How doctors can help patients get ahead of extreme nausea and vomiting in pregnancy

Women suffering extreme nausea and vomiting, or Hyperemesis Gravidarum (HG), during pregnancy may feel so distressed and unwell that many consider terminating their pregnancy and avoiding future pregnancies.But more than that—a survey conducted by researchers in Australia found that significant numbers reported an inability to perform daily activities, consider early delivery to get away from the symptoms and suffer depression as a result of persistent HG. Findings were published in PLoS.When it came to the level of severity of symptoms and the reactions of pregnant people to the condition, the findings “were not entirely surprising,” said Luke Grzeskowiak, associate professor at the College of Medicine & Public Health, Flinders University in Adelaide. “Similar negative impacts of hyperemesis have been demonstrated across a number of studies undertaken in other countries,” he told the Canadian Healthcare Network in an email. However there is a lack of studies exploring women’s experiences with treatments for HG and how this compares to practice guidelines. Face the problem head onHG is a severe form of nausea and vomiting during pregnancy (NVP) that occurs in 0.3% to 10.8% of pregnancies, and can lead to hypovolemia, electrolyte imbalances, weight loss, and an increased risk of severe maternal-fetal and child outcomes, the study said. It is important to take complaints from pregnant people seriously, identify the problem early and find which medication best treats individual patients. Finding the right medication can include having to try different ones. Many guidelines recommend using the PUQE-24 (Pregnancy Unique Qualification of Emesis Scale) scoring system to help identify the condition and it’s severity. “While treatments for HG are reflected in a step-wise manner in guidelines, treatment should be directed at the severity of symptoms at the time of presentation, which may necessitate commencing treatments at a higher step rather than working through in a step-wise manner,” the study said. It noted there is little evidence supporting one anti-emetic over another, and patients may respond differently.The researchers surveyed women affected by HG, what treatments they used, and what their experience with treatments was in terms of perceived effectiveness and safety. The cross-sectional online survey included women in Australia who were currently, or who had previously experienced, severe NVP or HG.A total of 289 women responded to the survey. They had mean age of 33; 265 (94%) were Caucasian, and 110 (38%) were pregnant when they responded, while most of the remainder had been pregnant at some point up to two years previous. Most, 231 (80%) had been pregnant two or more times, and 254 (88%) had given birth at least once. When it came to the onset of NVP, results showed that the median onset was at six weeks gestation. Most women, 218 (75%), reported weight loss during pregnancy ranging from 1-to-40 kg with a median of 7 kg. Most reported great difficulty eating and drinking while pregnant, and nearly three quarters reported they had to go to hospital for IV fluids at some point. PUQE-24 scores revealed 118 (41%) had moderate NVP and 169 (59%) had severe NVP. Most respondents 224 (76%) had received a formal diagnosis of HG. When it came to whether HG affected daily life, more than half reported major impacts on areas such as social life, their ability to undertake daily chores, to eat or drink, work, take care of their other children and sleep. Some also reported HG had negative impacts on their partner relationship.More than half, 179 (62%), reported they ‘often’ or ‘always’ experienced depression or anxiety as a result of their HG symptoms. As well, 108 (37%) said they requested labour induction to bring forward delivery as a result of their HG symptoms. Another 155 (54%) respondents reported they had considered terminating their pregnancy, and 259 (90%) said they considered not bearing any more children.According to the study, all the women reported they had used at least one anti-emetic during pregnancy, with the mean number of anti-emetics taken being 4.2, ranging from 1 to 9. The most common anti-emetic used was ondansetron, in 263 (91%) women, followed by pyridoxine in 202 (70%); doxylamine 201 (70%); metoclopramide 200 (69%); and ginger in 152 (53%). The most common combination used, in 33 women, “was ginger, metoclopramide, doxylamine, pyridoxine and ondansetron, followed by doxylamine, pyridoxine and ondansetron” in 16 of the participants. Side effects from the treatments commonThe study stated that “Doxylamine (78%), ondansetron (73%) and promethazine (72%) each had the highest proportion of women reporting one or more side effects. Medications most likely to be ceased as a result of side effects included metoclopramide (31%), ginger (24%), and prochlorperazine (23%),” the study said. Constipation and sedation were the most common side effects with some of the medications. About 5% to 31% of the study participants reported they stopping taking a medication because of side effects.Fewer than 10% of the women reported that pyridoxine or ginger was ‘effective’ or ‘very effective’. The medications that were rated as being the most effective were corticosteroids, ondansetron, and doxylamine with more than half saying they were ‘effective’ or ‘very effective’ This left about half less satisfied.According to Dr. Grzeskowiak, “The perceived effectiveness of different medications appeared to vary quite considerably. The 50% figure is based on an average across all medication. The number reporting medications not being very effective at all ranged from 5% to 80%, depending on type of medication. The remainder was made up of people who reported the medication as being slightly to very effective, suggesting they experienced some degree of benefit from using the medication.”How people perceive how effective a medication is can depend “partly on how the severe symptoms were to begin with and what their expectations are regarding medication use,” said Dr. Grzeskowia.When it comes to practice, he stated that “The management of hyperemesis often occurs in a stepwise manner, but I personally feel that there continues to be an improved need for individualised care and management. The most obvious conclusion generated from our survey is the need for a more nuanced and holistic approach to clinical management.”For a Canadian perspective, a review for the management of HG was published in 2024 in the CMAJ.

How doctors can help patients get ahead of extreme nausea and vomiting in pregnancy

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