HYPEREMESIS GRAVIDARUM AS EXPERIENCED BY THE PATIENT
Women accessing support from the charity Pregnancy Sickness Support (PSS) regularly report severe disruption to their lives from severe Nausea and Vomiting of Pregnancy (NVP) and Hyperemesis Gravidarum (HG). Women with HG need a great deal of help and understanding. Unfortunately, because HG is rarely properly described in popular media, and because its causes have been misunderstood for over a century, women can struggle to get the help they need. This document is intended to provide an overview to assist Health Care Professionals and family and friends to understand what it is like to suffer from HG. This is not intended to discuss its causes, or treatment, but focuses on how women feel when they are suffering and the particular difficulties they face. It has been written by a former sufferer who has indepth knowledge of the academic literature, extensive experience of supporting women with HG and has conducted a survey of such women, mainly in the UK.
Severe NVP and HG cause severe physical suffering of high intensity over a prolonged period of time. The frequency of vomiting/dry retching can be extreme; it is not uncommon to vomit and/or retch more than 20 times per day and it is possible to do so, literally, hundreds of times per day. Vomiting is often painful, overwhelming and eventually can cause tearing or rupture of the oesophagus, burst blood vessels and acid erosion of tooth enamel. While vomiting is bad enough, most women find that they are more troubled by the incessant nausea. The degree of nausea is the most severe imaginable; sufferers feel as though they are just on the verge of vomiting and are constantly fighting against it. The nausea can last at maximum intensity for hours on end without relief. The intensity of nausea may change through the day but for most sufferers it will never go away completely. Some women feel nauseous to a greater or lesser degree for every waking moment of their lives, for months on end. For some, this lasts for the entire duration of the pregnancy.
Women feel overwhelmed and miserable because of the physical symptoms. Some of them talk of having suicidal thoughts and report that this is the most intense suffering they have ever experienced. Almost any sensory stimulation can be a trigger for intensification of symptoms; aromas of almost anything, including partners or children, but especially food; any kind of movement, even turning the head or eyes; being in a moving vehicle; walking; reading; watching TV. Foodstuffs are strong triggers, many women cannot even think about food; even the sight of a supermarket bag, or a TV food advert can be a trigger. For most women, lying motionless removed from any sensory stimulation is the only option.
Eating and drinking is incredibly difficult, if not impossible, and women must try many different food and drinks to find something that they can contemplate ingesting. Sometimes the nausea abates to be replaced by painful hunger, but sufferers may still not able to eat as putting anything in/near the mouth triggers retching. The ensuing side effects of dehydration such as headache, constipation and cracked lips add to the physical suffering. Many also suffer from hypersalivation (excess production of saliva) but are unable to swallow and must spit almost continually into a cup. The only relief from the nausea comes with sleep, but insomnia is a common complaint. Women often wake up to be sick then cannot return to sleep because they are either too hungry or nauseous.
The physical suffering of HG renders women incapable of even the most basic tasks and they are unable to look after their children and to carry out household duties. Many of them are completely bed bound and dependent on partner, relatives and friends to care for them. Even a visit to the bathroom or an attempt to wash can trigger a bout of vomiting/dry retching. Some women are so weak that they are unable even to walk and must be assisted to do their own basic care.
Natural History of Illness
Women with HG rarely have relief of symptoms by 14 weeks and many suffer symptoms until birth. (see How long does it last?). Typically (though not always), there is a point at which the symptoms lessen considerably, but this is around the middle of pregnancy and most women would not describe this as a complete resolution of symptoms; they may still be dependent on antiemetics, have a limited diet and cannot carry out all of their normal duties. Rather, they consider that they still have HG, but now it is better than before and they feel as though they have a chronic illness which they are managing. Most women find that they still need extra rest, even when the worst of the symptoms have abated. HG is also characterised by periods of partial recovery and relapse - women talk of having good days and bad days. Factors which can cause a bad day include poor night's sleep, any stressors such as family or work discord, travel and inability to eat and drink enough. Good days are commonly misunderstood by family and friends, HCPs and women themselves, as signalling a complete recovery from the illness. This can make it all the more demoralising when relapse occurs. A proper description of the illness so that women know what to expect would help them manage their and their family's expectations. It is not uncommon for HG to increase in severity in the third trimester, having abated somewhat in the second.
