Hyperemesis Gravidarum or Morning Sickness? We Break It Down

Image: Getty

We all know that vomiting, nausea and food aversions are common during pregnancy, especially in the first trimester. And even though they can happen any time of day, these symptoms are typically all grouped under the umbrella term “morning sickness.” But there’s a line where morning sickness actually becomes a dangerous and debilitating condition called Hyperemesis Gravidarum (HG). Here’s what you need to know about morning sickness vs. Hyperemesis Gravidarum:

What exactly is HG?

“HG is used to identify persistent nausea and vomiting during pregnancy or just persistent nausea without vomiting,” says Dr. Danielle Plummer, PharmD, founder of HG Pharmacist and a three time HG survivor. She’s also on the board of directors of the HER Foundation, the global voice for HG awareness. “According to the HER Foundation, HG is ‘a potentially life-threatening pregnancy disease that may cause weight loss, malnutrition, dehydration, and debility due to severe nausea and/or vomiting, and may cause long-term health issues for mother and baby(ies).'”

There are no accurate records that reflect how many women suffer from HG as the lack of education around this condition impacts the number women who are actually diagnosed. Studies do show that the risk of reoccurrence ranges from 66-75%, so if you suffered with your first pregnancy, you are very likely to suffer again – and there is no proven way to prevent it. Thanks to well known figures like Amy Schumer and Kate Middleton being public about their own experiences with HG, the condition is, however, gaining more attention and being taken more seriously.

How is it diagnosed?

The criteria for diagnosis varies among practitioners. “It’s important that practitioners look at the whole picture, including changes in lifestyle and mental health, and do not use lab results alone,” says Dr. Plumer. “For example, some women are told that their ketones are fine therefore they do not need fluids. What these doctors are missing is that this is a disease of malnourishment and will escalate without replenishing nutrients.”

According to Dr. Plummer HG is often diagnosed when nausea and vomiting cause the following criteria:

  • Frequent and/or severe nausea and vomiting
    • Constantly dehydrated even after rehydration
    • Vomiting that will not stop
  • Losing 1-2 pounds per week, 5-20 pounds since becoming pregnant, >5% of prepregancy weight or failure to gain weight by the second trimester
  • Chronic fatigue
  • Inability to work, take care of children or do daily tasks like showering, brushing teeth or preparing meals.
  • Lab results that include signs of dehydration and starvation:
    • Increased urinary ketones
    • Increased urine specific gravity
    • Increased blood urea nitrogen (BUN)
  • Electrolytes including potassium, magnesium, sodium, phosphate are deficient
  • Vitamins including thiamin, vitamin K and vitamin D are depleted
  • Thyroid and parathyroid levels are abnormal
  • Liver enzymes are increased
  • Blood volume is reduced

Nausea and vomiting in pregnancy range from mild morning sickness (MS) to severe HG. There are a variety of factors to consider when determining where you lie on the spectrum, which Dr. Plummer outlines below.

  • Weight: MS may cause transient decreased appetite that resolves while HG often leads to consistent, potentially dangerous, weight loss
  • Nausea and/or vomiting:
    • Even with nausea and vomiting during MS, by the end of the day, the mum will have had enough to eat and drink while nausea and vomiting in mums with HG cannot keep food or liquids down leading to dehydration and malnourishment
    • Mums with MS may vomit intermittently while HG mums often vomit consistently, vomit bile or blood, and may even rupture their esophagus
    • Vomiting in MS mums resolves by the end of the first trimester while many HG mums continue to vomit through their entire pregnancy
    • HG mums need IV therapy to take in nutrients needed for survival
    • HG mums need a multitude of medications and medical treatments to be able to eat and drink
  • Lifestyle and mental health
    • MS mums feel better by adjusting diet and lifestyle while no traditional treatments improve with HG mums
      • Crackers and ginger work for MS mums, but please do not mention these two foods to an HG mom!
    • MS mums may take a week or so off from work due to feeling ill while HG mums literally cannot work for months and end up quitting, getting fired or are forced to resign. HG mums cannot even drive to work. FMLA only covers 13 weeks!
    • MS mums can still take care of household needs, care for other family members and do basic hygiene including cleaning, cooking, brushing teeth and showering, yet HG mums often cannot complete these tasks.
      • When a mum has HG, relationships are often pushed to their limits
    • MS mums may feel intermittent sadness or stop socializing during the first trimester while HG mums are pushed to the brink of humanity due to isolation which may lead to depression or anxiety requiring profession intervention
    • HG mums often have postnatal PTSD and triggers that need professional intervention
    • MS mums may continue to have more children without thinking twice about how they felt during the pregnancy while HG mums are terrified to become pregnant again, often stopping with only having one child even if they wanted more
    • Unfortunately, many HG mums terminate their pregnancies out of desperation
  • Finances
    • MS mums may see a slight hardship on their finances due to lost work days and increased medical bills while HG mums finances are devastated due to loss of jobs, cost of medical interventions and cost of extra care for household and family needs

