InnovAiT, 12(8), 434–441

Hyperemesis gravidarum
Dr Yusra Khan
GP, Stoke Gifford and Conygre Medical Centre, Bristol
Email: yusrakhan@doctors.org.uk

N ausea and vomiting in pregnancy (NVP), or morning sickness, is the most common
symptom experienced by pregnant women and affects 80% of pregnancies. NVP
occurs across a spectrum, ranging from mild to severe, with hyperemesis gravidarum
(HG) representing the most extreme form. HG is a complication of pregnancy affecting
1% of pregnancies, and if left untreated can cause maternal and fetal morbidity and mor-
tality. Early treatment of NVP in primary care can prevent progression to HG. This article
aims to help GP trainees understand the natural history of HG and provides a framework for
its assessment and management.

The GP curriculum and hyperemesis gravidarum

Clinical module 3.06: Women’s health states that GPs should:

. Be aware that women-specific health matters including contraception, pregnancy, menopause and disorders of repro-
ductive organs will account for over 25% of your time as a general practitioner
. Recognise common signs and symptoms of, and know how to manage gynaecological disease
. Be the first port of call for pregnancy, eating disorders and other conditions confined to or more common in women,
involving other members of the healthcare team as appropriate
. Recognise and intervene immediately when patients present with a gynaecological or obstetric emergency
. Be familiar with and implement the key national guidelines that influence healthcare provision for women’s problems
. Discuss the psychosocial component of women’s health and the need, in some cases, to provide women patients with
additional emotional and organisational support (e.g. in relation to pregnancy options, hormone replacement therapy,
breast cancer and unemployment)

Clinical presentation
An internationally agreed definition for hyperemesis gravi-
darum (HG) does not exist. GPs need to be able to differen-
tiate nausea and vomiting in pregnancy (NVP) from HG and
implement the guidelines proposed by the Royal College of
Obstetricians and Gynaecologists (RCOG) on NVP (RCOG,
2016), which advise diagnosing HG when there is protracted
NVP with the triad of:
. More than 5% pre-pregnancy weight loss
. Dehydration
. Electrolyte imbalance(s)
Symptoms must occur before the 12th week of gestation
with exclusion of other medical causes of NVP. Nausea and
vomiting typically starts between the fourth and seventh week
of gestation. A literature review by Gadsby and Barnie-
Adshead (2011) has reported that day 39 from the last men-
strual period (LMP) is the mean day of onset, and in 13.2% of
women symptoms start before day 28, and thus before the
missed period. The symptoms peak between 7 and 9 weeks
from the LMP (Gadsby et al., 1993).
The intractable nausea can be markedly more debilitating
than vomiting, thus it is important not to under appreciate this
symptom. Excessive salivation (ptyalism) is also reported to be
a disturbing symptom. Symptoms are exacerbated by stimuli
such as noise, light, smell, heat and movement. Affected
women may find it difficult to walk to the toilet or even
stand. Avoidance of such triggers often impels the sufferer to
seek isolation in a dark room with self-care, domestic and
employment responsibilities proving impossible. NVP settles

