"Morning Sickness", or as we prefer to say, Pregnancy Sickness (as it is rarely confined to the morning) is a fairly normal part of pregnancy, affecting up to 80% of pregnant women. Although it is generally considered pretty unpleasant it should not interfere with a woman's ability to function normally and her ability to eat and drink normal normally. When mild, pregnancy sickness, can be improved with a range of self help techniques such as eating little and often, resting, avoiding triggers such as odours and caffinated drinks and possibly with remedies such as ginger (as a 250mg capsule 4 times a day... not as a ginger biscuit!).

Hyperemesis Gravidarum (HG) is a severe complication of pregnancy and NOT a normal part of it. When a woman has hyperemesis she will find normal functioning very difficult and struggle to maintain adequate food and fluid intake. Women can experience vomiting in excess of 30 times per day, dry retching and feel severely nauseous constantly. The condition is characterised by dehydration and weight loss of more than 5% of pre-pregnancy weight (weight loss can be up to or in excess of 20% of pre-pregnancy weight. Other symptoms women with hyperemesis may experience include extremely heightened sense of smell, extreme fatigue, headaches, depression and extreme isolation. Vomiting may not be as extreme as 30 times a day - extreme nausea which leads to weight loss and dehydration may be classed as hyperemesis gravidarum also and many levels in between. Pregnancy sickness and hyperemesis gravidarum are on a spectrum and the levels of tolerance to different symptoms will vary between women.

Hyperemesis gravidarum can lead to more severe complications including oesophageal tears, muscle wasting and risk of DVT from bed rest, serious vitamin deficiency from excessive vomiting and complications from extreme dehydration. Recent research has shown increased risk of placental abruption and small for gestational age babies in cases of hyperemesis continuing in 2nd trimester. Before IV fluid was introduced hyperemesis was the leading cause of death in early pregnancy.

Hyperemesis gravidarum affects 1-2% of pregnant women. Extreme pregnancy sickness, which does not result in hospital admission, may affect many, many more pregnant women and countless number of pregnant women are suffering at home without treatment. If your mother or sister had hyperemesis then your risk of having it increases to 30-35%

The exact mechanism of pregnancy sickness is not fully understood but it is suspected that it is due to the hormones produced during pregnancy, which are at their highest levels in the first trimester. (For interested healthcare professionals there is further information on the PSS website). Why pregnancy sickness can develop into hyperemesis gravidarum for some women is unknown. Research in America is looking for a genetic cause and the familial link mentioned about would support this.

There are a number of treatments available for pregnancy sickness and hyperemesis gravidarum and there is information about the various options on our website. Initially though, an old fashioned antihistamine, such as Cyclizine combined with Pyridoxine (Vitamin B6) is thoroughly proven to be safe and effective; it is these components that make up a drug called Diclectin which is licensed in Canada for treatment of nausea and vomiting in pregnancy and in America under the name Diclegis! It also retails in Spain under the name Cariban but is unlicensed for pregnancy. If this treatment is started early it is very safe and effective. In subsequent pregnancies using this pre-emptively is found to significantly reduce the severity of the condition.

However, for many women with hyperemesis these drugs alone are not enough and in these cases there are a range of other treatment options from metocloprimide to ondansetron and steroids. All treatment options should be tried before a woman faces the final "treatment" - termination.

Pregnancy Sickness Support is the only national UK charity for Pregnancy Sickness and Hyperemesis Gravidarum. It aims not only to provide information and support for women suffering with the condition and their carers but also raise awareness both in the public and within the medical field about this little known and often misunderstood condition. They are involved in ongoing research and provide information and education to the public, healthcare professionals and the media. Although I am a trustee for the Charity, this blog is my own, views and opinions do not represent PSS and the information I provide here should not substitute the information provided by the charity which is evidenced based and up to date.

If you are in the USA the Hyperemesis Research Foundation can provide information and support.

In the Netherlands there is an organisation which can help called Steunpunt Hyperemesis Gravidarum.

Support is hugely important, in fact, it cannot be overstated. Hyperemesis gravidarum is so massively debilitating and in first pregnancies can be sudden, totally unexpected and really quite scary. What was supposed to be a happy and exciting time can rapidly become a horrible depressing nightmare! Often the nausea is just as bad, if not worse than the vomiting and it can be hard for people around to understand because they can't see it. Hyperemesis is hugely isolating as the sufferer is often bed-bound and well meaning comments such as trying alternative therapies, getting fresh air or thinking positively can really add to that sense of isolation as it highlights to the sufferer that no one understands how seriously ill they feel. The reality is that it is very hard to understand if you have not been through it and that is why I have helped to developed a national peer support network of women who have suffered HG and want to support others suffering. PSS can provide telephone, email or text support and on occasion supporters may visit sufferers at home or in hospital. They also provide information leaflets and have an online support forum on their website. For further tips and advice about supporting a loved one see my posts on:

ADD LINKS!

