By Dr Vicky O’Dwyer, Consultant Obstetrician at the Rotunda Hospital
“I vomited 20 times in one day. I was a shell of my former self. This almost constant nausea and vomiting was still there even when I was in labour.” This is the experience of hyperemesis, a severe pregnancy sickness that affects 1% of pregnant women. Unlike normal pregnancy sickness hyperemesis puts both the mum to be and baby at risk of complications. Hyperemesis can lead to dehydration, electrolyte imbalances and weight loss. If the degree of weight loss is more than 5% of the woman’s normal weight, then there is a risk of growth restriction in the baby and preterm birth. If you consider that a pregnant woman with a normal weight and BMI prior to pregnancy should gain between 12 and 18kg over the course of pregnancy than you realise that losing weight means she is losing a significant amount.
The new Irish guideline for management of hyperemesis in pregnancy is under development and the focus is on a holistic and multidisciplinary approach to care of a woman with hyperemesis. New additions to the guideline include an emphasis on psychological support, the importance of dietetic input into care and prevention of complications of hyperemesis.
“I felt guilty. I couldn’t function to mind my other children”. “The mental impact was devastating. It was a dark lonely time.” Low mood, depression and post-traumatic stress disorder can all be experience by women with hyperemesis, during and after pregnancy. Both peer support and professional support are beneficial and should be offered as part of maternity care. In recent years there has been investment in and expansion of perinatal mental health services nationally. Hyperemesis Ireland also provides support services through their website www.hyperemesis.ie. Women speak about difficulties with normal daily activities, inability to work and care for their children. Others describe a lack of understanding about the condition leading to unsympathetic comments which make them feel guilty that they are not enjoying their pregnancy or managing to function despite this all-consuming condition.
So, what can we do to help women with hyperemesis? The role of the dietitian is a key factor in managing hyperemesis. An individual consultation should be offered to women with hyperemesis and ongoing support as required. The aptly named PUQE score is used to assess the degree of hyperemesis as mild, moderate or severe based on the number of times per day that a woman experiences nausea, vomiting and retching. The score is used to decide what treatment is needed and whether this treatment can take place as an outpatient, in a day care unit or requires admission to hospital. The first step is rehydration with iv fluids. Vitamin supplementation with B1 (thiamine) is also given by an iv drip to prevent a rare but severe complication of hyperemesis called wernicke’s encephalopathy. This condition causes vision problems, unsteadiness when walking and confusion. For those who are dehydrated and immobile the risk of a clot in the leg or lung increases even higher than the normal increase in risk that is experienced by pregnant women. To prevent a clot compression socks and sometimes blood thinning injections of heparin are recommended. Dietetic support looks at what works for each woman, calorie intake, nutrition requirement s and practical advice for managing symptoms.
“Cariban helped me but it was so expensive”. Cariban is a combination of pyridoxine (vitamin B6) and doxylamine antihistamine that is imported from Spain and is first line treatment for hyperemesis in the current Irish treatment guideline. The combination of doxylamine and pyridoxine has been demonstrated to reduce nausea and vomiting in pregnancy in randomised, placebo-controlled trials. This combination has been highlighted as a first line treatment in Canadian and US clinical guidelines with good safety data in pregnancy. However, cariban is licensed in Spain but not in Ireland so it is not available with a medical card or on the drug payment scheme. Women have shared stories of spending 100 euro a week on this medication. Some were able to buy it a lower cost of 35 euro per week, often through a hospital pharmacy. The brand that is licensed in Ireland, Xonvea, is not marketed or sold in Ireland. HSE discussions on reimbursing Xonvea stalled and Hyperemesis Ireland has been campaigning to reach a solution that puts Irish women first and create a solution. There are also several anti-sickness medications that are used in both tablet form for home management and injection form for day care and during hospital admission. These include prochlorperazine, ondansetron and promethazine. When I was training these medications were used and cariban was not. Inpatient care was standard at that stage. Thankfully treatments and care pathways have improved. But there is still more to do.
This article is contributed by Dr Vicky O’Dwyer – Vicky is a Consultant Obstetrician at the Rotunda Hospital. She has a special interest in preventing preterm birth and caring for women with medical conditions who are pregnant. She has a medical doctorate and has published extensively on the topic of caesarean section. Vicky is married to Brian and has three children, Patrick, Holly and Jack.