434 InnovAiT, 2019, Vol. 12(8), 434–441, ! The Author(s) 2019.

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InnovAiT
between 9 and 16 weeks, whereas the majority of HG patients
continue to have symptoms after 16 weeks (Goodwin, 2008)
with 1 to 2% of patients enduring symptoms until delivery
(Saleh and Sykes, 2014).
Aetiology
The incidence of HG is found to be greater with: nulliparity, a
previous pregnancy affected by HG, female fetus, gestational
trophoblastic disease, twin pregnancy, fetal chromosomal
abnormalities, central nervous system malformations, and in
women under 25 years of age. Sisters of women with HG have
a 17 times greater risk of suffering from HG, and there is a
more than 27-fold increased risk of mother–daughter recur-
rence when a mother has HG with two daughters (Zhang
et al., 2011). Smoking is shown to decrease the risk of HG
(Zhang et al., 2011).
Until recently, the cause of HG was believed to be a com-
bination of hormonal, immunological, genetic and psycho-
logical factors, with the hormonal theory playing a
predominant role. Underlying mental health problems as a pro-
posed cause are perpetually disputed. The importance of beta
human chorionic gonadotrophin, which is increased in condi-
tions associated with greater pregnancy sickness such as twin
pregnancy and trophoblastic disease, has also been demoted.
A large genome-wide study found that the genes Growth and
Differentiation Factor 15 (GDF15) and Insulin-like Growth
Factor binding protein 7 (IGFBP7) are associated with a
greater risk of HG (Fejzo et al., 2018). Both genes are implicated
in placentation, appetite and cachexia. The receptor for GDF15
is expressed in the hindbrain causing nausea and taste
aversion (Fejzo et al., 2018). Inhibition of GDF15 in mouse
models of cancer has restored appetite and weight gain. This
supports the hypothesis that inhibition of these genes may be a
therapeutic option for HG (Fejzo et al., 2018).
Clinical assessment
Thirty percent of patients experiencing high levels of morbid-
ity from severe nausea and vomiting do not receive a diagno-
sis of HG (Gadsby and Barnie-Adshead, 2011). It is important
to be familiar with what to ask in the history as outlined in
Box 1, the essential aspects of the examination as outlined in
Box 2 and how to tailor the investigations for a patient with
potential HG.
There is no single investigation to detect HG or measure
severity. Clinicians usually perform a urine dipstick to look for
ketones. The presence of ketones does not equate with dehy-
dration, but rather reflects catabolism of adipose stores with
prolonged starvation. A diagnosis of dehydration should be
based on identifying relevant clinical symptoms and signs as
listed in Box 2. A systematic review and meta-analysis (Bias
et al., 2014) found no correlation between the grade of keto-
nuria and the severity of HG. Only a minority of patients with
HG will actually have ketones, and hence ketonuria should
not be used in the diagnosis of HG. Ketones should be looked
for if diabetic ketoacidosis is being considered. A urine dip-
stick can also be used to rule out other diagnoses, such as a
Box 1. History taking.
. Date of last menstrual period?
. Frequency of vomiting, haematemesis?
. Intensity, duration and triggers for nausea?
. Degree of weight loss compared with pre-pregnancy
weight, stabilised weight or ongoing weight loss?
. Fluid and food intake over last 2–3 weeks (not just the
last 24–48 hours)?
. Past medical history: any chronic conditions causing
nausea or vomiting predating the pregnancy?
. Impact on quality of life and mental health (anxiety,
depression, suicide risk)?
. Functional ability (domestic and occupational)?
. Personal or family history of HG or NVP?
. Support network (partner, relatives, friends, employer)?
Box 2. Examination.
. Signs of malnutrition: Weight loss, muscle wasting
. Signs of dehydration: Reduced skin turgor, reduced
urine output and dark/orange colour, rapid heart rate,
reduced blood pressure, postural blood pressure drop,
increased respiratory rate, drowsiness, confusion,
irritability
. Abdominal examination: To rule out differentials as out-
lined in Box 3. Tenderness other than mild epigastric
discomfort after retching is not a feature of HG
urinary tract infection, or to detect glycosuria. A list of differ-
ential diagnoses is outlined in Box 3.
The literature proposes Helicobacter pylori as an important
environmental factor in the development of HG, with studies
showing a high rate of sero-positivity for H. pylori in HG suf-
ferers and an improvement in nausea and vomiting with H.
pylori eradication (Bias et al., 2014). However, more robust
studies are required before investigation of H. pylori can be
formally suggested. Gastric ulceration caused by H. pylori
infection should be considered in patients with HG refractory
to standard treatment. Other investigations include ultrasound
to identify a viable intrauterine pregnancy, multiple pregnancy
or trophoblastic disease and blood tests.
Routine blood tests can help detection of anaemia, infec-
tion, abnormal electrolytes (including hyperkalaemia, hypo-
kalaemia and hyponatraemia) and diabetes. Lymphocytosis
is common in HG.
For patients with previous HG or refractory HG, additional
tests are indicated (Table 1). Liver function tests are abnormal in
approximately 40% of HG patients (Rotman et al., 1994). A
raised level of alanine aminotransferase may indicate severe
HG. A low level of albumin may indicate malnutrition. The
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Box 3. Differential diagnosis of HG. Management

