Hyperemesis Gravidarum: who is likely to get it and what can you do about it?
Thanks to some high profile sufferers like Kate Middleton and Amy Schumer, more people are aware of the condition Hyperemesis Gravidarum - which is essentially extreme sickness and nausea during pregnancy. The effects of which can be debilitating to the sufferer. We look at the latest science behind what it is, how likely you are to get it, how to identify if you have it, the risk factors that can make it more likely (interestingly it seems more common in Western countries (3)) and some ways to treat it/things you can do.
So, what is it?
As many as 70-85% of pregnant women experience nausea and vomiting during pregnancy (51), but only 1-3% suffer from the extreme form of this known as Hyperemesis Gravidarum (HG). This is when excessive nausea and vomiting leads to weight loss and dehydration resulting in ketosis (the breakdown of fat for energy) and this is not ketosis in a good way!
How do you know if you have hyperemesis gravidarum?
As above, the chances are that in the first trimester you’re not going to feel on your finest form. In part linked to peaking hCG levels, you’re likely to feel nauseous but hyperemesis gravidarum is much worse than that and can be dangerous if left untreated.
In fact the earlier it is identified and treated the better.
Some signs to look for:
Prolonged and severe nausea and vomiting, which may not get better by 14 or even 20 weeks and in some cases can last until the baby is born (which happens in around 10% of cases). (8)
On average this starts around 5-6 weeks into pregnancy (5-7)
Variable Dehydration especially if your fluid intake is below 500mls per day. Signs of that include: thirst, loss of appetite, fatigue, headache and head rush, dry skin, flushing, dark coloured urine.
Low blood pressure - especially when standing (feeling faint)
Ketosis and build up of ketones (acidic chemicals) in the blood as there is a breakdown of fat for energy. Signs of that: bad breath, reduced appetite, fatigue and weakness, constipation and/or diarrhoea and insomnia.
Weight loss: of more than 5% of bodyweight (51)
Some other symptoms that you may experience:
Extremely heightened sense of smell
Excessive saliva production
Headaches and constipation from dehydration.
Episodes of urinary incontinence as a result of vomiting combined with the pregnancy hormone relaxin.
Exhaustion due to severe sickness, which stops you doing everyday tasks
Feelings of isolation and uncertainty if you can cope with the rest of the pregnancy due to the feeling of illness (9)
Anxiety and depression (10)
Could it be something else?
There can of course be other reasons or causes behind these symptoms, but, the good news is that there are actually new blood test markers that can help your doctor diagnose this condition (19). Other things that they will likely look for or consider: more than one baby, ectopic pregnancy and molar pregnancy (where a non-viable egg implants).
Your doctor may also consider gallstones and/or appendicitis amongst other things. Plus, if the nausea and vomiting starts after 9 weeks then preeclampsia amongst others may also be considered.
The key thing here however, is that if you suspect you may be suffering from this you need to speak to your doctor as soon as possible so it can be checked out. The earlier it is treated the better and crucially it lowers the risk of further complications for you and your baby developing.
Are there any risk factors for developing hyperemesis gravidarum?
Women who experience nausea and vomiting pre pregnancy related to travel sickness and/or those who suffer from migraines may be more likely to be affected.
Women who have immediate family members who have experienced it (there are in some cases genetic links).
If you have had hyperemesis gravidarum previously. (21)
Other potential risk factors:
Maternal Age: the older you get the higher the chance of complications
Thyroid conditions or other pre pregnancy hormonal factors (22)
A lack of physical activity pre pregnancy (23)
Are there any things you can do to reduce your risk?
The exact cause of hyperemesis gravidarum is unknown at this stage. However, there are a few theories that focus on changes and impact that pregnancy has on hormones and the gastrointestinal system.
What are these?
When you are first pregnant, the level of a hormone called hCG: human chorionic gonadotropin rises. This peaks during the first trimester and is linked to the feelings of nausea and vomiting (26, 27). When this occurs alongside higher estrogen it can make vomiting much worse (28).
Genetics also can play a part - two genes in particular (GDF15 and IGFBP7) have been linked with hyperemesis gravidarum which is why it can be seen in women who have close relatives who have also suffered from it.
Thyroid issues have also been linked to the development of hyperemesis gravidarum. Plus issues with digestion/gut dysbiosis (an imbalance in bacteria in the gut: click here for more) - once again the power of a healthy gut showing its hand - nutritional deficiencies and even asthma and allergies (51) have been indicated to potentially play a role in increasing risks.