Difficulty in obtaining help – the battle for antiemetics
Women often find it problematic to obtain pharmacological treatment, particularly from their GPs, often describing it as a battle. They report being ‘fobbed off’ and having their experience trivialised. Often, a GP will only give a prescription after a woman has been admitted to hospital for fluids and been seen by a consultant obstetrician. Even then, many GPs encourage women to stop taking the antiemetics as soon as possible and women report difficulty in securing repeat prescriptions. The act of obtaining treatment can itself cause a worsening of symptoms. This is for two main reasons: the physical effort of having to go to the surgery and the stress of dealing with an unsympathetic doctor. Many women are extremely anxious that their doctor will refuse to give them a prescription and this anxiety can be enough to trigger symptoms. While antiemetics rarely give complete relief of symptoms, they are, nevertheless, a lifeline for sufferers who view them as the only thing that is keeping them from returning to a deep well of misery and suffering. Women express overwhelming gratitude when they do find a sympathetic doctor who will give them the antiemetics they need and the corresponding joy, relief and improvement of mood impacts positively on their experience of the illness.
Lack of joined up healthcare
Women would appreciate communication between different sectors of the NHS so that they are not left in a 'care gap'. Women may leave hospital with a prescription for antiemetics but find that their GP knows nothing about it and refuses to prescribe any more. Sometimes women call an out of hours GP to be told to wait until they can speak to their own GP. In the absence of any other option they must then attend A&E. This is distressing, miserable and often embarrassing to the point of humiliation as they are compelled to vomit in public. Triage nurses are rarely educated about HG so women may sit for hours waiting for treatment. Women also complain about a lack of re-referral pathways for readmissions for IV fluids and they can be left with no choice but to go to A&E multiple times during their pregnancy. Women greatly appreciate specialist HG day clinics which are available in a limited number of hospitals and they would like more community services, such as home IV. Women dislike overnight hospital stays, not just because of separation from children, but because they cannot control their environment. At home, they will be able to minimise unwanted odours, have palatable foods available and have the most comfortable environment possible in which to sleep. Lack of sleep badly exacerbates symptoms, so overnight stays in hospital are not ideal. There is also the problem of the journey home; some report that the nausea induced by the car journey returns them to their previous state of inability to eat or drink and necessitates a return to hospital for more treatment.
Women report that they are often denied help, especially at A&E, because their urinary ketones are not deemed to be high enough. There is some confusion about what ketones mean and how they are interpreted. Women report that one doctor will treat at plus one, while another, even in the same hospital, wants them to be higher before they will give antiemetics and/or IV fluids. Women themselves do not generally know what ketones are and why they are used as a diagnostic indicator. Even when they are given ketostix to take home, it is often not explained what they should be looking for and at what stage to seek help again.
Most women with HG suffer from a lowering of mood as a result of the misery and difficulties which come from the illness. HG is associated with increased incidence of depression and anxiety. There are numerous factors, particular to HG which can exacerbate mental health problems which are discussed below.
Trivialisation and lack of belief
In many cases, HG will be trivialised as ‘just morning sickness’ and sufferers will be told that it's not that bad and they just have to put up with it. This is the most common message in popular culture but it is also prevalent in the medical professions; women have reported dismissive attitudes from GPs, hospital doctors (at all grades up to and including consultant), community midwives, hospital midwives, practice nurses, hospital nurses, paramedics, sonographers and physiotherapists. This can also be the response from their partner, relatives, friends, colleagues and employers. There is a prevalent societal belief that NVP is a first trimester problem, so women who continue to suffer into the second and third trimesters are met with accusations that they are exaggerating their symptoms to elicit sympathy or special treatment. This in itself causes a great deal of emotional distress. There are also prevalent beliefs in society and the medical profession that non-pharmacological remedies such as ginger, acupressure bands, small bland meals, hypnosis and acupuncture are highly effective for NVP. Non-pharmacological remedies are not effective for HG, but despite this, women are advised to try them by almost everyone, including HCPs. This is frustrating and demoralising for women who have tried everything they can think of to no avail and are desperate for relief. It also underlines for them and reinforces their belief that nobody understands or appreciates the severity of their suffering. Women express deep frustration and even anger towards those, especially HCPs, who advise these 'remedies'.
