What is the priority intervention for a pregnant mother diagnosed with hyperemesis gravidarum?

Our Trustee Dr Caitlin Dean recently had an article published about how midwives can help women with hyperemesis in the Essentially MIDIRS journal. Access the full text of the article.

Nausea and Vomiting in Pregnancy and in particular, Hyperemesis Gravidarum is a challenge for both mothers suffering and the midwives caring for them. Below is some information for Midwives about how they can help women with this debilitating and devastating condition both in the community and as in patients on ward.

• Reduce sensory stimuli and triggers as far as possible - In particular odours from food, perfumes, coffee and so on but also lighting and noise levels, motion and general interruptions to rest. Women admitted to hospital with hyperemesis gravidarum should be in a side room so as to reduce sensory stimulation.
• Listen to her: loneliness and isolation may well be a major part of her distress.
• Watch for signs of psychological illness as a result of the condition and refer for assessment as appropriate. Depression is not a cause of hyperemesis but can certainly be caused by it!
• If possible, refer to a physiotherapist to minimise the effects of atrophy from prolonged bed rest
• Measure legs and prescribe TED Stockings to reduce the risk of Deep Vein Thrombosis.
• Ask for permission before discussing food and before mentioning food names in case it triggers nausea
• Ascertain the level of sickness by asking what foods and drinks have been tried, what has helped/what has not and taking a thorough history. Encourage her to fill in a daily diary to look for a pattern
• Be careful if recommending "morning sickness cures" to an HG sufferer; she will have been told innumerable times to try crackers and ginger. It may undermine confidence in healthcare professionals as well as adding to her feeling of isolation. Many sufferers of hyperemesis report that the suggestion of ginger instils feeling of anger and hopelessness
• Do not challenge what she is or is not eating/drinking; anything is better than nothing (within current recommended guidelines).
• Refer her to this website for information on eating and drinking and coping strategies as well as for support for both the mother and her partner
• Watch for signs of dehydration, (Ketones are not a sign of dehydration)
• Alleviate any guilt and reassure the mother if she has been unable to take prenatal vitamins. Medication is necessary for severe hyperemesis gravidarum and women should be reassured of the need for safe, effective treatment.
• Remind her to take the pregnancy a day at a time and that the HG will end, even if that is not until delivery.
• Remember that pregnancy sickness is not always a ‘good sign’. There are many cases of women whose HG has continued despite later discovering that the foetus died weeks earlier. Unpublished evidence has shown that women with HG likely to suffer foetal demise (see www.hyperemesis.org/HER-Research). Furthermore remember that many women with HG suffer so badly that they consider termination as their only remaining option.
• Encourage appropriate medication.
• Those with prolonged illness and inadequate medical care - e.g., those with greater than 10 per cent loss of pre-pregnancy body weight or those who fail to gain weight for two consecutive trimesters - are at increased risk of serious complications such as pre-eclampsia and pre-term labour. A referral should be made to an obstetrician or assessment unit to check for signs of Intra Uterine Growth Retardation.
• Remember that recovering from HG takes time and that there may be a long-term impact on both mother and baby.

If you are currently treating a sufferer of Nausea and Vomiting in Pregnancy or Hyperemesis Gravidarum and would like further information please contact our helpline

T: 024 7638 2020

E:

An online survey conducted in 2014 of 345 women who had been admitted to hospital with hyperemesis in the last five years found that 45% had experienced having to empty their own vomit or urine bowl and 40% encountered ward staff who smelled of perfume or cigarettes which exacerbated their symptoms.

Unfortunately, it is often the negative experiences which have a profound impact on the women suffering. However on a positive note it is also relatively easy to make a big positive difference to women you encounter with hyperemesis by ensuring their care is evidence based and effective.

This sample care plan was developed by registered nurse and trustee Caitlin Dean for nurses and midwives to adapt to appropriate in their own professional environments. 

Download a printable version.

Care Plan for ___________________________________

Date of admission _______________________________

Weeks gestation at admission ___________________________

Pregnancy number ___________Children at home____________

History of twins: yes / no

Weight at admission: _______________________ KGHeight _______________________ CM

BMI___________

Patient reported weight loss __________________ or % of pre-pregnancy weight loss _____________

Blood Pressure _________/___________

TED Stockings provided? YES / NO

Aims of Care Plan:1. Reduce nausea and vomiting2. Correct dehydration3. Prevent further weight loss4. Provide emotional and psychosocial support

5. Provide a comfortable environment

Nursing Actions for Care Plan:

1. Reduce Nausea and Vomiting

• Ensure medication is provided on time to enable stable blood levels of anti-emetics.
• Reduce sensory stimulation by providing a side room away from ‘smelly areas’, if possible, and ensuring staff are quiet and free from perfume whilst providing care.
• Provide snacks when required where possible.
• Review effectiveness of medication and interventions daily or as required, using MUST or PUQE tool.

2. Correct dehydration

• Provide IV fluids as per prescription.
• Warm IV fluids to 37 degrees before administration, if possible. This is to reduce calorific loss from cold IV fluid administration.
• Encourage oral fluids as and when they can be tolerated.
• Provide information on suitable fluids for pregnancy and tips on getting fluids, for example, via ice lollies.
• Monitor fluid balance input/output if appropriate 

3. Prevent Further Weight Loss

• Encourage oral food intake where possible.
• Provide information on fortifying food and fluid. 
• Ensure medication regime is controlling vomiting and nutrient loss. Adjust timings to maximise ability to eat at mealtimes.
• Provide snacks as and when she feels able to eat.