Some studies have shown risk reduction from multivitamin intake before 6 weeks of pregnancy (24, 25) focusing specifically on Methylfolate (which is the food version of Folic Acid - click here for more). Other very interesting research has shown evidence that an active lifestyle pre-pregnancy (23) can serve to reduce risks with a study in Norway of 40,000 people indicating that a lack of leisure time, physical activity was associated with increased odds of developing HG (23).
Will hyperemesis gravidarum harm my baby?
HG is unpleasant with dramatic symptoms, but the good news is it's unlikely to harm your baby, if treated effectively. (31)
That being said, if it causes you to lose weight during pregnancy, there may be an increased risk that your baby may be born smaller than expected (have a low birth weight) and that can increase the chances of preterm delivery. (32-35). However the risks of congenital anomalies are not increased.34,36
There has however been some research reporting a potential increased risk of autistic spectrum disorder in the children of mothers who suffered from hyperemesis gravidarum. Although it is by no means conclusive and may be linked to other related factors. (37)
How can hyperemesis gravidarum be treated?
The earlier you start treatment, the more effective it will be. Dietary modification and emotional support are useful.39. Initial treatment typically begins with Methyfolate supplementation (click here for more) and ginger supplementation (250 mg orally 4 times daily) as needed, and by applying acupressure wristbands. (40,41). Other research has shown some benefit from eating smaller meals more often (if the case is mild) and meals rich in carbohydrates and protein and avoiding acidic and spicy foods. In more extreme cases medications can be used during the first 12 weeks which include vitamin B6 (pyridoxine) and B12, as well as antihistamines such as doxylamine. (42,43). This is something that you should discuss fully with your doctor.
What is the research around medications used?
If you continue to experience significant symptoms but no signs of dehydration then further anti-sickness medications including antihistamines and dopamine antagonists can be used either orally, intravenously or intramuscularly (39,44). Of course no one wants to be taking medication during pregnancy, however, one particular medication, ondansetron is recommended as being safe by the Royal College of Obstetricians and Gynaecologists with most studies reporting no association between maternal ondansetron use in early pregnancy and congenital anomalies. There is inconsistent evidence for a small increase in congenital heart disease associated with ondansetron, but this is by no means conclusive. (45)
Steroids may be considered when other treatment combinations have been exhausted and when used in combination with other medication may boost the effects of other anti-sickness medication.46
Should you/will you get medication?
It is a tricky one as prescriptions of anti-sickness medication by your doctor for use in this case for the most part would be “off licence”, that being said, more and more are prescribing treatment, particularly if the case is severe. That being said, only a third of women admitted to hospital for HG had received anti-sickness prescriptions before hospitalisation. (47,48)
If your nausea and vomiting cannot be controlled, you may need to be admitted to hospital so that you can receive the correct treatment to protect the health of both you and your baby. This may include hydration through a vein (intravenous fluids) or anti-sickness drugs via a vein or a muscle. The other thing that your doctor may consider as a result of severe dehydration is the increased risk of developing a deep vein thrombosis so you may require medication to prevent this as well.
Other support you may not have considered:
Anyone who has experienced HG will tell you how tough this is not only physically but also mentally, and many women (understandably) struggle with anxiety and depression as a result of this. Constant nausea and vomiting is extremely distressing. This is a time to not only just look out for your physical health but also your mental health to support you through. Evidence suggests that psychological intervention, such as counselling, in conjunction with medical treatment, can improve outcomes (49). This type of extra support should be considered.
In fact: there are various charities that can provide support for you and your family:
Pregnancy Sickness Support (PSS) UK. www.pregnancysicknesssupport.org.uk; tel: 024 7638 2020.
Hyperemesis Education and Research (HER) Foundation, USA and International; www.helpher.org.
Hyperemesis Ireland, Ireland. www.hyperemesis.ie50
What else can I do?
Unfortunately as we don’t fully understand the exact causes there isn't a silver bullet solution to prevent it from occurring. However, a daily intake of a multivitamin with folate 4-6 weeks prior to conception not only reduces the risk of congenital anomalies but can also reduce the frequency and severity of nausea and vomiting in pregnancy.
Eating “little and often” and resting are likely to help. Stress, once again is the enemy!