Lack of belief that HG is a physical illness comes not only from friends and family, but from Health Care Professionals (HCPs). It is likely that this stems from the continued mistaken belief in many quarters of the general public and medical community that HG is a psychosomatic illness. Women report having been explicitly told by their HCPs (mainly GPs and midwives) that the illness is psychological. Women themselves are quite sure that they are feeling depressed and anxious because of the HG, not that their feelings have caused it. Some women report that it has even been suggested to them that they are unconsciously trying to abort their baby by making themselves sick. For women who desperately want their baby, they describe this suggestion as bordering on abusive.
Isolation – both physical and mental
Many women lie alone in bed for extended hours, sometimes the entire day; this can continue for months. They are bored, exhausted from the mental effort of trying not to vomit and suffering from unbearable nausea. They may be unable even to watch TV or use a computer as this will induce vomiting or intensification of nausea. For some even talking is a trigger. This physical isolation is compounded by a lack of validation of the woman’s experience. HG is not adequately described either in the academic nor popular pregnancy literature. The course of the illness as described to PSS by the hundreds of women it supports is at odds with that described anywhere in common sources of information about pregnancy. Therefore, women never see any descriptions which accord with their experience. This exacerbates the disbelief with which they are treated by others, and can even make them doubt their own experience or cause them to consider themselves to be weak or imagining the severity of the illness. HG is, as a consequence, poorly understood by the general public and HCPs alike. It is uncommon enough that women will rarely encounter anyone else who has suffered it. Conversely, they will meet many women who have suffered mild to moderate NVP and will offer their (ineffective) advice or be outright dismissive. Comments from other women such as ‘I had morning sickness and I just had to get on with it’, ‘we didn’t have this in my day’ (often from parents/parents-in-law) and ‘I didn’t have time to be sick I just had to go to work’ are common.
Grief for pregnancy they couldn’t have
The prevalent cultural attitude is of pregnancy as a special time to be enjoyed and women are expected to be happy to be pregnant. The discord between their hopes for their pregnancy and the reality is a source of extreme distress for many women. They talk of being robbed of the enjoyment of pregnancy and have to grieve for the pregnancy they could not have. Many women report feeling extreme and uncontrollable feelings of jealousy towards other women who are having normal pregnancies. Sometimes they cannot feel happy for a friend or relative as they are confronted by the pregnancy they wish they’d had. They then report feeling shame for having these feelings. This is regularly the topic of online HG forums as women feel that they will be judged harshly for voicing these feelings to others in their lives, and that only other sufferers can relate to it. Women report feeling that they have to play down their suffering to friends and family who may be undergoing fertility treatment or struggling to become pregnant, as they are met with the retort that they should be happy to be pregnant. Women are sometimes made to feel that they should be so grateful to be pregnant, no matter how bad it is, that any amount of suffering is acceptable and does not entitle them to complain.
Sources of Anxiety
Women feel guilty for not being able to attend to their existing children. In the most severe stages of the illness, many women cannot even tolerate the smell of their own child much less feel able to care for them. Many women report that they miss their child and feel that they are missing out on seeing them grow up, but simply cannot tolerate the exacerbation of symptoms which ensues if they are with them. Some families have no option but to send the child to relatives to be cared for if the partner is working. Many women find it difficult to cope with knowing that they are putting their child through this separation and the trauma of seeing their mother being ill and can only rationalise it by the comfort of knowing that they are providing their child with a sibling.
