BHUBANESWAR: Barely two weeks into her second pregnancy, Sahana, 32, realised that the next few months would not be easy. Going by her previous experience, she knew that the nausea would only get intense in the coming days, and the vomiting would be a regular ordeal within minutes of even a light snack or meal. She also knew that it could be managed with help from a doctor and would come to pass. Nine months later, she once again delivered a healthy baby.
Pregnant women often complain of nausea and vomiting, which subsides after the first trimester. But some pregnant women experience severe bouts of nausea and vomiting for a prolonged period. According to health experts, this extreme form of nausea and vomiting experienced during pregnancy is called hyperemesis gravidarum that can lead to dehydration, electrolyte imbalances and weight loss. It is more intense than typical morning sickness and can significantly impact a pregnant woman's quality of life.
The prevalence of hyperemesis gravidarum in India varies and it has emerged as a cause of concern for pregnant women due to its potential effects on both maternal and foetal health. More than 80% pregnant women experience morning sickness and it is usually manageable unlike hyperemesis gravidarum, which requires medical treatment to address symptoms and ensure better health.
For nine months
Even as the exact incidence is not well-documented in Indian healthcare settings, the condition is being increasingly recognised by gynaecologists. Unlike typical morning sickness, which usually resolves by the end of the first trimester, hyperemesis gravidarum can persist throughout the pregnancy and can be severe. Studies suggest this pregnancy complication affects about 0.3% to 3% of pregnant women.
Dr Sweta Singh, head of the Obstetrics and Gynaecology department of AIIMS-Bhubaneswar, said most pregnant women experience nausea and vomiting which is very common in early pregnancy. But a few of them suffer from hyperemesis gravidarum that causes uncontrollable vomiting and makes women vomit several times per day during pregnancy, leading to weight loss and volume depletion, resulting in ketonuria and/or ketonemia.
Causes and symptoms
The exact cause of hyperemesis gravidarum has not been fully ascertained yet. However, there are several factors that contribute to this health condition during pregnancy. The factors responsible include genetic, hormonal changes and underlying health issues.
Some of the risk factors associated with hyperemesis gravidarum are increased placental mass, history of motion sickness or migraine, and having family history of first-degree relatives like mother or sister who had hyperemesis gravidarum when they were pregnant.
Dr Sanghamitra Satapathy, senior consultant (O&G) at Jagannath Hospital, said elevated levels of pregnancy hormones such as human chorionic gonadotropin (HCG) and estrogen play a role in hyperemesis gravidarum. "There could also be a genetic predisposition, as HCG sometimes runs in families. Underlying health conditions like thyroid disorders or gastrointestinal issues might exacerbate the symptoms. Women, who experience nausea and vomiting, due to consumption of estrogen-containing medications, exposure to motion, or have a history of migraines are at higher risk," she said.
Complications
Hyperemesis gravidarum can create severe complications if not diagnosed and treated. If a pregnant woman experiences severe vomiting and her weight gain in pregnancy is less than 7kg, it may lead to preterm birth and low birth weight in baby. If hyperemesis gravidarum is left untreated, pregnant women will suffer from a sequelae of micronutrient deficiency and sometimes the symptoms lead to complications such as liver dysfunction and kidney problems.
Dr Singh said women with hyperemesis gravidarum may suffer from wernicke encephalopathy or wet brain, which is caused due to deficiency of vitamin B1. Some also suffer from diathesis or very rare bleeding and embryopathy due to vitamin K deficiency apart from adverse effects of malnutrition like poor wound healing and muscle wasting.
"Placental dysfunctions like preeclampsia, abruption, and restricted foetal growth have also been reported in some cases. Esophageal tears, esophageal rupture, diaphragmatic tear, venous thrombosis, acute tubular necrosis, splenic avulsion, pneumothorax, rhabdomyolysis, pneumomediastinum, osmotic demyelination syndrome and hepatic insufficiency are other rare complications witnessed in patients with persistent severe vomiting if left untreated," she said.
Treatment and prevention
Hyperemesis gravidarum is a serious condition that requires prompt and comprehensive care to ensure the health and well-being of both the mother and the baby. It can be managed through medical treatment, lifestyle changes and sometimes hospitalisation in case of severe complications.
Gynaecologists prescribe oral rehydration solutions or intravenous fluids to treat dehydration apart from anti-nausea medications to help alleviate symptoms. In cases where oral intake is severely restricted, nutritional supplements or tube feeding is advised. Modifications in lifestyle, small and frequent meals, and avoiding triggers such as strong odours will also help manage symptoms.
"Correction of hypovolemia and ketonuria is done with intravenous fluids that can also treat electrolyte abnormalities. We also aim to minimise the potential fetal effects of maternal pharmacotherapy through medications like vitamin B6, H1 antagonists (antihistamines), dopamine antagonists, serotonin antagonists, and rarely glucocorticoids," said Dr Singh.
Pregnant women can also prevent vomiting by avoiding environmental triggers along with dietary changes. Ideally, all women of child-bearing age should take a daily multivitamin with folic acid for at least one month prior to conception. This reduces the risk of congenital anomalies, particularly neural tube defects, and may help decrease the frequency and severity of nausea and vomiting during pregnancy. Managing heartburn and acid reflux prior to pregnancy will also prevent or reduce the severity of symptoms in pregnancy, she added.