Hyperemesis Gravidarum - how nurses and midwives can help

During a wonderful twitter chat last week by @WeMidwives, part of the We Nurses community a number of the midwives involved highlighted that the difference between normal “morning sickness” and hyperemesis gravidarum (HG) wasn't clear and they didn't feel confident in identifying the point at which treatment is indicated. Further, they didn't feel confident in knowing how best to treat and support a woman with HG.

Therefore, in addition to the information currently available on the Pregnancy Sickness Support website, I though I would clear the matter up a little and this post is particularly for all the nurses and midwives who are coming into daily contact with women suffering HG.

The difference between the two

Morning sickness (a misnomer as it is rarely confined to pre-midday!) is a normal part of pregnancy, effecting 80% of women. It's not particularly nice but it's not that bad either, a bit of a queasy feeling sporadically during the day or night, particularly if you haven't eaten. Perhaps throwing up sometimes and then feeling a bit better. Believe it or not most women actually look forward to this normal part of pregnancy as a sort of “right of passage”. It's an indication and reminder of the pregnancy which she has planned and is oh so excited about and generally considered a sign of a progressing pregnancy.

Normal pregnancy sickness is usually over by 12 weeks and can be eased by self help techniques such as rest and eating little and often and possibly by wearing acupressure bands and taking a capsule of ginger extract, 1000mg per day.

You are unlikely to lose significant weight with normal pregnancy sickness and it won't be interfering with your ability to go to work or look after your household. It may to the sufferer feel awful but ultimately it's not that bad in the scheme of things and we all know it's worth it in the end.

Most women with normal pregnancy sickness don't moan that much about it, are unlikely to present to a GP or in hospital and won't suffer significant emotional upset or long term complications from it.

Pregnancy sickness is on a spectrum from the very mild to the life threatening and somewhere around the moderate-severe end of Nausea and Vomiting in Pregnancy (NVP), before it can be fully considered HG, it needs treatment.

If the nausea is so constant that she is unable to eat and drink normally then she needs treatment. If she is having time off work and is house or bed bound then she needs treatment.

In many cases the first line treatment of antihistamine (ie. Cyclizine or Promethazine) plus vitamin B6 will do the trick and enable her to get on top of eating and drinking again and prevent further deterioration. Now this is important: The VAST majority of women, particularly if the pregnancy was planned, do NOT want to take medication in pregnancy. Fears over safety and the impact on the baby will be overwhelming her as she takes that first tablet. It is the role of the nurse or midwife to reassure her and comfort her with the mountains of evidence for their safety. It is NOT the role of the nurse or midwife to add to her stress and worry with comments such as “well you really shouldn't take anything in pregnancy, we don't know if it's safe”. If you personally don't know if it is safe then do some research. Midwifery and nursing are evidence based professions and all qualified staff should be more than capable of accessing and reviewing the relevant literature.

Moving on - When severe NVP gets worse and a woman is dehydrated then she has HG and probably needs admission for fluids and IV anti-emetics. Criteria to look for include: weight loss greater then 5% of pre-pregnancy weight; dehydration and starvation either with ketosis or fluid intake less than 500ml/24hrs; quality of life severely affected ie. Unable to get out of bed, wash, watch TV, read etc.

If a woman has HG then she needs treatment as not treating can lead to serious complications for both mum and baby. Woman should be reassured that in a risk verses benefit are assessed, taking the medication is the safer option.

There are a number of treatment options to move on from the first line of antihistamine/B6 and adding in rather than switching meds is generally more effective as various anti-emetics work in different ways. More information about treatments are available here.

Supporting a woman with HG

So how can nurses and midwives support patients with this horrid condition? Well, believing her will get you off to a good start. See my previous post on “what not to say to a woman with HG”. In particular, healthcare professionals (HCP's) should avoid suggestions of alternative therapies. Not only do many of them lack an evidence base, or indeed safety data, but you can rest assured that by the time a woman is presenting with HG she will have tried almost all of them and she will have heard of the rest. Suggesting them will undermine her confidence in your ability as a nurse/midwife and will add to her feelings of isolation by highlighting that you don't know what she is going through. If she is still throwing up on anti-emetics then believe me, ginger isn't going to make the blindest bit of difference - plus it burns on the way back out! Suggestions of ginger and hypnosis should be left to the mother-in-laws and the second cousins once removed. And speaking of those “helpful” relatives and friends, you could always print off this leaflet for when they visit.