• What not to say to a woman with hyperemesis gravidarum 
• 10 tips to help a friend with hyperemesis gravidarum
• On Advocacy - A post for partners
• In Sickness and in Health - tips for right plonkers
• 10 things NOT to say while your partner is spewing up

If you are online looking at this site then the chances are you have more than “regular morning sickness”. Although it's pretty unpleasant to have nausea and/or vomiting to any degree, women with regular pregnancy sickness tend not to seek help and find that self management strategies such as eating little and often, taking ginger or wearing travel bands will help enough. With regular pregnancy sickness you are unlikely to lose much weight (although a little is normal, particularly if you've stopped drinking alcohol and started eating healthily for your pregnancy anyway). Regular sickness is over with by 12-14 weeks and many women find it a reassuring sign that the pregnancy is progressing and healthy.

Hyperemesis on the other hand is utterly debilitating. You may not be able to get out of bed or roll over without vomiting. You are likely to have lost significant weight in a short amount of time and will rapidly dehydrate if you vomit back any fluid you try to drink. Hyperemesis is a dangerous complication of pregnancy and needs rapid treatment. In the days before effective treatment and IV fluids women died quickly from hyperemesis gravidarum. If you are unable to eat and drink, are loosing weight and you are not weeing regularly (more than once in 8 hours) and your urine is very concentrated then you need to get help and treatment.

Pregnancy sickness is on a spectrum though and there are various stages between “normal” and full blown hyperemesis. As a way of a guide for seeking help though, you should see a doctor and ask for treatment once the nausea and vomiting is effecting your ability to live normally. By that I mean, needing time off work, not being able to look after yourself, such as prepare meals, wash properly and so on. By starting treatment at the point that things are getting bad you will hopefully prevent further deterioration and avoid hospital admission.  

Preparation is absolutely key to surviving subsequent hyperemesis pregnancies. I have written widely on this and devised a care plan for treatment which is available on the Pregnancy Sickness Support website. There is also a worksheet on there to help you prepare and the book I will have published this year has lots more information about preparing for hyperemesis gravidarum.

Preparing for a third pregnancy is what started this blog and it made the pregnancy far more manageable than the previous two. Use the info on the PSS website and if you have any further questions please get in touch either through PSS or through here.

Yes it is normal... you are suffering immensely for a baby which as yet seems an abstract concept. You hear all the time “it'll be worth it in the end” but unless you already have kids it's impossible to really believe that!

Many, many women consider termination... lots of them do terminate, usually due to poor treatment and a lack of support, occasionally because the mother's life is in danger. Lots more women, most I would say, fantasise about miscarrying and just want the pregnancy over. You are not alone in these feelings and you shouldn't add to your suffering by feeling guilty about it. Sadly, most women who terminate for hyperemesis regret it as soon as they feel well and find that they just have to face the suffering all over again from the start when they conceive again.

Get in touch with Pregnancy Sickness Support and get matched with a volunteer to support you. She will understand your feelings and be able to help you. Join the forum on the website too. If you are in America or elsewhere then get in touch with the HER Foundation.

Before going ahead with a termination though, make sure first that you have tried ALL the treatments available, particularly ondansetron and steroids and combinations of the other options.

Ultimately, if you do decide to terminate then there are international charities such as Marie Stopes that can help and support you. If you then go on to have another pregnancy then preparation will be key, both mentally and physically. Or alternatively you could consider adoption as an option for your family.

Connect with other women who have been through termination for hyperemesis on the forums mentioned above.

The fact that you are online looking at how to help is a great start. Showing empathy is a major part of helping reduce the isolation a woman is suffering and not undermining her suffering. It's as much about what you don't say as what you do! See my posts on What Not to Say as well as my post on how healthcare professionals can help. Advocacy is key as many women feel unable to speak up about their suffering to doctors and consultant.

There are also little difference you can make to a sufferers environment to reduce factors that exacerbate symptoms. Not wearing perfume to work is important and ensuring that the room or ward the women is in is no where near an area where people smoke. Noise, light and movement can all trigger emetic episodes. A survey I ran recently found a shocking number of women had found themselves having to dispose of their own urine and vomit bowls while in hospital... a sorry state of affairs!

The way we can make a difference to hyperemesis care of the future is to lead by example. Here are some ideas about how you can help the Hyperemesis Improvement Movement:

• Educate student midwives and healthcare assistance in your setting.

• Hold a teaching session on the care of the hyperemesis patient? Invite student and junior doctors too!

• Check if your hospital has up-to-date guidelines in place for hyperemesis treatment.

• Devise a care plan for the ward environment.

• Challenge misconceptions and misguided attitudes amongst colleagues you may hear in the staff room or at handover.

• Write up case studies and look to get them published.

• Do a wall display on your ward about pregnancy sickness, you could do a myths about hyperemesis chart and provide facts and statistics on there.

• Print off information leaflets from the Pregnancy Sickness Support site for all women admitted with hyperemesis. Perhaps have a stock in a folder so that it becomes standard to provide information on admission.

• Let women know they are not alone and there is help out there. Refer them to the support network and let them know about the forum where they can get peer support in a safe and supportive environment.

You can also download the article I wrote for MIDIRS earlier this year and use it as a reference for assignments or portfolio pieces. Print off a copy for the staff room too.

If you are a healthcare professional then you should have access to online libraries where you can access research about hyperemesis gravidarum. The Pregnancy Sickness Support website provides a number of references and full text articles to get you started and so does the HER Foundation website.

There is also a website by my friend and colleague Margaret O'Hara called Pregnancy Sickness SOS, which provides an extensive list of references and you can contact her for guidances on specific questions - her brain is like a massive library of hyperemesis research!