Gastrointestinal Ear, nose and throat Lifestyle measures
. Gastroenteritis disease
. Gastritis . Labyrinthitis A combination of self-help lifestyle measures, pharmacological
. Hepatitis . Meniere’s disease support, and psychological support is essential to treat HG
. Biliary tract conditions . Vestibular lesions adequately. GPs should not offer lifestyle advice as the main-
. Peptic ulcer disease stay of HG treatment, but rather as a means of preventing
. Pancreatitis Drugs exacerbation of symptoms. Sufferers have altered olfaction,
. Appendicitis . Opioids and hence, odours such as those related to fatty and fried
. Gastroparesis . Iron foods should be avoided. A survey of 114 women found that
rest was noted by most respondents to be the only effective
Genitourinary Psychological management strategy apart from antiemetic medications
. Urinary tract infection . Eating disorders (O’Hara, 2013). Women should endeavour to eat and drink
. Pyelonephritis small amounts of whatever appeals to them when the nausea
Neurological is reduced or absent. A structured daily diary can help to plan
Metabolic . Central nervous eating and drinking. Maintaining a healthy diet is extremely
. Diabetic ketoacidosis system disease difficult for HG sufferers; they appear to tolerate a high carbo-
. Hyperthyroidism . Migraine hydrate and sugary diet best (Gadsby and Barnie-
. Addison’s disease Adshead, 2011).
. Hypercalcaemia Pregnancy-related Encouraging patients with HG to use a ‘morning sickness’
. Uraemia conditions cure, such as crackers or ginger, is inappropriate. Ginger is a
. Acute fatty liver therapeutic option for women with mild-to-moderate NVP,
of pregnancy which is commonly improved by dietary changes; however,
. Pre-eclampsia HG requires medical treatment including medications and
intravenous fluids. A self-selected internet-based survey of
512 women hospitalised with HG within the past year and
collectively experiencing 965 HG pregnancies, concluded
that ginger was unhelpful in controlling HG symptoms. It
Table 1. Blood tests in HG. also caused unpleasant side-effects, worsening of mood,
Patient type Tests breakdown of the doctor–patient relationship and a delay in
receiving effective management with worsening and longer
All patients with Routine bloods: duration of symptoms (Dean and O’Hara, 2015). Women felt
suspected HG . Full blood count their condition was being trivialised and were wrongly
. Urea and electrolytes given no hope of relief. Ineffective treatment of HG is a sig-
. Blood glucose nificant risk factor for termination of pregnancy. Women with
HG who had undergone terminations were three times more
Patients previously Additional/monitoring bloods:
likely to report that their healthcare providers were uncaring
admitted or with . Liver function tests
or did not realise the extent to which they were sick
refractory HG . Calcium
(Poursharif et al., 2007). Therefore, ginger should not be rec-
. Phosphate
ommended for HG.
. Amylase
A systematic review comprising 14 studies and meta-ana-
. Thyroid function tests
lysis showed that acupressure and electrical stimulation at the
pericardium 6 point may have some benefit in NVP but not
HG. There is no evidence of benefit from complementary
therapies such as acupuncture or hypnosis in HG (RCOG,
level of bilirubin may be mildly raised in HG without jaundice. 2016).
Higher rises in the level of alanine aminotransferase should
prompt consideration of other causes such as hepatitis or gall
Pharmacological treatment
stones (RCOG, 2016). Additional tests can detect hypocalcae-
mia and hypophosphatemia. The serum amylase level can be Women who are vomiting but not dehydrated, managing
slightly raised in HG. Two-thirds of HG patients have a raised some oral intake, and with no other complications can be
thyroxine and/or a suppressed thyroid stimulating hormone managed in the community. The onset of HG is commonly
level (RCOG, 2016). Negative antithyroid autoantibodies and before the booking midwife appointment. GPs are often the
the absence of a goitre rule out Grave’s disease and point to first to make the diagnosis and can offer antiemetic medica-
gestational transient thyrotoxicosis; the biochemical abnormal- tion. Antiemetic medications do not cure HG, but rather palli-
ities usually resolve by 20 weeks when HG typically improves ate the symptoms until natural improvement occurs. Several
and do not require treatment (Goodwin et al., 1992). Thyroid antiemetic medications from different drug classes are typic-
function tests should only be performed in refractory cases or if ally required to control symptoms, and arranging review after
clinical symptoms and signs of thyrotoxicosis are present. the initial appointment is mandatory. The recommended first

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InnovAiT

Figure 1. Treatment ladder for HG.

