Hyperemersis gravidarum: past hysteria and present needs.

Abstract

Hyperemesis gravidarum (HG), characterised by extreme nausea and vomiting during pregnancy, was first clearly described by the surgeon to the French emperor, Antoine Dubois, in 1852 and was first discussed in BJOG in 1905 (Stevens J Obstet Gynaecol Br Emp 1905;7:266–75). The clinical diagnosis now also includes loss of more than 5% of the pregnancy weight and electrolyte imbalance. Treatment is by oral anti-emetics, although severe cases should be admitted to hospital for intravenous rehydration, thiamine supplementation and thromboprophylaxis. The RCOG Green-top guidelines (No. 69, June 2016; London: RCOG) do state that the women's psychological state, both during pregnancy and postnatally, should be monitored and any symptoms should be validated. Although the standard of evidence is low, these guidelines suggest a referral for psychological support if necessary. The guidance is based on the findings from numerous studies that look at the association between HG and anxiety and depression. However, until the systematic review of Mitchell-Jones et al. (BJOG 2017;124:20–30.), a reliable overall estimate of the degree of association was not available. From 12 eligible studies, the review found significantly higher scores for depression and anxiety, equivalent to very large and large effects, respectively. The authors highlight the debate as to whether HG is the cause or the effect of psychological illness, which has persisted throughout the twentieth century. In 1959 in St Louis, MO, USA, a classic case–control study of 48 women with HG and 45 control women concluded that as 41% of the ‘vomiters’ were without psychiatric illness up to 3.5 years later, HG was not exclusively associated with a chronic condition, although there was an increased frequency of hysteria (Guze et al. N Engl J Med 1959;261:1363–8). This study conceded that it could not establish whether acute psychological distress, such as an unwanted pregnancy, was the cause of HG, although this was one of the prevailing views of the time. A neurogenic origin to HG was also attributed to five women out of 28 in a study by Youseff and Barsoum (J Obstet Gynaecol Br Emp 1953;60:388–97), who were described as ‘mostly of a highly strung nature’ but whose vomiting resolved after hospitalisation and reassurance. Interestingly, this study also proposed an allergic origin for 17 of their case series, suggesting adreno-cortical insufficiency as a potential causative factor. In this group, they administered first an antihistamine (antazoline), then the mineralocorticoid desoxycorticosterone for the refractory cases, which resulted in cessation of vomiting in all cases. They propose a gonadotrophin hormone as the putative allergen. The casual dismissal of women, describing HG as a consequence of their being of a neurotic disposition, has fortunately been forgotten. Mitchell-Jones and colleagues report that several studies indicate women with HG can be stigmatised and feel they are left unsupported. Clinical services need to routinely extend beyond the immediate management of the effects of vomiting and dehydration and to also address the psychological needs of women. This should extend postnatally, given the reported increase in problems with breastfeeding and long-term adverse effects and impact on subsequent pregnancies highlighted in this review. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.