Dedicated to improving care for women with hyperemesis gravidarum (HG)
Over the past 5 years I have been undertaking research into how we can improve care for women who suffer this hugely debilitating condition. At present, we have limited evidence on medical therapy for the condition. Currently, treatment is supportive using intravenous hydration, vitamin supplements and anti-sickness medications which have variable efficacy in reducing symptoms of nausea.
Whilst other researchers are undertaking extremely important research endeavouring to develop better mediation for the condition, my work has been focussed on improving the overall care we offer to patients with HG, particularly addressing the psychological and social implications the ilness has for women.
My first trial was to assess the efficacy of ambulatory (outpatient) treatment of HG, allowing women to be at home with their families during treatment. This type of treatment approach is used in some units across the country receiving positive feedback from patients. The trial was the first to compare ambulatory management as a direct alternative to standard inpatient therapy for treatment of HG. Women receiving ambulatory treatment had fluid hydration, vitamin and anti-sickness treatment over a 4-hour period on a daily basis whilst the women receiving inpatient care were admitted for standard treatment. The study demonstrated the ambulatory treatment was equally effective in treating HG. The study conclusion was that this treatment is clinically effective and may have psychological and social benefits for women. During the study women had open access to the research team with one woman reporting “the support and understanding I received from the research team was invaluable and I had a totally different experience than last time I suffered HG which left me traumatised. Having ambulatory care meant I could be at home to spend time with my son which really helped me get through 10 weeks of what I can only describe as ‘hell’” (trial patient 2015). Many other women reported the availability of a point of contact was incredibly important leading me to believe that an ambulatory service for HG patients should be led and supported by a specialist team of healthcare professionals accessible to HG patients(Mitchell-Jones et al., 2017).
My other research has been focused on the psychological implications of HG which are thought to be hugely underestimated. I initially conducted a review of all the relevant literature looking at the association between HG and psychological illness. From this review, I conducted a meta-analysis which combines data from all relevant research studies to provide a bigger evidence pool. A meta-analysis is the highest level of evidence and this was the first to investigate the association between HG and psychological illness. The study demonstrated a large effect association between HG and anxiety and a very large effect between HG and depression. All the studies we assessed as part of the meta-analysis demonstrated a relationship between HG and/or depression and anxiety. The theory of HG being a physical manifestation of psychological illness still exists, despite many studies reporting the opposite. In this meta-analysis, all the studies used either excluded women with a history of psychological illness or compared the frequency of current or previous psychological illness between women with HG and health controls, all finding no difference in frequency of past mental health problems (Mitchell-Jones et al., 2016).
My final study to date has been looking at psychological illness (depression), hospital experience, infant bonding and psychosocial experiences of pregnancy for women with HG compared to women that did not suffer the condition. The study was run in 3 London hospitals. Recruited women were asked to complete online surveys at the end of the first trimester and 6 weeks postnatal. There were multiple aspects to the study. To compare women’s experience of hospital experience, a second control group were recruited; these were women who were admitted with other early pregnancy complications such as abdominal pain, vaginal bleeding or medical problems. Infant bonding and the psychosocial experiences of women in the study were assessed at 6 weeks after women had delivered their baby.
In terms of depression the study showed that women with HG were 14 times likely to report symptoms of a major depressive illness at the end of the first trimester compared to women of the same gestation without and significant nausea and vomiting of pregnancy. 7 women in the HG group reported feeling frequent thoughts of self-harm. At 6 weeks postnatal the effect was less marked but still significant. Women in the HG group were 5 times more likely to report symptoms of major depression demonstrating the long term psychological impact the condition. There was no direct difference in maternal-infant-bonding between groups but women with depressive disorders were found to bond less well with their babies suggesting an indirect association between HG and infant bonding. One woman in the study reported “I don’t think I’ll ever forget what I went through, I considered ending the pregnancy so many times even though my husband and I desperately wanted a family. I still think about what I went through and because of my experience I sadly won’t be having any more children” (study participant 2016)
Women were asked to complete two surveys about the care they received in hospital; one relating to general care and the other emotional care during their hospital admission. Women had a significantly more negative experience of hospital care, both general and emotional care, compared to women with other pregnancy symptoms. The most common issue was a failure of hospital staff to listen to them and validate their symptoms. One women reported “I was ignored on the ward and had to ask for anti-sickness drugs and a drip, the doctors spent 2 minutes with me a day and my drugs weren’t changed even though they weren’t working, I felt like a time waster when looking back I was really sick and lost 10kg of weight in the first trimester” (study participant 2016).
Women with HG were more likely to seek help for mental health symptoms in pregnancy but no more likely than women without nausea and vomiting to receive a diagnosis of or treatment for a mental health condition. Most women saw their GP and were not referred on to specialist perinatal psychiatry services. Despite the frequency of depressive disorder identified amongst the HG group there was no difference in the number of women seeking help for mental health symptoms in the postnatal period.
Women in the HG group were a staggering 61 times more likely to take 4 or more weeks off work prior to planned maternity leave during pregnancy compared to their counterparts. Many women reported they were not paid whilst ill or asked to take early maternity leave due to prolonged illness.
This study has highlighted the significant psychological morbidity caused by HG which has long term mental health implications. Women with current mental health disorders were excluded and the frequency of those with previous mental health problems was the same in all groups. Like many other authors I have found no evidence to support pre-pregnancy psychological illness as a cause of physical symptoms. The vast majority of women in the HG group developed depression ‘de novo’ having not had mental health problems before.
It is the first study to assess women who have suffered HG during pregnancy in the postnatal period. This has demonstrated the long-lasting effect of HG persisting beyond pregnancy and affecting infant bonding for those with ongoing depression. Our care of women with HG in hospital appears to be in need of significant improvement. The findings of this case-control study indicate that women with HG suffer a significant amount of psychological, social and psychosocial morbidity.
It appears that many healthcare professionals are not aware of the burden of the condition and this leads to poor care for HG suffers. Education of healthcare professions, dissemination of research findings and the development of specialist services, including provision of daycase management , will improve the care we offer to sufferers.
MITCHELL-JONES, N., FARREN, J. A., TOBIAS, A., BOURNE, T. & BOTTOMLEY, C. 2017. Ambulatory versus inpatient management of severe nausea and vomiting of pregnancy: a randomised control trial with patient preference arm. BMJ Open, 7, e017566.
MITCHELL-JONES, N., GALLOS, I., FARREN, J., TOBIAS, A., BOTTOMLEY, C. & BOURNE, T. 2016. Psychological morbidity associated with hyperemesis gravidarum; a systematic review and meta-analysis. Bjog.