Hyperemesis Gravidarum (HG) – in the news…..

No doubt there will be a lot of press coverage relating to “morning sickness” in the next week or so. Interestingly in 2006 we published a case control study matching 286 women with HG with the same number of controls without the condition (http://www.ncbi.nlm.nih.gov/pubmed/16720621) . There was no increase in the number of multiple pregnancies or molar disease. Interestingly when a women had HG she was less likely to miscarry. Our conclusion was that we did not need to scan women with this condition as they were not at risk. This data was in contrast to the old “textbook” teaching – but in our view reflects the reality of what is happening with this disorder.

Many women have nausea in early pregnancy and it is mild and generally self-limiting. Women are usually advised to avoid spicy or fried food and eat “little and often” – trying to keep down dry foods. Ginger has often been said to be helpful and certainly there is no harm in trying this. There is also some evidence to suggest acupuncture may have an impact in some cases. Hydration is important. It is usual to check the urine for ketones and to take blood to check for liver disease – but this is unusual.

In the event of “moderate” HG – more supportive therapy is needed. This takes the form of anti-emetic drug treatment and the use if intravenous fluids to maintain hydration. Both these can usually now be managed on an outpatient basis – with women coming in to a day care facility for intravenous fluids before going home. A variety of anti-emetics may be used as first line treatment – promethazine (25 mg 4 to 6 hourly) and metoclopramide (10 mg four times a day) are the ones generally advised – and they are safe to use in pregnancy. If these do not work then Odansetron (4mg 6 hourly) may be substituted. In terms of intravenous support – an isotonic fluid (essentially salt or similar  solution) should be used, and this should be supplemented by Thiamine and Folic acid. During intravenous treatment blood tests need to be taken to check electrolytes (sodium, potassium levels etc). Finally if there is no response a trial of steroid treatment can be given – as trials have shown that this works. If there is still no response after 4 to 5 days consideration needs to be given to more intrusive supportive management.

Generally the situation will be stabilised as an outpatient – however occasionally the condition is severe enough to merit admission to hospital. This may involve better management of fluids and nursing care – but may if there is no resolution involve feeding using a naso-gastric tube or even enteral nutrition. If an inpatient it is important to be alert to the risk of venous thromboembolism as dehydation, pregnancy and immobility are risk factors. However it must be emphasised that these cases requiring prolonged admission are rare.

There is no doubt that HG is very unpleasant – however in the majority this is a self limiting condition that settles after relatively minor treatment or a short stay in hospital. The emphasis now is very much on outpatient management whereas not that long ago admission was the norm.

 

 

 

Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.

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About Professor Tom Bourne

Professor Tom Bourne is Adjunct Professor at Imperial College London, and Consultant Gynaecologist at Queen Charlotte's and Chelsea Hospital. He is also visiting Professor at KU Leuven, Belgium. He has extensive clinical and research experience in early pregnancy care as well as gynaecological ultrasound. He has published over 300 academic papers with an H-index of 63. He advises NICE, is trustee of the ectopic pregnancy trust, President of the UK association of early pregnancy units (AEPU) and on the board of ISUOG. He has a private practice at The Women's Ultrasound Centres at 86 Harley Street and Parkside Hospital in Wimbledon.
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