Hyperemesis Gravidarum (HG)

Definition

• Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy leading to significant dehydration, weight loss and electrolyte imbalance

• It often requires medical intervention and can markedly affect maternal quality of life and emotional well-being

• The diagnosis is clinical and necessitates exclusion of other causes such as urinary tract infection, thyroid disease or gastrointestinal conditions

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Aetiology and Pathophysiology

• Strongly associated with high human chorionic gonadotropin levels, particularly in multiple or molar pregnancies

• May involve increased oestrogen levels and transient thyrotoxicosis contributing to symptom severity

• The condition is multifactorial, with genetic, endocrine and possible psychosocial components

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Non-Pharmacological Management

• Dietary adjustments include small, frequent meals, high-protein snacks and low-fat food choices while avoiding spicy or fatty foods

• Ginger supplements or ginger in various forms may help alleviate symptoms, although evidence is mixed

• Encourage adequate oral hydration and, if oral intake is insufficient, initiate intravenous rehydration

• Advise avoidance of strong odours and stress, and promote good sleep hygiene and rest

• Supplement with a multivitamin formulation without iron to reduce gastric irritation

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Pharmacological Management

• First-line treatment comprises pyridoxine (vitamin B6) combined with doxylamine, with dosing adjusted as required

• If symptoms persist, consider adding antiemetics such as metoclopramide or ondansetron while discussing risks and benefits

• Alternative options include promethazine, prochlorperazine and, in refractory cases, low-dose prednisolone may be considered

• Selection of agents should prioritise maternal and foetal safety, taking into account pregnancy drug categories

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Monitoring and Follow-Up

• Regularly assess weight, hydration status and electrolyte levels to monitor disease severity and response to treatment

• Check for ketonuria and signs of dehydration to guide the need for hospital admission

• Ensure prompt review, ideally within one week if symptoms continue, to adjust management accordingly

• Early and tailored intervention improves both maternal and foetal outcomes

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Complications and Outcomes

• Severe hyperemesis can lead to nutritional deficiencies, electrolyte disturbances and complications such as Wernicke encephalopathy

• Prolonged symptoms may result in significant psychosocial morbidity, including secondary depression and reduced work capacity

• Timely intervention with appropriate rehydration, nutritional support and antiemetic therapy is essential to prevent adverse outcomes

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Notes

• Although nausea and vomiting affect up to 85% of pregnant women, hyperemesis gravidarum occurs in approximately 0.3–1.5% of pregnancies

• Symptoms typically peak around 9 weeks gestation and resolve before 14 weeks, though a minority may experience symptoms beyond 20 weeks

• Exclude other causes of severe nausea and vomiting with appropriate investigations such as liver function tests, thyroid function tests and ultrasound examination

• Adjunctive therapies like acupressure at the P6 (Neiguan) point may be considered as a low-cost, low-risk option despite mixed evidence

• Underutilisation of effective antiemetics may contribute to unnecessary morbidity, making careful drug selection and dosing vital for optimal management