Keeping as fit, healthy and active pre pregnancy is another great thing to do overall, but some research suggests that having a high BMI or being inactive can increase your odds of getting HG (23).
If you are planning another pregnancy and have had hyperemesis gravidarum before, you are likely to get it again as such, plan ahead, such as arranging child care so you can get plenty of rest. Also, think back to what helped the first time round and make sure you implement that this time around as early as possible.
Finally, don't be afraid to reach out for help not only physically but mentally as getting the proper help and support has been shown to reduce the severity of symptoms and put you in a better position.
1. Erick M, Cox JT, Mogensen KM. ACOG Practice Bulletin 189: Nausea and Vomiting of Pregnancy. Obstet Gynecol. 2018 May;131(5):935.
2. Matthews A, Haas DM, O'Mathúna DP, Dowswell T. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2015 Sep 08;(9):CD007575
3. Kimura M, Amino N, Tamaki H, Ito E, Mitsuda N, Miyai K, Tanizawa O. Gestational thyrotoxicosis and hyperemesis gravidarum: possible role of hCG with higher stimulating activity. Clin. Endocrinol. (Oxf). 1993 Apr;38(4):345-50.
4. London V, Grube S, Sherer DM, Abulafia O. Hyperemesis Gravidarum: A Review of Recent Literature. Pharmacology 2017;100:161-171.
5. Lacasse A, Rey E, Ferreira E, Morin C, Bérard A. Epidemiology of nausea and vomiting of pregnancy: prevalence, severity, determinants, and the importance of race/ethnicity. BMC Pregnancy Childbirth. 2009 Jul 02;9:26.
6. Mullin PM, Ching C, Schoenberg F, et al. Risk factors, treatments, and outcomes associated with prolonged hyperemesis gravidarum. J Matern Fetal Neonatal Med 2012;25:632-6. 10.3109/14767058.2011.598588 21916750
7. Kramer J, Bowen A, Stewart N, Muhajarine N. Nausea and vomiting of pregnancy: prevalence, severity and relation to psychosocial health. MCN Am J Matern Child Nurs 2013;38:21-7. 10.1097/NMC.0b013e3182748489 23232775
8. Goodwin TM. Hyperemesis gravidarum. Obstet. Gynecol. Clin. North Am. 2008 Sep;35(3):401-17, viii.
9. Kjeldgaard, H.K., Eberhard-Gran, M., Benth, J.Š. et al. Hyperemesis gravidarum and the risk of emotional distress during and after pregnancy. Arch Womens Ment Health 2017 20: 747. https://doi.org/10.1007/s00737-017-0770-5
10. Yildirim E, Demir E. The relationship of hyperemesis gravidarum with sleep disorders, anxiety and depression. J Obstet Gynaecol 2019;39(6):793-798.
11. Eroğlu A, Kürkçüoğlu C, Karaoğlanoğlu N, Tekinbaş C, Cesur M. Spontaneous esophageal rupture following severe vomiting in pregnancy. Dis. Esophagus. 2002;15(3):242-3.
12. Liang SG, Ooka F, Santo A, Kaibara M. Pneumomediastinum following esophageal rupture associated with hyperemesis gravidarum. J. Obstet. Gynaecol. Res. 2002 Jun;28(3):172-5.
13. Garg R, Sanjay, Das V, Usman K, Rungta S, Prasad R. Spontaneous pneumothorax: an unusual complication of pregnancy--a case report and review of literature. Ann Thorac Med. 2008 Jul;3(3):104-5.
14. Spruill SC, Kuller JA. Hyperemesis gravidarum complicated by Wernicke's encephalopathy. Obstet Gynecol. 2002 May;99(5 Pt 2):875-7.
15. Kim YH, Lee SJ, Rah SH, Lee JH. Wernicke's encephalopathy in hyperemesis gravidarum. Can. J. Ophthalmol. 2002 Feb;37(1):37-8.
16. Oudman E, Wijnia JW, Oey M, van Dam M, Painter RC, Postma A. Wernicke's encephalopathy in hyperemesis gravidarum: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019;236:84-93. doi: 10.1016/j.ejogrb.2019.03.006.