First-line an!eme!cs
(PO= oral, IM=intramuscular, PR=rectally, IV=intravenous (secondary care or “IV at home service”)
CYCLIZINE: 50mg PO, IM or IV 8 hourly.
PROCHLORPERAZINE: 5-10mg PO 6-8 hourly, 12.5mg IM/IV 8 hourly, 25mg PR daily or as BUCCASTEM 3mg twice per day
(posi!oned along top gum and dissolves).
PROMETHAZINE: 12.5-25mg 4-8 hourly PO, IM, IV or PR.
CHLORPROMAZINE: 10-25mg 4-6 hourly PO, IV, IM or 50-100mg 6-8 hourly PR.
XONVEA (10mg doxylamine succinate/10mg pyridoxine hydrochloride): maximum dose is 1 tablet am, 1 tablet mid-
a"ernoon and 2 tablets at night.

Second-line an!eme!cs

METOCLOPROMIDE: 5-10mg 8 hourly DOMPERIDONE: 10mg 8 hourly PO, 30- ONDANSETRON: 4-8mg 6-8 hourly PO,
PO, IV, IM (maximum 5 days use) 60mg 8 hourly PR 8mg over 15 minutes 12 hourly IV.

Referral
Criteria for inpa!ent management: Criteria for ambulatory day care management or “IV at
• Con!nued nausea and vomi!ng and unable to keep down home” service if available:
oral an!eme!cs. • PUQE score of 13 or above and no complica!ons and not
• Con!nued nausea and vomi!ng associated with weight loss refractory to an!eme!cs.
(greater than 5% of body weight) despite oral an!eme!cs. • Women may prefer ambulatory day care to avoid prolonged
• Confirmed/suspected co-morbidity such as a urinary tract hospital stay and arrangement of overnight childcare.
infec!on and unable to keep down oral an!bio!cs.
• Recurrent nausea and vomi!ng despite ambulatory day care
treatment as at risk of electrolyte imbalance and nutri!onal
deficiencies.

and second-line antiemetic medications are outlined in Fig. 1.
Intractable vomiting can cause gastro-oesophageal reflux dis-
ease, oesophagitis or gastritis. Gastro-oesophageal reflux can
in turn cause nausea and vomiting, hence proton pump inhibi-
tors or histamine H2 receptor antagonists should be
considered.
Safety netting advice to patients about symptoms and signs
of dehydration, weight loss, and failure of treatment is essen-
tial. If the oral route is not tolerated, the intramuscular or per-
haps even the rectal route can be useful in the community to
prevent dehydration and other complications associated
with HG.
Antiemetic medications are readily prescribed in secondary
care, but there is a reluctance to prescribe these within primary
care, in part following the history of thalidomide, but also
because the majority of antiemetic medications remain unli-
censed. Patients are also reluctant to accept medication. The
antiemetic medication Xonvea (10 mg doxylamine succinate
and 10 mg pyridoxine hydrochloride) has recently gained
license for the treatment of NVP when conservative manage-
ment has failed. It is used as a first line agent in the USA,
Canada, Spain, and Ireland, and has been prescribed to over
33 000 000 women over 40 years. A randomised controlled trial
has shown doxylamine and pyridoxine to be more effective at
reducing nausea and vomiting than metoclopramide (Basirat
et al., 2013) or at least equally effective and with fewer adverse
effects (Abas et al., 2014). Although Xonvea is not licensed for
the management of HG, it can be offered as part of a combin-
ation drug regimen.
Ondansetron is an antiemetic medication that is the subject
of debate. A large retrospective analysis of data from the
Danish birth registry of 608 385 pregnancies found no
increased risk of major birth defect, stillbirth, preterm labour
or small-for-gestational-age babies with ondansetron use
(Pasternak et al., 2013). Data from the Swedish Medical and
Birth Register demonstrated a small increased risk of cardio-
vascular defects and cardiac septal defects (Danielsson et al.,
2014). Ultimately, RCOG guidance supports use of ondanse-
tron and considers it safe and effective as a second-line agent
following ineffective trial of first-line antiemetic medications.
Although dopamine agonists such as metoclopramide are
safe and effective, they can cause extrapyramidal disorders
and tardive dyskinesia, particularly in younger patients
(European Medicines Agency, 2013). Therefore, metoclopra-
mide should be considered a second-line option and the max-
imum dose and duration should be 30 mg or 0.5 mg/kg in 24
hours for 5 days only (RCOG, 2016).
It is important to be vigilant of drug interactions. Caution is
advised when ondansetron is used alongside phenothiazines,
due to the risk of QT prolongation. A laxative should be

