More Than Morning Sickness: Treating Hyperemesis Gravidarum

Laura Arenschield

May 19, 2019

Nausea and vomiting might seem to go hand-in-hand with pregnancy, but severe sickness can be a sign of a more complicated condition that can lead to esophageal tears, liver and renal dysfunction, postpartum depression, post-traumatic stress, and — in extreme cases — death.

It is also underdiagnosed. "A lot of clinicians know that hyperemesis gravidarum exists, but they don't truly know how to recognize the difference between morning sickness and hyperemesis gravidarum," said Kimber MacGibbon, RN, cofounder of the HER Foundation, a nonprofit organization dedicated to hyperemesis gravidarum research and education for patients and healthcare providers.

"And when they do recognize it, they often don't know how to treat it," she told Medscape Medical News.

Hyperemesis gravidarum — in the news in recent years because comedian Amy Schumer and Kate Middleton, Duchess of Cambridge, both experienced it during their pregnancies — can be grueling.

Women often vomit until they faint or lose control of their bladders, MacGibbon said during a presentation at the Infusion Nurses Society 2019 Annual Conference in Baltimore. They also experience profound fatigue.

Complications for Both Mother and Baby

Symptoms typically begin about 4 to 6 weeks into a pregnancy and peak at about 11 to 13 weeks. However, 22% of women with hyperemesis gravidarum have symptoms throughout their pregnancies, MacGibbon reported. The longer symptoms persist and the more severe they are, the greater the risk of long-term complications for both mother and baby.

Children of mothers with untreated hyperemesis gravidarum can develop neurodevelopmental delays, behavioral issues, and vitamin K–deficiency embryopathy. They are more likely to be born premature or with intrauterine growth restriction. Treatments can help, but healthcare providers first have to be able to diagnose the condition, MacGibbon said.

"A lot of doctors wait until moms are really sick and then they don't give them IV fluids to help metabolize medications," she explained. "There are a lot of medication strategies that need to be improved."

Women with hyperemesis gravidarum have elevated levels of the hormone GDF15, which is produced by the placenta during pregnancy, according to research funded by the HER Foundation (Geburtshilfe Frauenheilkd. 2019;79:382-388 and 2018;78:866-870).

Hormonal and Genetic Influences

And some of that research has shown that GDF15 — which plays a role in appetite control and has been linked to cachexia in patients with cancer — and the IGFBP7 gene are associated with hyperemesis gravidarum (Nat Commun. 2018;9:1178).

In the past, "physicians would tell women it was psychological or caused by the pregnancy hormone," said Marlena Fejzo, PhD, from the David Geffen School of Medicine in Los Angeles, who was lead investigator on that study.

But "that is not true. This study showed that there is a genetic component," she explained. The hormone interacts with a pregnant woman's brain, provoking uncontrollable vomiting.

Fejzo said she is interested in looking at potential medications to block the hormone from telling the brain to start vomiting, but that work is likely years away. However, treatments for cachexia in cancer patients currently in clinical trials might have applications in hyperemesis gravidarum, she pointed out.

We have women who have had their retinas detach, who have had rib fractures, blown eardrums, esophageal tears - all from the violence of vomiting.

In the meantime, helping doctors, nurse practitioners, and other healthcare providers to identify the condition is the priority.

"We have women who have had their retinas detach, who have had rib fractures, blown eardrums, esophageal tears — all from the violence of vomiting. Women whose fingernails have fallen off because of malnutrition," she said.

And "there have been increasing reports of Wernicke's encephalopathy," when women don't get enough thiamine and are not able to take their prenatal vitamins because they are vomiting, she said, including the case of a 15-year-old girl.

But the brain disorder can be treated if caught early enough, Fejzo noted.

Tools to help pregnant women and their doctors determine whether symptoms meet the criteria for hyperemesis gravidarum, and information on treatment protocols for patients and clinicians are available on the HER Foundation website. In addition, a smartphone app to help women track their symptoms has been developed by the foundation and UCLA.

"These women need treatment," MacGibbon said. "We need practitioners to begin using these tools, believe these women, and treat them." It is not appropriate to tell them "to go home and drink more fluids."

MacGibbon and Fejzo have disclosed no relevant financial relationships.

Infusion Nurses Society (INS) 2019 Annual Conference: Presented May 19, 2019.

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