The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 15th 2012 is the first annual Hyperemesis Gravidarum Awareness Day, sponsored by the H.E.R. Foundation.  H.E.R. is an acronym for Hyperemesis Education and Research, and this non-profit organization’s mission is three-fold;

  • Find a cure for hyperemesis and its complications through advanced research,
  • Provide education and support to those seeking effective management strategies for hyperemesis, and
  • Provide information on new resources and treatment options as they become available.

I had an opportunity to speak with Ann Marie King, one of the co-founders of H.E.R. Foundation, to learn more about this disease of pregnancy and what the foundation offers to affected women.  The foundation was founded in 2002 by Ms. King, her husband, Jeremy King and Kimber MacGibbon, and is 100 percent volunteer run. Ms. King told me that “women are struggling and may need help recognizing when the situation has progressed beyond normal morning sickness.  It is not a willpower issue but a disease of pregnancy.”

Hyperemesis Gravidarum (HG) is different than the “normal” nausea and vomiting that affects 50-80 percent of pregnant women, most often in the first trimester (Matthews, 2010).  In most cases, typical “morning sickness” (which can occur at any time of the day or night) resolves itself around the end of the first trimester and becomes a distant memory as women prepare to meet their baby.

Hyperemesis Gravidarum can be a serious complication of pregnancy and may require medical intervention to prevent permanent  or serious injury to mother or baby.  According to the American Congress of Obstetricians and Gynecologists (ACOG), the most commonly cited criteria for diagnosis include;

  • Persistent vomiting not related to other causes
  • A measure of acute starvation, usually large ketonuria (indicated by ketones, the byproducts of inadequate nutrition, in the urine)
  • A discrete measure of weight loss, most often at least 5% of prepregnancy weight (ACOG, 2004).

Hyperemesis Gravidarum  affects between 0.5 and 2.0% of pregnant women and accounts for over 285,000 hospital discharges in the United States annually (Wier, 2008).  Women with HG may experience dizziness, fainting, weakness, hematemesis (vomiting blood), dehydration, nutritional deficiencies and electrolyte imbalances.  In extreme cases, mothers may suffer renal failure and liver dysfunction along with other severe complications.  Babies born to mothers who have experienced prolonged HG may experience low birth weight, intrauterine growth restriction (IUGR), preterm delivery and in some cases fetal or neonatal death (Dodds, 2006).

While most cases of HG resolve before 27 weeks of pregnancy,  22% of the women diagnosed with HG continue to suffer with the symptoms all the way up to delivery (Fejzo, 2009).

Health care providers are not able to predict who will suffer from HG during pregnancy, but research indicates that women who have the following characteristics may have a higher incidence of HG:

  • Higher body weight
  • Allergies
  • Prior restrictive diet (vegetarian diet, lactose intolerant or food sensitivities)
  • Younger age at time of pregnancy (Mullin, 2012)

More research is needed to determine if HG is an autoimmune disease but some study results indicate that there may be an autoimmune component.

The impact of HG on pregnant women is significant and cannot be underestimated.  Daily function is severely impaired, and the ability to work or take care of family is limited.  Repeated hospitalizations impact the entire family and may create a financial burden with the additional medical expenses.  Depression and anxiety are more common among women who suffer from HG throughout their entire pregnancy (Mullin, 2012).   Family members and friends of women diagnosed with HG may struggle with understanding the disease and are unsure of how to offer support to those who suffer from it.

Treatment for HG includes IV hydration, antiemetics, serotonin inhibitors (a form of antidepressant medication) and in severe cases, parenteral nutrition (nutrition that bypasses the digestive system and is delivered directly into a vein). Dealing with severe cases of HG earlier in pregnancy appear to reduce the length of the overall problem.

More than 80% of women who had HG had a negative psychosocial impact.  After delivery, women who have experienced HG have been diagnosed with Posttraumatic stress symptoms (PTSS) at a rate of 18%.   Postpartum self care difficulties, impact on breastfeeding rates,  ability to care for children, more missed work or school, financial and maritall difficulties are areas where the impact of HG is observed, even though the symptoms of HG have been resolved (Christodoulou-Smith, 2011).

