Introduction

Spitting, nausea and/or vomiting is common in pregnancy, affecting 3 in 4 pregnant women. It usually begins around the sixth week of pregnancy and generally starts to settle by about 13 or 14 weeks, although 1 in 10 women may continue to feel sick after the 20th week of pregnancy.

Nausea and vomiting in pregnancy will normally not cause any harm to you or your baby and will not usually require any treatment. However, a few women develop severe nausea and vomiting (referred to as Hyperemesis) that requires medical intervention.

What causes Hyperemesis?

The exact cause of nausea and vomiting in pregnancy is not known. However, a number of different causes have been suggested, including:

• Increased oestrogen levels - during pregnancy, the female sex hormone (oestrogen) levels begin to rise. They tend to be at their highest during the first three months when these symptoms are at their worst.

• Increased hCG levels - after conception (when the sperm fertilises the egg), the body begins to produce a hormone called human chorionic gonadotrophin (hCG). It is thought that this rise may cause nausea and vomiting during pregnancy.

• Nutritional deficiency – especially a lack of vitamin B6.

• Gastric problems – the hormone progesterone which is produced in pregnancy to prepare the womb, may reduce the movement within the stomach and small intestine, resulting in nausea and vomiting.

• Psychological influences – this theory is not supported by research. It is now thought that psychological symptoms are likely to be the result rather than the cause of nausea and vomiting in pregnancy.

Can I do anything to help?

Yes, by altering certain lifestyle, eating and drinking habits, you may be able to help reduce the symptoms.

The following is a list of measures that have been shown to be helpful:

• Drink little and often rather than in large amounts, avoiding fizzy and caffeinated drinks (including tea and coffee).
• Avoid drinks that are cold, tart (sharp) or sweet.
• Avoid meals very early and very late in the day, although sometimes eating a plain biscuit before getting up may help.
• Eat smaller, more frequent meals that are high in carbohydrate and low in fat (savoury foods, such as toast, crackers and crisp-bread, are usually better tolerated than sweet, spicy or greasy foods).
• Avoid food or strong smells that trigger your symptoms (occasionally even your own perfume).
• Stop smoking (and ask your partner to stop smoking around you).
• Stop taking iron tablets (you can start again after the vomiting stops).
• Stop the use of all non-prescription medicines (including herbal remedies). • Avoid stressful situations by trying not to do too much and perhaps consider asking your GP for a sick note etc, as stress can worsen and prolong the condition.
• Get plenty of rest, because tiredness can make nausea worse.
• Wear comfortable clothes without tight waistbands, which can sometimes make you feel uncomfortable.
• Acupressure bands, which are special bands placed around the wrist (often used in travel sickness), have also been found to help with pregnancy related sickness.
• Ginger - there is some evidence that ginger supplements may help reduce the symptoms, however check with your nurse, doctor or pharmacist before using.

When should I seek medical help?

Any affected woman who finds it difficult to eat and/or drink or who persistently vomits after eating or drinking should seek medical help. You should always contact your GP first, who will then refer you on to hospital if necessary.

You should seek medical help urgently if you develop any of the following:

• Very dark-coloured urine or if you do not pass urine for more than 8 hours.
• Unable to keep food or fluids down for 24 hours.
• Weight loss.
• Muscle wasting.
• Dizziness and/or fainting.
• Palpitations (fast heart beat).

Urgent medical advice can be via calling 111 (NHS Direct) or attend the Emergency Department at Hospital.

What happens in hospital?

You will be seen and examined by a doctor or nurse who will ask you some questions and:

• Check your weight.
• Test your urine.
• Perform blood tests.
• Arrange an ultrasound scan (if not done already), to check that your baby is fine.

The results of all these tests will help the medical staff to decide the best treatment option for you.

What are the different treatment options?

Ambulatory treatment of Hyperemesis

Ambulatory treatment is very useful for women with more severe forms of Hyperemesis and those who have not improved with out-patient treatment, but who are still well enough to come into hospital on a daily basis.

Along with testing your urine, we will insert a cannula, take blood samples to check levels of dehydration, and give you a short infusion of fluid into your veins along with anti-sickness medication (anti-emetics). This treatment usually takes 4-5 hours each time, after which you can return home. You will be given anti-emetics and vitamins to take home. It will then be arranged for you to return to hospital daily for further ambulatory treatment if required.

If your symptoms do not improve with ambulatory treatment, we would recommend admission to hospital.

In-patient treatment of Hyperemesis

Admission to hospital may be necessary for women with very severe symptoms such as excessive weight loss (more than 5% of body weight), muscle wasting, dehydration, dizziness and palpitations, those with abnormal test results, and women who do not respond to ambulatory treatment.

We will perform additional blood and urine tests, sometimes as often as daily. Hospital treatment involves replacing lost body fluid through an intravenous drip and injecting medicines directly into your muscles and/or veins. You will also be given a vitamin supplement. If you do not improve with these measures, we will consider treating you with steroid injections.

Very occasionally, we might invite other specialists to contribute to your care if we feel they can help with your treatment.

Anti-sickness medication in pregnancy

Due to complex regulations, most medications are not licensed for use in pregnancy. This is mainly due to a lack of clinical trials amongst pregnant women.

Prescribing of medications in pregnancy always follows a careful assessment, which weighs the risks against the benefits.

Medication with the best safety and effectiveness record over time is usually chosen as first line treatment. The benefits of treating Hyperemesis outweigh the potential risks of treatment.

Anti-sickness medication can be given in the following ways:

• By mouth.
• An injection into your leg.
• Directly into a vein through a drip.

These medicines, used in combination with the self-help measures detailed above can be very successful in treating Hyperemesis.

Summary

It is important for you to understand that Hyperemesis is due to your pregnancy and has not arisen because of anything you have done or failed to do. Family help and support is very useful at times like this and we would encourage you to share the information contained here with your partner and other family members.

Although it might not appear so to you just now, the condition does resolve on its own, usually from about 14 weeks of pregnancy.

 You can be reassured that we know from research that, if treated properly, this condition is very unlikely to be harmful to you or your baby. Please feel free to discuss any anxieties you may have with the nurse or doctor looking after you.

Useful contacts

EPAC/GAU Nurses  01935 384385 (Monday to Friday 8am-8pm, BH and weekends 8am-4pm)

Advice and support can be sought form Pregnancy Sickness Support www.pregnancysicknesssupport.org.uk or 024 7638 2020

Ref: 14/2020/03
Review: 11/22