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Figure 2. PUQE index.

Motherisk PUQE-24 scoring system

In the last 24 hours, for how Not at all 1 hour or 2–3 hours 4–6 hours More than 6
long have you felt nauseated (1) less (3) (4) hours
or sick to your stomach? (2) (5)
In the last 24 hours have you 7 or more 5–6 !mes 3–4 !mes 1–2 !mes I did not
vomited or thrown up? !mes (4) (3) (2) throw up
(5) (1)
In the last 24 hours how, many No !me 1–2 !mes 3–4 !mes 5–6 !mes 7 or more
!mes have you had retching or dry (1) (2) (3) (4) !mes
heaves without bringing (5)
anything up?
Total score is sum of replies to each of the three ques!ons.
PUQE-24 score: Mild ≤ 6; Moderate = 7–12; Severe = 13–15.

How many hours have you slept out of 24 hours? Why?

On a scale of 0 to 10, how would you rate your wellbeing?

0 (worst possible) 10 (the best you felt before pregnancy)

Can you tell me what causes you to feel that way?

Reprinted from Ebrahimi N, Maltepe C, Bournissen FG, Koren G. Nausea and vomiting of pregnancy: using the 24-hour Pregnancy-Unique Quantification
of Emesis (PUQE-24) scale. Journal of Obstetrics and Gynaecology Canada, 31, 803-807, 2009, with permission from Elsevier.

prescribed with ondansetron, as constipation is a common and
problematic side-effect. Caution is needed with the use of
metoclopramide and phenothiazines together, particularly at
high doses for prolonged periods, as this increases the risk of
drug-induced extrapyramidal symptoms and oculogyric crises
(RCOG, 2016).
Ultimately, a Cochrane review (Matthews et al., 2010) and
birth registry data (Gill and Einarson, 2007) have reported the
safety of antiemetic medications in pregnancy (RCOG, 2016).
GPs can reassure patients regarding the safety of antiemetic
medications using the Motherisk and Bumps website.
The benefit of treatment can be assessed using the preg-
nancy-unique quantification of emesis (PUQE) score. This
looks at nausea, vomiting and retching in the last 24 hours
combined with a quality of life score as shown in Fig. 2
(RCOG, 2016) This score is not sensitive enough to diagnose
HG, but can be used to differentiate NVP from HG (PUQE
score over 15) and for monitoring once the symptoms of
nausea and vomiting are controlled.
Inpatient management
Maternal mortality is now rare, but HG remains the most
common cause of hospitalisation in the first half of pregnancy
and the second-leading cause of hospitalisation thereafter
(Goodwin, 2008). GPs need to review secondary care treat-
ment on discharge to decide ongoing treatment and monitor-
ing to avoid further complications.
Dehydration commonly occurs and requires treatment with
intravenous fluids to prevent electrolyte imbalance and renal
failure. Normal saline with potassium chloride is used and is
best suited to the hyponatraemic, hypochloraemic, hypokal-
aemic state with which HG patients present. Dehydration in
addition to immobility and pregnancy increases the risk of
venous thromboembolism. Low-molecular-weight heparin
and thromboembolic deterrent stockings should be pre-
scribed, and a risk assessment should be repeated on dis-
charge and in the community if the clinical situation changes.
Protracted vomiting can lead to oesophageal tears, retinal
detachment, splenic avulsion or pneumothorax. Protracted
starvation can lead to weight loss, anaemia and peripheral
neuropathies caused by vitamin B6, B12 or thiamine defi-
ciency. Oral or intravenous thiamine supplementation is essen-
tial in protracted vomiting or where dextrose or parenteral
nutrition is being considered to prevent Wernicke’s encephal-
opathy. If the level of weight loss is over 10%, daily parenteral
vitamins including B complex are needed. Oral thiamine sup-
plementation should be continued on discharge for women
with ongoing vomiting. Chronic Wernicke’s encephalopathy
can occur in the presence of mild and recurring thiamine defi-
ciency, presenting with slow and episodic symptoms. Non-spe-
cific symptoms such as headaches, anorexia, irritability and
abdominal discomfort occur, and these can be confused with
HG, leading to missed diagnosis. In cases of severe and sudden
thiamine deficiency, such as where HG co-exists with a high
thiamine requirement state such as infection, Wernicke’s
encephalopathy can develop rapidly with confusion, drowsi-
ness, memory disturbance, blurred vision and an ataxic gait.
Signs include nystagmus, ophthalmoplegia, hyporeflexia or
areflexia and coordination abnormalities.
Intravenous steroids should be reserved as a third-line
treatment for intractable cases of severe hyperemesis where
intravenous fluids and antiemetic medications have failed.