Childbirth educators who teach early pregnancy classes have a fantastic opportunity to support and offer resources to women who may be suffering from HG.  Referring women to local health professionals who recognize that early treatment can reduce the severity of HG can be extremely helpful.  A list of health care providers and facilities experienced in treating HG who have self identified or been referred by women suffering from HG is available on the website.

Encouraging local mental health counselors to offer perinatal support groups for women with HG may help reduce the trauma that women experience during pregnancy and in the postpartum period.  Consider speaking with your hospital or prenatal clinic about adding this feature to your programs.  Take a moment during your childbirth class to acknowledge that some women may be continuing to deal with the emotional and physical challenges of HG and let them know about local and online resources available to them.  If a LCCE or other professional was interested in having a speaker come in to class to talk about this disease, the Foundation can provide a list of available women.  The H.E.R. Foundation website includes an extensive peer support forum where women can connect online with other mothers suffering from HG if local support is not available.

If you are aware of women who have been impacted by Hyperemesis Gravidarum, consider asking them to participate in a survey and study looking at genes and risk factors for this debilitating condition.  Info on participation can be found at this link.

Share with us how this issue of Hyperemesis Gravidarum is being addressed in your community and what are your favorite resources to provide to women who may be in your classes with this challenging condition.

Sources

Bailit JL. Hyperemesis gravidarum: Epidemiologic findings from a large cohort. Am J Obstet Gynecol 2005;193:811–814.

Christodoulou-Smith, J., Gold, J. I., Romero, R., Goodwin, T., MacGibbon, K., Mullin, P., Fejzo, M., (2011). Posttraumatic stress symptoms following pregnancy complicated by hyperemesis gravidarum . Journal of Maternal-Fetal and Neonatal Medicine , 24(11), 1307-1311.

Dodds L, Fell DB, Joseph KS, Allen VM, Butler B. Outcomes of pregnancies complicated by hyperemesis gravidarum. Obstet Gynecol 2006;107:285–292.

Fejzo MS, MacGibbon K, Korst L, Romero R, Goodwin TM. Extreme Weight Loss and Extended Duration of Symptoms among women with hyperemesis gravidarum. J Women’s Health 2009;18:1981–1987.

H.E.R Foundation http://www.helpher.org/

Kallen B. Hyperemesis during pregnancy and delivery outcome: A registry study. Eur J Obstet Gynecol Reprod Biol 1987;26:291–302.

Matthews A, Dowswell T, Haas DM, Doyle M, O’Mathúna DP. Interventions for nausea and vomiting in early pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD007575. DOI: 10.1002/14651858.CD007575.pub2.

Mullin, P. M., Ching, C., Schoenberg, F., MacGibbon, K., Romero, R., Goodwin, T. M., & Fejzo, M. (2012). Risk factors, treatments, and outcomes associated with prolonged hyperemesis gravidarum. Journal of Maternal-Fetal and Neonatal Medicine, 25(6), 632-636.

Nausea and Vomiting of Pregnancy. ACOG Practice Bulletin No. 52 American Congress of Obstetricians and Gynecologists. Obstet Gynecol 2004; 103:803-15.

Verberg MF, Gillott DJ, Al-Fardan N, Grudzinskas JG.Hyperemesis gravidarum, a literature review. Hum Reprod Update 2005;11(5):527–539.

Wier LM, Levit K, Stranges E, Ryan K, Pfuntner A, Vandivort R, Santora P, Owens P, Stocks C, Elixhauser A. HCUP facts and figures: statistics on hospital-based care in the United States, 2008. Rockville, MD:Agency for Healthcare Research and Quality; 2010

17 Comments

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 15, 2012 07:00 AM by Kathy Morelli
Hmm, new information for me, will have to keep this in mind and look into this further, Can't imagine running a group for HG survivors, as it is so hard to fill mom groups, women are so busy! Been trying for years! Online seems to work better! But sure can work this into individual therapy, as it can be a confounding issue to be aware of. I had severe morning sickness with my son (17 yo now). It was so bad, it felt like I was on a boat. I couldn't work. I couldn't drive. I stopped eating & drinking, dr was mulling over whether to hospitalize me. My husband came home one day, looked at me laying sick on the couch. Said, You are going to an acupuncturist! Off I went to my fave local acupuncturist (thank you, Dr Kadar) and voila no more morning sickness! I ate a huge meal after the first treatment, then went back for a second session and that was it. I'm not saying this will work for everyone..but worked for me. I wonder if the PTS symptoms are from a combo of hospitalization and the severe morning sickness...med tx, even when necessary are traumatizing...?? thanks for bringing up something new to keep in mind. take care, Kathy

