Hyperemesis is no doubt a physiological disease. Treating it as anything else is not therapeutic and can be detrimental to the mother and her unborn child (download research results PDF). Early, aggressive therapy can often result in fewer complications and reduce overall medical costs. Medications, bed rest, IV fluids, and nutritional therapy are typically the most effective therapies for HG. HG may last throughout pregnancy in varying severity. As each woman is different, it is most critical that therapies target a mother's symptoms and response to treatment.
Women left untreated may terminate a wanted pregnancy to end the misery. Often secondary psychosocial challenges such as depression and anxiety result and complicate management (download research results PDF). Depression is a natural consequence of being confined to home or bed, and unable to perform even simple daily activities, much less care for one's family. Further, the accompanying anxiety often results from the thought of vomiting and retching relentlessly for hours, as well as feeling severely nauseous in between. Many women fear dying and feel guilty that they may cause the death of their unborn child if they don't force feed themselves, despite the inevitable vomiting that will follow. Treating the complex physiological changes that cause such severe symptoms can be very challenging.
Further, each woman will respond differently to treatments since the cause is multifactorial, so a single medication cannot be prescribed. It is becoming clear that proactive intervention with a treatment plan, can decrease both severity and duration, not to mention prevent many complications for many women. The challenge is finding the treatment that works for each woman.
The general good care of women with severe hyperemesis extends beyond the use of steroid therapy. Thiamine replacement, possibly with other water-soluble vitamins is required if vomiting has been prolonged in order to avoid Wernicke's encephalopathy. Deficiency can arise after lack of food intake for several weeks. Thiamine is an essential cofactor for critical enzymes of carbohydrate metabolism and it is important that it is replaced before carbohydrate is given. However, once thiamine has been replaced, provision of calories as i.v. 10% Dextrose (which provides 400 kcal/L) hastens recovery. Significant heartburn is frequently caused by the regurgitated gastric acid and this requires treatment with ranitidine. Finally, mobilization must be gradual as physical movement exacerbates the underlying nausea. Discharge is not wise as soon as i.v. fluids are no longer necessary, as this may be associated with loss of control precipitated by the journey home. Full and sympathetic explanation of the condition and likely prognosis is also part of routine management.
Al-Ozairi MBChB MRCP, E., Waugh MBBS MRCOG, J. J. S. , & Taylor MD FRCP, R. (2009). Termination is not the treatment of choice for severe hyperemesis gravidarum: Successful management using prednisolone. Obstetric Medicine. 2, 34-37.
The HER Foundation Survey found bed rest and IV hydration to be two of the most beneficial treatments for HG. This does not mean these alone are adequate, rather these are nearly universally beneficial in women with HG. IV fluids can be given at home in some countries at very low cost and minimal risk. Fluids can also include much-needed vitamins. Insurance coverage often includes home IV care which allows the mother to have continuous fluids instead of cycling from hydration to vomiting and dehydration. This cycle worsens HG and delays recovery. Many women state they feel so much better after their trip to the emergency room for IV fluids, only to begin vomiting and have to return a few days later for more fluids. Home IV fluids can prevent this. A regular IV can be left in for up to a week, provided it does not infiltrate or become infected. 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 IV fluids, preferably with IV vitamins. Vitamins are critical in mothers vomiting more than a few weeks to prevent life-altering complications.
Antiemetic (anti-vomiting) medications are the most common and typically most effective treatments for HG. The risks are often outweighed by the benefits.
- Complementary and Alternative Medicine (CAM)
CAM is sometimes effective in easing nausea and vomiting in milder cases of HG, however, it most often is used in conjunction with allopathic medicine (traditional medical care).
- Nutritional Therapies
Research shows that nausea and vomiting for more than a few weeks causes significant deficiency of important nutrients, which can worsen nausea and vomiting. If not replaced, a woman is at risk for more complications and a prolonged recovery. These can be replaced via an intravenous (IV) line or directly into the gastrointestinal (stomach/intestines) system.
- Behavioral Therapy
This therapy uses stimulus control and imaging procedures and is occasionally used in mild cases with some positive effects. It is absolutely not a primary treatment modality.
- Bed Rest
Prolonged bed rest can produce negative effects like atrophy and a delayed recovery time after delivery. The best strategy is to do all you can to get effective care and stay as mobile as possible. Physical therapy may be beneficial.
- Sensory Deprivation Therapy (SDT)
This is essentially placing a women in a room without any interaction or stimulation of any kind. She is denied any visitors such as her family for days or weeks. This is cruel and ineffective for true cases of HG. Isolation and secondary depression only worsen HG and increase the stress on a woman. It should never be used. However, since odors, noise and light may worsen her symptoms, it is helpful to minimize as much as she requests.
This treatment may be effective for secondary complications such as depression and anxiety, if used in conjunction with antiemetic medications and hydration. It should never be used as a primary modality for treating HG. It can help women manage the emotions and trauma resulting from HG, and the typical adjustments to pregnancy and motherhood. Further, it is often very beneficial postpartum for managing PPD and PTSD. Since HG is not a psychological disorder, this therapy must follow symptom management and is not considered a replacement for anti-emetic therapy like medications and IV fluids.
- Therapeutic Abortion
Abortion in most cases of HG is avoidable with aggressive use of novel and currently available treatment options. Women who choose abortion do so most often because of delayed, ineffective or inadequate medical intervention. Women left untreated sometimes become so metabolically imbalanced, abortion is chosen to save the life of the mother. However, it should be considered only a last resort. The long term consequences, both physically and physiologically, cannot be overlooked or underestimated.
- Other Treatments
Women with HG have numerous other symptoms that often cause significant distress. One is ptyalism (also called hypersalivation, sialorrhea or hyperptyalism). Ptyalism is essentially 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. Attention must be given to fluid levels as the amount of saliva lost can be very significant.
Other issues like pain from prolonged periods of inactivity are typically managed with over the counter pain relievers like Tylenol.
Updated on: Feb. 20, 2015