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InnovAiT
The recommended dose of intravenous hydrocortisone is
100 mg twice daily converting to oral prednisolone 40–
50 mg daily once clinical improvement occurs (RCOG,
2016). The dose is then gradually tapered until the lowest
maintenance dose that controls the symptoms is reached. A
short course of steroids has been shown to reduce the like-
lihood of recurrence of vomiting and readmission for HG
(Carlan and Duggar 2001). Ideally, steroids should be
avoided before 10 weeks of gestation, unless the clinical
state absolutely warrants it due to the risk of cleft lip or
palate with methylprednisolone use in the first trimester
(Carmichael and Shaw, 1999). However, it should be noted
that the overall teratogenic effect is small at 1 or 2 cases per
1000 treated women (Shepard et al., 2002).
Enteral and parenteral feeding is required to provide nutri-
tional support when HG has not responded to medical treat-
ment and the patient cannot maintain her weight. A weight
gain of less than 7 kg throughout pregnancy is associated with
a low-birth-weight baby, preterm delivery and a 5-minute
Apgar score of less than seven (Dodds et al., 2006). Patients
with HG, particularly those with symptoms continuing into the
second trimester, require greater attention to detect adverse
outcomes; serial ultrasound scans are required for monitoring.
Due to the increased risk of a small-for-gestational-age foetus
with severe hyperemesis, one would also expect the incidence
of stillbirth to increase, but the increased rate of spontaneous
and iatrogenic elective preterm deliveries outweighs this
effect, leading to a lower risk of stillbirth overall (Gadsby
and Barnie-Adshead, 2011)
Termination of pregnancy is the last resort once all thera-
peutic measures have been employed without success.
Pregnancy Sickness Support UK (2013) found that 10% of
pregnancies complicated by HG end in termination in
women who would not otherwise have chosen this option,
and many of these women were not treated adequately with
only 10% being offered steroids before deciding to terminate
(BBC News, 2015).
Psychological support
Depression and anxiety is more prevalent in patients with HG.
A study by Heitmann et al. (2017) described the burden HG
has on domestic and occupational functioning: 84% stated that
NVP had major adverse effects on their ability to care for their
children, 43% said it had a major impact on the relationship
with their partner, and 94% reported a major impact on their
work capacity with 90% being off sick due to the condition.
Healthcare professionals and relatives often have unrealistic
expectations of patients with HG who are often expected to
continue their daily roles as mothers, wives and employees
despite having a severely debilitating illness. Their symptoms
are too often dismissed with suspicions of psychosomatism or
considered a normal part of pregnancy, rather than a compli-
cation of pregnancy. This approach leads to inadequate treat-
ment, in some cases termination of otherwise wanted
pregnancies, and a restrictive effect on the woman’s future
reproductive plans and choices.
A biopsychosocial approach to the management of HG is
required. A depression and anxiety screen should be per-
formed, and if appropriate, referral to perinatal mental health
services should be pursued. Due to the debilitating nature of
this illness, home visits can be helpful and provision of sick
notes should be facilitated. Referral to the Pregnancy Sickness
Support charity can be useful for patients. Discussion of symp-
toms or concerns with the helpline coordinator and accessing
the online forum for support can be helpful. This support is
from people sharing the same experience and being matched
and supported by trained women who have also previously
endured HG. The website www.pregnancysicknesssupport.or-
g.uk has useful resources for patients, relatives and healthcare
professionals, including documents on eating advice, sick leave
and employment rights. Although the Hyperemesis Education
and Research Foundation is based in the United States, it does
collaborate internationally; it can be accessed via the website:
www.helpher.org. Women with prolonged symptoms are also
likely to require mental and physical health support following
delivery; these women are more likely to report postnatal
depression, post-traumatic stress disorder, anxiety, motion
sickness and muscle weakness (Fejzo et al., 2009).
Recurrence and pre-emptive planning
The recurrence rate of HG is very high at 70–80%: 26% report
more severe symptoms, 44% less severe symptoms and 30%
experience the same degree of severity (Brecht-Doscher and
Jones, 2010). Women should be encouraged to develop a care
plan with their GP before a positive pregnancy test. This can
empower patients to seek advice and treatment when the
symptoms of HG strike again. Antiemetic medications should
be started as soon as a positive pregnancy test is obtained, to
reduce the severity and duration of symptoms. Early access to
prenatal appointments should also be arranged. The criteria
and route for admission should be agreed. A healthy body
mass index is advised, aiming for the higher end of normal
as weight loss is likely to occur. Financial, employment and
domestic concerns should be discussed and resolved, where
possible, prior to conceiving (Dean, 2014).
KEY POINTS
. Diagnose HG when there is protracted NVP with at least
5% pre-pregnancy weight loss, dehydration and electro-
lyte imbalance
. Ketones are neither diagnostic of HG nor do they indi-
cate the severity of HG; the detection of ketones does
not indicate dehydration
. New research has proposed a genetic cause for HG with
the genes GDF15 and IGFBP7 implicated
. Morning sickness cures such as ginger are not recom-
mended for HG
. Antiemetic medications are not licensed in the UK, but
are safe to use in pregnancy
. HG has a global impact on domestic, social and occu-
pational functioning; holistic care is essential
439