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 15, 2012 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
Thanks Kathy, you are so right, Complimentary and Alternative Medicine (CAM) like acupuncture, can be a big help for women dealing with this, and for some may offer the relief they need. I am glad it worked for you! Being open to all potential alternatives is very important.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 15, 2012 07:00 AM by Karen
If it wasn't for HER I would have had next to no support through my HG pregnancies. Spend some time reading the HER forums and a recurring theme is "I am so glad I found you, now I am not alone!!" So many doctors and midwives either undertreat HG and/or blame the mother. My first HG pregnancy I received NO treatment and was told, "Don't call until you can't keep any fluids down for three days." THREE DAYS? And I listened. Thankfully I received adequate and compassionate care for the other HG pregnancies. Therapies and treatment are important but moral support is almost as important to the HG sufferer. Knowing she isn't alone, she isn't crazy, she isn't a bad mother, she isn't a closet bulimic, she isn't a hypochondriac....these are just as important for her long term mental health as zofran and IV fluids are for her short term physical health.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 15, 2012 07:00 AM by Ami Burns, LCCE, FACCE
This is a really important topic-glad you covered it! I had severe morning sickness well into my 2nd trimester with both of my pregnancies. I just wrote about it, too: http://www.allparenting.com/my-pregnancy/articles/946059/hyperemesis-gravidarum Thanks for sharing this info-yet another way for moms to get support and know they are not alone.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 15, 2012 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
@Ami Burns, CD(DONA), LCCE, FACCE Thanks Ami, I look forward to reading your story! HG really sounds like such a difficult thing to deal with, I have so much compassion for those mothers who suffer(ed) from it.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 15, 2012 07:00 AM by Connie Sultana, BA, CD (DONA), LCCE
I apprecaite that the archives are listed on the right. Well done! Is there a way that the archives could list topics - rather than scroll down through the articles each month - perhaps start each month with a list of headers so we can easily scan the topics? There are times that I want to refer to an old S&S and if I just had a list of what topic when it would be great!

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 16, 2012 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
Connie, I am not sure, but I can look into it. You could also try the search field in the upper right, search for a keyword that you think might be in it, and see what comes up. There are some changes in the works, regarding the look of the site, so I may wait a week or two until that dust settles and then reply again!

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 17, 2012 07:00 AM by JJ Luna
This was a fine article, but the first 2 comments were a little alarming. HG is minimized and downplayed enough by medical and non-medical persons alike that "acupuncture fixed my HG entirely," while fine as the experience of one person, could be construed as minimization/ downplaying to the majority of us with HG. Speaking for myself, I could find that comment as invalidating as "eat some crackers and you'll feel much better."

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 17, 2012 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
@JJ Luna Thanks for sharing your thoughts. I agree that HG is a severe and debilitating illness that deserves appropriate and effective medical care. Utilizing alternative methods of treatment, like CAM alongside allopathic medicine, is adding another tool to the toolbox to deal with this serious condition. Many hospitals in my area of Seattle now have acupuncturists, massage therapists, craniosacral therapists etc. on staff and available to see admitted patients at their request. These providers collaborate with other providers and are recognized as part of the health team. Everyone has the same goal of helping the mother, suffering from the effects of this disease of pregnancy. Everyone is different and experiences are quite varied. This mother was sharing her own personal experience. Thank you for doing the same. I appreciate your contribution.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 18, 2012 07:00 AM by Erin
Thank you for this post. I suffered from what I label "moderate" HG in my second pregnancy (mild in the first). I use these designations because I was not hospitalized (ER visits only) and didn't need a PICC line as many women with HG do. I got all my support from the HER forum, which made a *huge* difference in my life - I felt so isolated because there is so little sympathy or understanding about hg, or even morning sickness. People (including physicians) are so casual - oh, that's normal! Women are belittled and under-treated; it's really shocking. And there can be long-term health consequences. I had two nasty and unusual bouts of stomach viruses (with vomiting) this winter, and went back to the HG forum and saw that many women were reporting long-term sensitivity to stomach viruses during and after hg. The gift that keeps on giving! I wish I had gone to an acupuncturist, (I've had great results with it in the past) but I also believe that it would not have "cured" my hg, only minimized the symptoms (I took two types of antiemetics; it stopped the vomiting, but not the nausea, which was unrelenting). I don't meet any of the criteria for women at higher risk for hg, fwiw.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 18, 2012 07:00 AM by Erin
(I just wanted to add that I get frustrated that most of the surveys/studies on hg require TPN to be eligible for the study, which somehow cuts out those of us who had hg but not at such a severe level. I worry that it narrows the definition of hg, distorting both its reach and possible causes.)

