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

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