This study was conducted to elucidate gaps in the current management of NVP/HG. As such, our data shows that over one-half (57.1%) of respondents diagnosed with HG have taken at least three different medications to alleviate their symptoms, some relying on more than five separate daily medications. As a result, over two-thirds (68%) of these patients experienced side effects from their treatment options, ranging from fatigue and constipation to depression and anxiety, for some. Our data suggests that we do not have an effective, well-tolerated treatment option for our NVP/HG patients. The Hyperemesis Education and Research (HER) Foundation has one of the most robust resources for management protocol of this disease, though it is often overlooked in clinical practice 18. ACOG also has a detailed management protocol for NVP/HG, which is more widely accepted amongst the Obstetrics community 5. However, even the evidence presented in the Practice Bulletin used to create the guidelines is limited.
Pyridoxine plus doxylamine is first-line pharmacologic therapy for NVP and HG and is shown to be safe and effective 5,15,16. However, around one-third of respondents taking this medication, reported central nervous system adverse effects (sleepiness/drowsiness) 5. Another commonly used class of medications, dopamine antagonists, may lead to maternal extrapyramidal symptoms such as tardive dyskinesia, especially when combined with phenothiazine medications 5,15. Furthermore, the combination of serotonin antagonists and phenothiazine derivatives may result in QT prolongation with severe cardiac risk 5,16. Additionally, there is conflicting evidence regarding the formation of cleft palate birth defects with use of ondansetron (a serotonin antagonist) in early pregnancy 5. In brief, there are options for treatment, albeit these treatments have associated risks and little clinically proven efficacy.
Most of these medications have at least proven to more effective than placebo when treating NVP/HG 5,16. Although, ACOG Practice Bulletin #189 states that “no single approach has been proved to be more effective than the other” 5.
HG has far-reaching implications that outlast the physical illness. In a cross-sectional population-based study conducted in Norway, respondents suffering from more severe symptoms were found to have a physical quality of life close to that among patients with breast cancer, and a mental quality of life comparable to that seen among mothers with postpartum depression 19. In an online survey of 377 patients who experienced HG, 18% met the criteria for posttraumatic stress syndrome 20. In a study of over 800 patients with HG, 15% of participants had terminated a pregnancy due to the severity of their HG symptoms 21. Two of five (40%) of participants in a separate Norwegian study expressed that they had contemplated abortion, and 8 subjects had a minimum of one elective abortion because of HG. 19% of subjects switched their doctor because they were not receiving satisfactory HG treatment. These patients also expressed confusion about their prescribed pharmacological regimens, and 87.9% used one or more complementary and alternative medicines, but only 12.8% of whom reported any positive effect on HG symptoms. More than half of the interviewees believed their general practitioner had no knowledge of HG 9.
The limitations of this study include the retrospective and subjective nature of our data collection. We relied on the mothers’ memories of pregnancies that may have happened decades in the past. Furthermore, we had did not have the resources to verify the claims of diagnoses of Hyperemesis Gravidarum or Nausea and Vomiting in Pregnancy or the treatments of said diagnoses. We cannot rule out a self-selection bias due to respondents who have been severely affected with NVP/HG potentially being more willing to participate, therefore leading to the potential overestimation of severity. The use of the internet to disseminate the questionnaire may also isolate a population who do not have access to the internet or have low internet-literacy, though web-based recruitment has been shown to be valid in terms of study design 22.