Health of the Unborn baby
Worrying about their unborn baby is a source of deep anguish and conflicting feelings. Women are aware of the importance of nutrition in pregnancy, as this message is ubiquitous in pregnancy related literature. Women may be worried that their baby will not receive the nourishment it needs because they cannot eat, or worry that the violence of the vomiting and/or retching will somehow harm the baby. This is compounded by the fact that is common for women with HG to be able only to eat a narrow range of foodstuffs, often junk food that they would normally eschew if they had a choice. Women express astonishment that a body so racked with illness and subsisting on low quantities of poor quality food is still capable of growing a new life. While women want to be reassured that their baby will be healthy, they are distressed when such reassurances are given in lieu of treatment. Women complain about simply being told that it’s acceptable to vomit continuously because the baby will be fine, as though their own suffering is a trivial and secondary matter. Women can also be conflicted about being told that the sickness is a sign that the pregnancy is proceeding well and the risk of miscarriage is lower. This can be presented as an invitation to feel happy about the illness, but women find this impossible; they then sometimes feel guilty about wishing that the pregnancy was less stable so they could feel less sick. Moreover, women sometimes misinterpret this information – or are told it in a misleading way – and are then devastated if they do miscarry, having been led to believe that they couldn’t have a miscarriage as they were so sick. It is common for women to secretly wish for a miscarriage; this is the kind of thought that they cannot voice to anyone in their life, but will disclose in a private forum with other sufferers. Women often berate themselves for these thoughts, especially if they have had a previous pregnancy loss or had difficulty conceiving.
Concern for her own health
Women suffer from the mental anguish of knowing that they are starving, and perhaps causing long term physical damage to their own health but powerless to do anything about it. Women report feeling as though they are watching themselves wasting away before their own eyes and often worry that they will be too weak to give birth when the time comes.
Women are conflicted over taking pharmaceuticals because of worries of teratogenicity, but at the same time are desperate for relief. Women still mention fears because of thalidomide. Many women report that their HCPs and/or family do not want them to take the antiemetics citing fears about birth defects. This can cause anguish for the mother for the duration of the pregnancy until the baby is born healthy. Women feel intense guilt and often view it as a strength of character issue – if only they were strong enough to suffer without drugs they could save the baby from the exposure. These feelings of guilt are exacerbated where HCPs give insufficient reassurance that the antiemetics are not teratogenic. Some women report that their doctors have told them that they will not prescribe for this reason, or give a prescription with dire warnings of the possible consequences. Some women take the prescription but don’t submit it, or obtain the medication but feel unable to actually take it. PSS also has regular reports of pharmacists in high street shops publicly berating pregnant women for submitting a prescription for antiemetics, or outright refusing to dispense them. Women are usually torn between wanting to save their baby an exposure, but needing the antiemetics. They deeply resent insinuations that they cannot put up with a little bit of sickness for the sake of their baby, or that they are taking drugs at the slightest encouragement without a thought for the possible consequences. Women would find it helpful if doctors could put the risk factors in context; they are often not physically or psychologically able to understand complex information about statistical risks and simply need to be reassured that the antiemetics are considered to be safe.
Some women become so desperate to end the suffering that they opt for a termination. Especially in cases of planned pregnancy where the baby was very much wanted, this causes a great deal of trauma, anguish and guilt. In many cases reported to PSS, termination is offered as if it were the only real treatment choice; women are told that there is nothing else that can be done. They are so desperately ill, sometimes in fear of their own death, that the decision is one of last resort. Subsequently some women find out about treatment options (particularly steroids) that they were not offered. They report feeling extreme bitterness, anger and inconsolable regret upon finding this out. Again, this can be viewed retrospectively as a strength of character flaw, 'if only I could have suffered my baby would have lived'. Women speak of deep shame in not being able to continue with their pregnancies. Other factors which may lead to a decision to terminate are the effect it is having on other children or partner, or financial difficulties from having to take leave from work.