17. Heitmann K, Nordeng H, Havnen GC, Solheimsnes A, Holst L. The burden of nausea and vomiting during pregnancy: severe impacts on quality of life, daily life functioning and willingness to become pregnant again – results from a cross-sectional study. BMC Pregnancy and Childbirth. https://doi.org/10.1186/s12884-017-1249-0
18. Fossum S, Næss Ø, Halvorsen S, Tell GS, Vikanes ÅV. Long-term cardiovascular morbidity following hyperemesis gravidarum: A Norwegian nationwide cohort study. PLoS One. 2019 Jun 12;14(6):e0218051. doi: 10.1371/journal.pone.0218051
19. Cintesun E, Akar S, Gul A, Cintesun FNI, Sahin G, Ezveci H, Akyurek F, Celik C. Subclinical inflammation markers in hyperemesis gravidarum and ketonuria: A case-control study. J Lab Physicians 2019 Apr-Jun;11(2):149-153. doi: 10.4103/JLP.JLP_151_18.
20. Pedigo R. First trimester pregnancy emergencies: recognition and management. Emerg Med Pract. 2019; 21(1):1-20.
21. Czeizel AE, Dudas I, Fritz G, Técsöi A, Hanck A, Kunovits G. The effect of periconceptional multivitamin-mineral supplementation on vertigo, nausea and vomiting in the first trimester of pregnancy. Arch. Gynecol. Obstet. 1992;251(4):181-5.
22. Ioannidou P, Papanikolaou D, Mikos T, Mastorakos G, Goulis DG. Predictive factors of Hyperemesis Gravidarum: A systematic review. Eur J Obstet Gynecol Reprod Biol 2019; 238:178-187.
23. Owe KM, Stoer N, Wold BH, Magnus MC, Nystad W, Vikanes AV. Leisure-time physical activity before pregnancy and risk of hyperemesis gravidarum: a population-based cohort study. Prev Med 2019; 125:49-54.
24. Emelianova S, Mazzotta P, Einarson A, Koren G. Prevalence and severity of nausea and vomiting of pregnancy and effect of vitamin supplementation. Clin Invest Med. 1999 Jun;22(3):106-10.
25. Bernstein L, Pike MC, Lobo RA, Depue RH, Ross RK, Henderson BE. Cigarette smoking in pregnancy results in marked decrease in maternal hCG and oestradiol levels. Br J Obstet Gynaecol. 1989 Jan;96(1):92-6.
26. Goodwin TM, Montoro M, Mestman JH, Pekary AE, Hershman JM. The role of chorionic gonadotropin in transient hyperthyroidism of hyperemesis gravidarum. J. Clin. Endocrinol. Metab. 1992 Nov;75(5):1333-7.
27. Soules MR, Hughes CL, Garcia JA, Livengood CH, Prystowsky MR, Alexander E. Nausea and vomiting of pregnancy: role of human chorionic gonadotropin and 17-hydroxyprogesterone. Obstet Gynecol. 1980 Jun;55(6):696-700.
28. Goldzieher JW, Moses LE, Averkin E, Scheel C, Taber BZ. A placebo-controlled double-blind crossover investigation of the side effects attributed to oral contraceptives. Fertil. Steril. 1971 Sep;22(9):609-23.
29. Brzana RJ, Koch KL. Gastroesophageal reflux disease presenting with intractable nausea. Ann. Intern. Med. 1997 May 01;126(9):704-7.
30. Fejzo MS, Sazonova OV, Sathirapongsasuti JF, Hallgrímsdóttir IB, Vacic V, MacGibbon KW, Schoenberg FP, Mancuso N, Slamon DJ, Mullin PM., 23andMe Research Team. Placenta and appetite genes GDF15 and IGFBP7 are associated with hyperemesis gravidarum. Nat Commun. 2018 Mar 21;9(1):1178.
31. Agmon N, Sade S, Pariente G, Rotem R, Weintraub AY. Hyperemesis gravidarum and adverse pregnancy outcomes. Arch Gynecol Obstet 2019;300(2):347-353.
32. Weigel MM, Weigel RM. Nausea and vomiting of early pregnancy and pregnancy outcome. An epidemiological study. Br J Obstet Gynaecol. 1989 Nov;96(11):1304-11.
33. Chin RK, Lao TT. Low birth weight and hyperemesis gravidarum. Eur. J. Obstet. Gynecol. Reprod. Biol. 1988 Jul;28(3):179-83.
