Hyperemesis is a physiological disease, although some persistent myths of a psychological etiology exist which detrimentally delay care for the mother. HER's collaborative research has identified multiple genes involved in the causation of nausea and vomiting, including GDF15 which causes cancer cachexia. Early, aggressive intervention often results in fewer complications and reduces overall medical costs. As each woman is different, it is most critical that therapies target a mother's symptoms and be adjusted to her response.
Most effective therapies for HG
Further, each woman 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 should also include much-needed vitamins, especially thiamin, K, and B6.
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 patient.
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.
- Most 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.
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 (peripherally-inserted central catheter) 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.
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 Scopolmine may help. Attention must be given to fluid levels as the amount of saliva lost can be very significant and contribute to dehydration.
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, B3, B6, 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 10-50 mg of Lipothiamine prior to conception and as long as is tolerated during pregnancy. Once intake is limited 100 mg of Lipothiamine 1-3 times per day is needed to prevent serious complications of thiamin deficiency.
A single vitamin like just B1 versus a multi-vitamin product (B Complex) 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 (100 mg/day minimum) in women with a high carbohydrate diet and always give 200 mg B1 IV before IV dextrose is given. Cofactors including magnesium, B6 and niacin should be given as well. Intramuscular injections are not appropriate for HG due to pain and muscle loss.
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.
Prolonged bed rest causes negative effects like atrophy and a delayed recovery time after delivery. It may also affect the child's prenatal development. The best strategy is effective care and remaining as mobile as possible. Physical therapy may be beneficial.
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.
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.
Complementary and Alternative Medicine (CAM)
CAM directed by a licensed holistic professional is sometimes effective in easing nausea and vomiting in milder cases of HG, however, it should be integrated with the options for traditional medical care.
Therapeutic abortion 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.
Therapeutic abortion should be considered a last resort. The long-term consequences, both physically and physiologically, are very significant.
HG patients 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
Secondary Psychosocial Sequelae
Women inadequately treated may terminate a wanted pregnancy to end the misery. Often secondary psychosocial challenges such as depression and trauma result.
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.
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).