Conflict of interest
Trustee on Pregnancy Sickness Support Charity UK, twice sufferer of
hyperemesis gravidarum.
References and further information
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with metoclopramide for hyperemesis gravidarum: A rando-
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for hyperemesis gravidarum: A systematic review and meta-ana-
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Preparation_for_the_hyperemesis_pregnancy.pdf (accessed 12
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AKT question relating to heavy menstrual bleeding
Single Best Answer
A 42-year-old lady comes to see you with problematic men-
orrhagia of 6 months duration. She has had blood tests and a
pelvic ultrasound scan showed a 1 cm fibroid. There are no
urinary or bowel symptoms. Her past medical history
includes a pulmonary embolism 5 years ago.
What is the MOST appropriate first-line treatment
option for her? Select ONE option only.
Dr Anish Kotecha
GP Partner, Cwmbran Village Surgery, Wales
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vomiting in pregnancy and hyperemesis gravidarum. MIDIRS
Midwifery Digest 24(2): 179–185.
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hyperemesis gravidarum. American Journal of Obstetrics and
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DOI: 10.1177/1755738019859982
A. Combined oral contraceptive
B. Copper coil
C. Hysterectomy
D. Levonorgestrel intrauterine system (Mirena! )
E. Tranexamic acid
Answer DOI: 10.1177/1755738019859984
441