4. Provide Emotional and Psychosocial Support

• Where available, discuss referral to peri-natal mental health team for support with psychological impact of HG and refer if appropriate.
• Provide information about PSS charity and make referral to support network if required.
• Ensure she has an advocate for ward rounds with doctors if she is struggling with speaking due to nausea and vomiting.
• Ensure informed consent is obtained for all treatments, tests and procedures.
• Provide written information about hyperemesis and any treatments or medication.

5. Provide a Comfortable Environment

• Provide a side room where possible to reduce sensory stimulation such as smell and sound and reduce distress from public vomiting and episodes of incontinence.
• Ensure staff are free from perfumes or cigarette smoke.
• Provide pressure relieving mattress to reduce the risk of pressure damage from prolonged bed rest.
• Ensure vomit bowls and urine samples are removed promptly and adequate empty receptacles provided.

REVIEW ARTICLES
Fejzo MS, Trovik J, Grooten IJ, Sridharan K, Roseboom TJ, Vikanes Å, Painter RC, Mullin PM. Nausea and vomiting of pregnancy and hyperemesis gravidarum. Nat Rev Dis Primers. 2019 Sep 12;5(1):62. doi: 10.1038/s41572-019-0110-3.

JOURNAL ARTICLES
Fejzo MS, Sazonova OV, Sathirapongsasuti JF, Hallgrímsdóttir IB, Vacic V, MacGibbon KW, Schoenberg FP, Mancuso N, Slamon DJ, Mullin PM, 23andMe Research Team.

Placenta and appetite genes GDF15 and IGFBP7 are associated with hyperemesis gravidarum. Nat Commun. 2018 Mar 21;9(1):1178. doi: 10.1038/s41467-018-03258-0.

Cohen R, Shlomo M, Dil DN, Dinavitser N, Berkovitch M, Koren G. Intestinal obstruction in pregnancy by ondansetron. Reprod Toxicol. 2014 Dec;50:152-3.

Oliveira LG1, Capp SM, You WB, Riffenburgh RH, Carstairs SD. Ondansetron compared with doxylamine and pyridoxine for treatment of nausea in pregnancy: a randomized controlled trial. Obstet Gynecol. 2014 Oct;124(4):735-42.

Fejzo M, Magtira A, Schoenberg FP, Macgibbon K, Mullin P, Romero R, Tabsh K.Antihistamines and other prognostic factors for adverse outcome in hyperemesis gravidarum. Eur J Obstet Gynecol Reprod Biol. 2013; 170: 71–76.

Pasternak B1, Svanström H, Hviid A. Ondansetron in pregnancy and risk of adverse fetal outcomes. N Engl J Med. 2013 Feb 28;368(9):814-23.

Mullin PM, Ching C, Schoenberg F, MacGibbon K, Romero R, Goodwin TM, Fejzo MS: Risk factors, treatments, and outcomes associated with prolonged hyperemesis gravidarum. J Matern Fetal Neonatal Med. 2012; Jun;25(6):632-6.

Mullin P, Bray A, Schoenberg-Paik F, MacGibbon K, Romero R, Goodwin TM, Fejzo MS: Prenatal Exposure to Hyperemesis Gravidarum Linked to Increased Risk of Psychological and Behavioral Disorders in Adulthood. J Dev Origins of Disease. 2011; 2:200-204.

Veenendaal MV, van Abeelen AF, et al. Consequences of hyperemesis gravidarum for offspring: a systematic review and meta-analysis. BJOG 2011;118(11):1302-1313.

Zhang Y., Cantor R., MacGibbon K, Romero R, Goodwin TM, Mullin P, Schoenberg Fejzo M. Familil Aggregation of Hyperemesis Gravidarum. AJOG 2011 Mar;204(3):230.e1-7.

Vikanes A, Skjaerven R, Grjibovski AM, Gunnes N, Vangen S, Magnus P. Recurrence of hyperemesis gravidarum across generations: population based cohort study. BMJ. 2010 Apr 29;340:c2050.

Fejzo MS, Poursharif B, Korst L, Munch S, MacGibbon KW, Romero R, Goodwin TM Symptoms and pregnancy outcomes associated with extreme weight loss among women with hyperemesis gravidarum, J of Womens Health. 2009 Dec;18(12):1981-7.

Fejzo MS, Ingles SA, Wilson M, Wang W, Mac Gibbon K, Romero R, et al.. High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals. Eu J Obstet Gynecol 2008; 141:13-17.

Goodwin TM, Poursharif B, Korst LM, MacGibbon K, Fejzo MS: Secular trends in the treatment of hyperemesis gravidarum. Am J Perinatol, 2008;25(3):141-7.

Poursharif B, Korst L, MacGibbon KW, Fejzo MS, Romero R, Goodwin TM. Elective pregnancy termination in a large cohort of women with hyperemesis gravidarum. Contraception.2007;76(6):451-5.

Seng JS, Schrot JA, van De Ven C, Liberzon I. Service use data analysis of pre-pregnancy psychiatric and somatic diagnoses in women with hyperemesis gravidarum. J Psychosom Obstet Gynaecol. 2007 Dec;28(4):209-17.

INTERNET
Healthcare Cost and Utilization Project (HCUP). Reviewed November 2019. Available from https://www.ahrq.gov/data/hcup/index.html Accessed Feb 24, 2020.