intravenous fluids for comfort and reduced calorie loss due to shivering.
- Offer warmed blankets and a bed (v. reclining chair).
- If multiple sticks are required for an IV, use anesthetic and utilize most skilled personnel to avoid scarring. Preserve the veins as repeat IVs are common!
- Try antiemetics and vitamins non-orally (sublingually, IV, subcutaneous, vaginally, or rectally); avoid intramuscular injections due to muscle atrophy and low pain tolerance.
- Minimize noise and odors, as well as interruptions to sleep.
- Request a PT consult for education on progressive exercise to minimize atrophy.
- Offer to listen with compassion and empathy.
- Do all you can to help her cope with the misery, losses, stress, and discomfort.
Antiemetic (anti-vomiting) medications are the most common and typically most effective treatments for HG. The risks are often outweighed by the benefits in most cases as the risks of nutritional deficiencies and chronic dehydration can be life-threatening. Pregnant women in general fear the safety of medication and will not request it unless necessary.
Numerous medications are available that can be combined and used in different format (compounded, transdermal, subcutaneous) and doses to achieve an effective treatment regimen. However, it is important to understand how medications work and what effects they have so mothers can determine if medications are effective.
Trying the most effective medications in different forms and doses is important before trying different medications.
- Symptom relief is not 100%.
- May need non-oral medications
- Medications don’t target nausea.
- Different medications may have to be tried.
- Medications should not be discontinued abruptly.
- Medications may be needed until delivery.
- Risks are similar regardless of dose.
Nausea and vomiting for just a few weeks causes significant nutritional deficiencies, which worsen nausea and vomiting. If nutrients are not replaced, serious complications and a prolonged recovery may occur. Intravenous (IV) administration is most effective and few women tolerate oral vitamins throughout pregnancy, and absorption is unreliable.
Preventing weight loss is crucial to reducing complications for both mother and baby, so strategies to improve nutritional intake are essential to effective HG management.
Therapeutic termination is usually avoidable with aggressive treatment of HG. Those who terminate do so most often because of:
- Debility impairing their ability to work or care for family,
- Delayed, ineffective, or inadequate medical intervention, and
- Care given by clinicians lacking understanding or compassion.
However, abortion should be considered a last resort. The long-term consequences, both physically and physiologically, are very significant.
Women with HG who terminate a wanted pregnancy often suffer with guilt, trauma, and depression, sometimes for decades.
- Compassionate & proactive care
- Effective & aggressive antiemetic therapy
- Family education & psychosocial support
- Rehydration and nutritional supplementation
Offsite Research: PubMed Research on HG and Abortion
CAM directed by a licensed holistic professional is sometimes effective in easing nausea and vomiting in milder cases of HG, however, it most often is integrated with traditional medical care.
Chiropractic, Osteopathic & Massage
Women on bed rest often have significant pain due to atrophy, pregnancy-related body changes, and immobility. It often increases in the third trimester due to rapid fetal growth. Use of these treatments assists in muscle relaxation and toxin release, increasing her sense of well-being. Forceful vomiting can cause dislocation of ribs which may worsen nausea and vomiting. Osteopathic manipulation by a skilled specialist can gently and safely ease resulting symptoms.
While effective for secondary complications such as depression and anxiety if used in conjunction with antiemetic medications and hydration, psychotherapy should never be used as a primary modality for treating HG. It can help women manage the emotions and trauma resulting from HG and recover from residual anxiety, PTSD and PPD (postpartum depression).
Women with HG have numerous other symptoms that often cause significant distress. One is ptyalism (also called hypersalivation, sialorrhea or hyperptyalism), an overproduction of saliva thought to be caused by increased hormone levels. It happens in non-HG pregnancies as well and worsens nausea. There are few treatments and most women just tolerate it by spitting into a cup or tissue.
In severe cases, a suction machine may be prescribed to avoid skin irritation on the lips and chin from constant exposure to saliva. Some report dopamine antagonists like Scopolamine may help. Attention must be given to fluid levels as the amount of saliva lost can be very significant.
The care of women with severe hyperemesis extends beyond non-oral medications, IV fluids, and steroid therapy. Thiamin replacement, along with other vitamins and minerals (particularly B1, folic acid, K, Mg, D) is required within 2 weeks of reduced intake and nausea/vomiting to avoid worsening of HG symptoms, and complications such Wernicke's encephalopathy. Oral thiamin prior to the onset of nausea/vomiting is highly recommended.
Women with a history of HG should take B vitamins including 50 mg of thiamin or more prior to conception and as long as is tolerated during pregnancy. A single vitamin like just B1 versus a multi-vitamin product may be better tolerated. Thiamin is an essential cofactor for electrolyte balance and critical enzymes of carbohydrate metabolism. Thus, it is important that thiamin is replaced orally and/or IV in women with a high carbohydrate diet and always before IV dextrose is given. Lack of thiamin can result in serious complications.
Significant heartburn and esophagitis is frequently caused by the regurgitated gastric acid and requires treatment with acid reducing medications or proton pump inhibitors. Reflux can be worsened by slow gastric motility and constipation. Ideally, acid reducing medications are used before erosion and damage occur in the mouth (e.g. teeth), esophagus and stomach.
Mobilization must be gradual as physical movement exacerbates the underlying nausea. A physical therapy consult may be helpful periodically with an at home exercise regimen as tolerated, most likely beginning in the 2nd trimester. Mobility also helps with gastric motility and overall conditioning.
Insurance coverage often includes home IV care or scheduled outpatient infusion visits which allows the mother to avoid frequent dehydration-rehydration cycle. This cycle worsens HG and delays recovery. Many women state they feel so much better after getting IV fluids, only to begin vomiting and have to return a few days later for more fluids. Scheduled IV fluids can prevent this.
A peripheral IV can be left in for up to a week, provided it does not infiltrate or become infected. However, consideration should be given to a longer dwelling catheter like a midline catheter if a mother has severe, refractory symptoms early in pregnancy. This can be left in for a few weeks and, unlike PICC lines, only goes about 3" into the vein so there may be less risk of complications due to sepsis. Both have risk of clotting due to physiological changes of pregnancy.
Many doctors are not aware of the concept of stopping the dehydration cycle to avoid exacerbation of HG. Any mother producing ketones or exhibiting signs of dehydration should receive methodical IV fluids with IV vitamins and electrolytes.
Importantly, ketones are not a reliable indicator of HG, and thus not required to diagnose or treat HG.
Vitamins are critical in mothers vomiting more than a few weeks to prevent life-threatening complications.