Advocacy: During my nurse training I was taught that the nurse should be an advocate for the patient who is unable to express themselves. Many nurses and midwives are actually intimidated by doctors and consultants and I've never really understood why. The doctors themselves admit they don't, indeed can't, know everything about everything and the vast majority are genuinely pleased if a nurse has a thorough knowledge of a subject. Our roles are different and most doctors really respect the professional knowledge of the nurses and midwives they proudly call colleagues. So speak up! Explain that she is suffering and desperate. Explain that she isn't making herself sick and doesn't just want drugs but that she feels like she's been poisoned and cannot move without retching. That she tried for this baby and wants it more than anything but she feels like she is dying and is scared. Suggest that if they aren't sure of the best way forward then they could contact PSS. Question why they aren't moving her on to the next level of treatment - they may have a good reason and you could then relay that to the patient, or perhaps they simply aren't aware of the use of ondansetron or steroids in HG management. 

Working in partnership: Many women feel utterly out of control when they have HG and that's scary. By helping women to understand their condition better and self manage in partnership with their HCP's you give her back some control over her life and you make your job easier too - Bingo! So how do you do that? First of all, listen to what does and doesn't work for her. Next, talk to her about the treatment plan, which medication has been prescribed and why, what the options are if those don't work and so on.

Plan the discharge with her and she is less likely to come back in! Teaching a woman to monitor her own fluid balance intake/output at home is easy enough, as is monitoring her own ketones at home (NB. She shouldn't have to do either of these for herself in hospital - that's your job and she needs to rest while she can). You can also come up with a care plan for self monitoring and knowing when to come back in for more fluids or to step up medication. Direct access to a ward is easy to arrange too and in some areas IV at home is possible to arrange for her. Call the GP to ensure he/she is on board with the treatment plan.

Practical tips for the ward environment: Ideally get her a side room, away from where food is served and not overlooking the smoking area. If the choice is ward bay with crying babies, side room by the kitchen or side room overlooking the smoking area then explain that, apologise for the lack of good option and ask which she would prefer. Do not wear perfume to work... but you already know that. Ensure a good stack of clean vomit bowls and try to check regularly to remove used ones. Be gentle with her battered veins. Where possible try to get her food when she wants it, I know it's not terribly practical on a busy ward but asking a care assistant to make a slice of toast could make a big difference - Or perhaps her visitor could use the ward kitchen? Try to get the drugs to her on time, again I know it's tricky but keeping blood levels stable with the anti-emetics is key to management. Perhaps any oral meds could be kept as patient own so she can take them exactly when she need them without relying on overstretched staff.

Finally, support her: She is lonely and miserable, she feels guilty that she isn't enjoying the pregnancy and is probably fantasising about miscarriage or termination, which adds to her guilt and worry. What can you do? Refer her to PSS for peer support. There is a forum she can go on to “meet” other sufferers. If you are concerned she is depressed, which is not a cause of HG but a common complication of it, (clearly 24/7 nausea and vomiting for weeks will make you depressed!), then refer for counselling or to the peri-natal mental health team in you area if you have one. She may be encouraged by a scan to see the baby so if that can be arranged then do.

I know HG is a frustrating condition to manage for staff and sometime the women come in and seem so miserable and unwilling to help themselves. It's because they are utterly exhausted, scared, depressed and feeling guilty, hormonal, and constantly nauseous. Lots of midwives and nurses I've spoken to over the years express exacerbation at feeling like they can't help but actually, just being empathetic and supportive of a woman with HG can make the most incredible difference to her miserable experience. To have just one supportive nurse or midwife is wonderful, to have a whole ward full... well sadly, to date, that's unheard of... hopefully not for much longer though!

Please share this blog with your colleagues and THANK YOU for reading it.