Optimizing assistance to mothers with hyperemesis gravidarum
When Catherine, the Duchess of Cambridge, was hospitalized for hyperemesis gravidarum (HG), many didn’t realize the condition is potentially life-threatening to both mother and baby. One comment online was typical of the reaction from coffee shop chit-chat to talk radio: “My bet is it’s just your everyday, ordinary, garden-variety morning sickness. And that this spoiled pampered princess who grew up never wanting for anything can’t handle it.”
Not so fast. Historically, HG was a death sentence. It killed Charlotte Brontë and her unborn child after four months of pregnancy. Today, competent healthcare and social support can save the lives of mothers and babies. However, in one study, 97 per cent of subjects who aborted because of maternal health had HG; in another study, one in six HG pregnancies ended in abortion.
Nausea occurs in up to 90 per cent of pregnancies; vomiting, in at least half. Only 0.5 to 3 percent of pregnancies meet the criteria for HG, which the HER Foundation defines as “a debilitating and potentially life-threatening pregnancy disease marked by rapid weight loss, malnutrition, and dehydration due to unrelenting nausea and/or vomiting with potential adverse consequences for the newborn(s).” A sufferer loses at least 5 per cent of her pre-pregnancy weight and vomits four to 20 times (or more) per day; the trajectory and treatment will vary. Most cases will resolve by 20 weeks; if not, prematurity and low birth weight may result.
For the sake of her baby’s well-being, a hyperemetic mother withstands extraordinary risks to her own health: electrolyte and pH imbalances, damage to retinas or teeth, eardrum detachment, lost fingernails, rib fractures, esophageal tearing, hyperthyroidism, gallbladder or liver disease, cardiac problems and even death. She needs diligent medical and personal intervention.
To her everlasting regret, HG advocate Ashli Foshee McCall aborted the first of her four HG pregnancies at 15 weeks. She’d lost 21 pounds, her skin was flaky and yellow, she was hallucinating, and her healthcare professionals were negligent. But as she now explains, “the debilitating maternal illness from which I suffered was for a time. Abortion is forever.”
Pro-lifers who want to help – as crisis pregnancy centre and sidewalk counsellors, Co-Workers of Life, or family members and friends – must take this disease seriously. McCall provides guidance to individuals who do not have formal medical training on how they can help.
Raise awareness. Frustrated, ignorant doctors have yelled at these patients. In advance, identify doctors you trust to treat a vulnerable mother and child pro-actively. Though some otherwise excellent HG resources don’t fully respect life, marriage, and the family, distribute them anyway, with caveats as necessary. The Motherisk program at Toronto’s SickKids Research Institute has an impressive flowchart for treatment in Canada of nausea and vomiting during pregnancy at www.motherisk.org/documents/Revised_NVP_Algorithm.pdf. HER celebrates Hyperemesis Gravidarum International Awareness Day every May 15.
Don’t confuse this disease with morning sickness or disparage her weakness. Fizzy drinks, saltine crackers, and frequent small meals won’t aid a mother who cannot eat or drink. When in doubt, have her condition assessed; if the response is inadequate, seek another opinion. HG can’t be cured, only managed. Medications include antihistamines, phenothiazines, serotonin receptor antagonists, and corticosteroids; some are prohibitively expensive. She may require short- or long-term intravenous hydration; homecare, and hospitalizations; and alternative nutrition through the nose, skin, or bloodstream. The patient needs to survive, and she may be unable to meet her previous home and work responsibilities. Propose practical and financial support.
Eliminate your coffee breath – and don’t give flowers. Strenuously avoid aromas. Body odours, food, alcohol, and tobacco smells, detergent, and any number of ambient fragrances can induce nausea and vomiting. Offer housekeeping. Especially in the bathroom, where the mother gets sick, and use unscented cleansers like water, baking soda, and salt. Help her choose less-scented personal products and shield her from the smell of others eating. Weather permitting, a small microwave and long extension cord could allow the husband/partner or support person to reheat donated meals outside. Check her individual preferences and triggers – for example, peppermint and lemon are soothing to some and noxious for others.
Don’t over-stimulate – calm. HG isn’t an eating disorder. The mother will eat on her own when she can. At that point, bring just what she’d like and can tolerate. Ask before adjusting the lights or temperature or making noise. When she’s ready, provide food, books, and entertainment devices. Let the husband/partner be one of the guys. Arrange respite childcare and pet sitting with trusted family and friends. Alternatively, move her to a room of her own somewhere else. Encourage her to follow medical advice for avoiding blood clots, but never nag the resting patient to get fresh air; motion could induce vomiting. Be generous with supplies: spit cups if she vomits saliva; a bucket, plus zippered plastic bags for outings; and baby wipes for herself.
Follow through. The sufferer is very likely to consider abortion even if she’d never do so under different circumstances, and even if she’s reached the second or third trimester. She remains abortion-vulnerable unless or until she feels her needs have been met. According to McCall, there is a very rare incidence of proper medical treatment being insufficient to save the mother’s life without termination of pregnancy, but in every abortion testimony she shares, healthcare and/or social support were inadequate. When the mother’s symptoms seem uncontrollable or her caregivers aren’t reassuring, she may truly believe she’s going to die. She isn’t vying for attention, and her ambivalence about the pregnancy isn’t frivolous. Her loved ones may feel powerless and recommend or demand abortion when she is too weak to fight for herself. Equip them to uphold her during the pregnancy.
Counteract isolation and promote hope. HG’s cause may be hormonal, immune-related, metabolic, neurologic, or genetic; we don’t know. What we do know is that HG isn’t a psychological illness. Sufferers have been accused of generating their own symptoms, and even been admitted to psychiatric wards for failure to stop vomiting. Others’ doubts, the physical degradation of malnutrition and dehydration, sleep deprivation, poor hygiene, and utter dependency can all lead to depression, anxiety, and even suicidal thoughts. Nearly one in five HG survivors have post-traumatic stress disorder. Don’t mistake mental health care for primary treatment, but do refer to a professional if warranted. If it would be welcomed, link her to pastoral care. Connect the mother to other sufferers and survivors, especially through online fora to accommodate her physical limitations. Keep her eyes on the prize: ask if she would welcome ultrasound pictures or baby photos on her bedroom wall.
Lend extra support to those with born children. Abortion is less likely if a mother perceives that she can meet the needs of both herself and the children she already has. Healthcare professionals and family members may scorn a woman who, perhaps deliberately, conceives again when “she should have known better” – and they may withdraw support. Openness to motherhood is natural. The HG survivor doesn’t want to be defeated by the illness, and the post-abortive mother may feel compelled to have a replacement child. Regardless of the circumstances of conception, she has a right to attentive, proficient care, and she and her unborn child have the right to life. Motherisk has found that, if previous sufferers are treated with the antiemetic Diclectin before or very early in their next pregnancy and followed throughout, a repeat of severe HG can be largely prevented.
Theresa Yoshioka is a former crisis pregnancy director and vice-president of a FertilityCare centre. Currently she writes and speaks with her husband, Alan; together, they blog at The Sheepcat