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 24, 2012 07:00 AM by The Well-Rounded Mama
Thanks for a good article about HG. I had never heard that a higher body weight was a risk factor for HG. Interesting. However, in those women of size who did get HG, I think it's a risk factor for it not being taken as seriously. Read an experience from a woman of size recently about how her HG was not taken seriously because she was a larger woman and she "could do with losing some weight." Augh. HG is serious whether it's in a small woman or a large woman. Losing weight itself is not the issue (many women of size lose a little bit of weight early in the pregnancy without it being HG), but if they are nauseous and constantly vomiting and having these other symptoms, it needs to be looked at and taken seriously and TREATED, whatever the woman's size.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 24, 2012 07:00 AM by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE
I agree, when a women is starting out from a place of "having extra to lose," HG can often be discounted as HCPs might be less concerned about significant weight loss. And yet, a weight loss of 5% in an obese woman can mean a large amount of pounds have been lost as a result of the HG. Despite being large to start with, the mother and baby are still suffering the very debilitating effects of severe HG, and should be treated appropriately.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

May 26, 2012 07:00 AM by links for thought, May 2012
[...] Sharon Muza at Science and Sensibility, “The Reality and the Research behind Severe Morning Sickness (Hyperemesis Gravidarum)” The impact of HG on pregnant women is significant and cannot be underestimated.  Daily [...]

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

June 18, 2012 07:00 AM by Jerry
I read everything and tried everything for me. I had a pick line for TPN and IV for 8 months. My last throwing out of my stomach fluid was on the C-section bed. while being cut ...N body knows about the real deal unless you go through it . The blood transfusion, the pick line infection, the liver damage. the gallbladder stone.. Above all the trauma of mien which left a big scar and scare until today. who would forget that ... the nurse who blames me for causing my won sickness. the judgment and the misunderstanding or my sickness. Is there any world good enough to express it ??!!! the 8 month hell went through just to be a mom? The everyday warning from my Dr. to take my bay out. the warning of losing my baby and my own life ...no body know the real deal except me and my doctor.

The Reality and the Research Behind Severe Morning Sickness (Hyperemesis Gravidarum)

December 3, 2012 07:00 AM by Ann F Grauer, LCCE, FACCE, AdvCD/AdvPCD(DONA)
I had this with my last pregnancy and, like the Duchess, was hospitalized for about a week because of it. I have never been so sick in my life and the only thing I can compare it to since is when I had shingles the first time. Absolute misery. What made it so much worse was the attitude of the nurses who took care of me. They and the hospital dietician were convinced it was because I had "emotional issues" due to the fact that my pregnancy prior to the last one ended in a stillbirth. I could not convince them it was not in my head and it was highly demoralizing. Thank goodness my doctor fully got it and told them to be quiet. It's very hard to be happy when you cannot sit up without vomiting, can't open your eyes without it happening, etc. The B complex vitamins through IV's finally made a difference. If not, I don't know what would have happened. Thank you for bringing this forward.

I only had the one pregnancy a

March 3, 2016 07:00 AM by Jaime
I only had the one pregnancy as my Hg was so severe it took me 5 years before i could even speak about it without crying..i still have flashes to that nightmare time 8 years on. I started vomiting at 6 weeks pregnant and didn't stop until my baby was born. I wasn't able to put a drop of water or food in my mouth for 10 weeks straight. I had to go to hospital every second day for fluids (for entire pregnancy) and finally at 16 weeks was given Ondancetron to help with nausea. If i sat up i threw up, even without any food in me. I was vomiting blood at the end and even burst some blood vessels in my eyes..by the time my baby was born (premature at 35 weeks) I'd lost 20 kilos. I have since developed an autoimmune disease that i believe is a result of my hg..has anyone else experienced a similar after shock?

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