34. Veenendaal MV, van Abeelen AF, Painter RC, van der Post JA, Roseboom TJ. Consequences of hyperemesis gravidarum for offspring: a systematic review and meta-analysis. BJOG 2011;118:1302-13. 10.1111/j.1471-0528.2011.03023.x 21749625
35. Bolin M, Åkerud H, Cnattingius S, Stephansson O, WikströmAK. Hyperemesis gravidarum and risks of placental dysfunction disorders: a population-based cohort study. BJOG 2013;120:541-7. 10.1111/1471-0528.12132 23360164
36. Vandraas KF, Vikanes AV, Vangen S, Magnus P, Støer NC, Grjibovski AM. Hyperemesis gravidarum and birth outcomes-a population-based cohort study of 2.2 million births in the Norwegian Birth Registry. BJOG. 2013 Dec;120(13):1654-60.
37. Fejzo M, Kam A, Laguna A, MacGibbon K, Mullin P. Analysis of neurodevelopmental delay in children exposed in utero to hyperemesis gravidarum reveals increased reporting of autism spectrum disorder. Reprod Toxicol. 2019;84:59-64.
38. Dean C, Murphy C. I could not survive another day: Improving treatment and tackling stigma: lessons from women’s experiences of abortion for severe pregnancy sickness. Pregnancy Sickness Support and BPAS, 2015, https://www.pregnancysicknesssupport.org.uk/
39. Loh KY, Sivalingam N. Understanding hyperemesis gravidarum. The Medical Jounral of Malaysia 2005; 60(3):394-9
40. Viljoen E, Visser J, Koen N, Musekiwa A. A systematic review and meta-analysis of the effect and safety of ginger in the treatment of pregnancy-associated nausea and vomiting. Nutr J. 2014 Mar 19;13:20.
41. Werntoft E, Dykes AK. Effect of acupressure on nausea and vomiting during pregnancy. A randomized, placebo-controlled, pilot study. J Reprod Med. 2001 Sep;46(9):835-9.
42. Koren G, Clark S, Hankins GD, Caritis SN, Umans JG, Miodovnik M, Mattison DR, Matok I. Maternal safety of the delayed-release doxylamine and pyridoxine combination for nausea and vomiting of pregnancy; a randomized placebo controlled trial. BMC Pregnancy Childbirth. 2015 Mar 18;15:59.
43. McParlin C, O'Donnell A, Robson SC, Beyer F, Moloney E, Bryant A, Bradley J, Muirhead CR, Nelson-Piercy C, Newbury-Birch D, Norman J, Shaw C, Simpson E, Swallow B, Yates L, Vale L. Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review. JAMA. 2016 Oct 04;316(13):1392-1401.
44. Goodwin TM. Hyperemesis gravidarum. Clin Obstet Gynecol. 1998 Sep;41(3):597-605.
45. Danielsson B, Wikner BN, Källén B. Use of ondansetron during pregnancy and congenital malformations in the infant. Reprod Toxicol 2014;50:134-7. 10.1016/j.reprotox.2014.10.017 25450422
46. Jordan K, Kasper C, Schmoll HJ. Chemotherapy-induced nausea and vomiting: current and new standards in the antiemetic prophylaxis and treatment. Eur J Cancer 2005;41:199-205. 10.1016/j.ejca.2004.09.026 15661543
47. Trovik J, Vikanes AV. Antiemetics in hyperemesis gravidarum: unawareness or negligence? BJOG 2019 https://doi.org/10.1111/1471-0528.15824
48. Flaschi L, Nelso-Piercy C, Deb S, King R, Tata LJ. Clinical management of nausea and vomiting in pregnancy and hyperemesis gravidarum across primary and secondary care: a population-based study. BJOG 2019. doi: 10.1111/1471-0528.15662.
49. Kim DR, Connolly KR, Cristancho P, Zappone M, Weinrieb RM. Psychiatric consultation of patients with hyperemesis gravidarum. Arch Womens Ment Health 2009;12:61-7. 10.1007/s00737-009-0064-7 19263196
50. Dean CR, Shear M, Ostrowski GAU, Painter RC. Management of severe pregnancy sickness and hyperemesis gravidarum. BMJ 2018;363:k5000
51. Wegrzniak LJ, Ripken J, Ural SH: Treatment of Hyperemesis Gravidarum: Reviews in Obstetrics & Gynaecology: 2012: 5(2): 78-84
This article is for informational purposes only. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The information on this website has been developed following years of personal research and from referenced and sourced medical research. Before making any changes we strongly recommend you consult a healthcare professional before you begin.