“The only key to preventing the nausea and vomiting from escalating to severe HG is by aggressively treating it from the beginning of the pregnancy,” says Dr. Plummer. “Strategies include continuously updating medication regimens by maxing out doses, trying alternate formulations which include creams, patches, suppositories and subcutaneous pumps, receiving IV therapy when oral medications or liquids are not tolerated and supporting mental health.”

Hyperemesis Gravidarum

Image: Getty

Risk factors.

The HER Foundation has some neatly outlines risk factors, however, Dr. Plummer is quick to note that she had HG in all three of her pregnancies yet did not have any risk factors. “The only risk factor clinically proven is having a family member with HG.”

Risk Factors 

  • Untreated asthma
  • High saturated fat diet
  • Low or high body weight
  • Posttraumatic stress disorder (PTSD)
  • Excessive social stress (worsens existing HG)
  • Multiple gestation (twins or more)
  • Food cravings and aversions before/during pregnancy
  • Epilepsy
  • Exposure to smoking

History of:

  • Nausea and vomiting during pregnancy
  • Motion sickness
  • Menstrual pain (dysmenorrhea)
  • Sensitivity to oral contraceptives
  • Nausea premenstrually
  • Migraine headaches
  • Allergies
  • Gallbladder disease
  • Gastritis or ulcers
  • **Female relative with HG
  • High blood pressure
  • Liver disease
  • Kidney disease
  • Poor diet
  • Abnormal thyroid levels

Think you have HG? Here’s what you should do. 

Seek treatment immediately! “I regularly have women contacting me who need help because their provider is not treating them, telling them old wives’ tales about how it’s normal and will go away on its own or telling them there is nothing else that can be done to help them. If you are not getting supportive care from your provider, find a new one who will treat HG with proper medical care.”

Reach out to your insurance plan to find out what they cover. Questions Dr. Plummer suggests asking include:

  • Where do I go for IV infusions? (ER, infusion clinic…)
  • Are there criteria that must be met prior to going to an ER?
  • Is home health covered by the plan? If so, what services exactly and how often? For example, patients receiving a TPN should get infusion three times per week along with electrolyte checks
  • What medications are covered?
  • What’s the process to get the plan to cover non-formulary medications or treatments? Examples include the Sancuso patch, an ondansetron pump or compounded metoclopramide cream
  • Do they cover a case manager to coordinate all your care?
  • Do they cover a registered dietician?
  • Do you need referrals to specialists?
  • What’s the process to change providers?

It cannot be overstated that getting help and getting that help early is critical. “Complications from the chronic dehydration and malnutrition caused by HG are vast and when not treated properly can be fatal for mum and/or baby,” says Dr. Plummer. “While pregnant, seek immediate intervention if the following occur: muscle weakness, confusion, vomiting blood or bile, vomiting that will not stop, losing weight into the second trimester. When these issues are not addressed immediately, they can lead to damaging multiple organs and organ systems.”

For more information, Dr. Plummer co-hosts a weekly Instagram Live @HGmoms and you can contact her at HG Pharmacist for education, advocacy and personalized treatment plans.

Suffering From Morning Sickness?