Going to work is impossible for women with HG and severe NVP. Some women find that they can return to work later in pregnancy when the severity of the NVP has reduced, but they struggle with full time work and relapse is common if they over-exert themselves. Where women have sympathetic employers and a suitable job, they can arrange to work part time or from home; often it is the actual journey itself which causes a return of symptoms. Some employers are unsympathetic as they believe the often reported statistic that NVP is a first trimester problem only. Women report that even when symptoms have abated somewhat, they still require a great deal of rest, and that trying to do too much can cause a relapse. This can be interpreted as laziness and engender hostility from colleagues. Some women have reported to PSS that they have lost their jobs because of NVP, or that they feel pressured to give up their job. Having to take long term sick leave can leave women and their families in financial difficulty, which can in turn, negatively affect their well being and relationship with their partner.
Relationships with partners and other family members can be badly affected by severe NVP and HG. Partners may struggle with continuing to work and care for other children and household while the sufferer is bed bound. Partners can be resentful of having to shoulder this extra burden, especially if they do not really believe that HG is a proper medical condition. If there are no other sources of family support, this can lead to a relationship reaching breaking point and PSS hear of numerous breakdowns of relationship which women attribute to severe NVP. Where the woman is not believed by family and partner, they may refuse to help, in the mistaken belief that offering support will encourage the sufferer to wallow in misery and that this is itself the cause of the HG. Women report being told by family and friends that they should simply get out of bed, be more active and get some fresh air. These beliefs, again, owe much to the prevalent myth of the psychogenic aetiology of HG.
Family and friend support can make the difference between a woman requiring hospitalisation and being able to cope at home. Because women with HG are on a knife-edge between vomiting and not vomiting, even the smallest movement may trigger it. If partners/carers bring food and drink to the bedside then the sufferer can remain lying down and may be able to eat and keep some of it down. If they have to walk to the kitchen to get food, the physical exertion may trigger vomiting/retching such that they are unable to eat. Also, women find that they have to try a large range of foods to hit upon something that they can tolerate. This can require forays to the supermarket that they cannot do themselves and partners are often sent at short notice to bring back a particular foodstuff. Women usually only have a short window of opportunity in which to eat, so this must be done quickly. Partners may find this inconvenient and not all are co-operative. A woman whose partner is willing to go to this effort to help them eat, may avoid ketosis, while an unsupported woman may decline into the vicious cycle of ketosis and further nausea which can only be remedied with an admission to hospital. This may be the reason for literature findings that HG is associated with poor social support; these are often interpreted within the paradigm of the psychogenic aetiology as meaning that these women are more likely to develop HG, but an alternative interpretation is that women with effective support are less likely to need to present themselves for fluids so do not end up included in HG statistics.
Emotional/Psychological After Effects
Most women report recovering almost instantly upon giving birth and some may suffer no further serious consequences. However, some have been so traumatised by the experience that they suffer Post Traumatic Stress Disorder. Many report continued gastric problems and some even describe it as an eating disorder. Some smells and memories remain as triggers for nausea, these are common for foodstuffs but also for other objects and articles of clothing. There are some situational contexts which can also trigger nausea, such as particular places eg the hospital where a woman was treated, or even her own home. Some women redecorate their bedroom or bathroom; some have even moved house to remove themselves from the associated memories of HG. Women report feeling the need for some kind of ‘debriefing’ process to talk about what has happened to them. There is also the difficulty of being physically weak, having suffered a prolonged and serious illness, and immediately having to deal with the demands of a newborn. Women often feel very down about this but are not sure if this should be classed as post natal depression or not. It would be beneficial if they could talk to a perinatal mental health team who have training in HG. Women express a fear of becoming pregnant again to the point where they abstain from sex or have themselves or their partner sterilised. Some women express feelings of fear and extreme anxiety every month when their period is due even if they are using contraceptives. Many women report that HG has stopped them from having the number of children they wanted. Few women are offered counselling, but those who are report that they find it beneficial in helping them to come to terms with their feelings.
Physical After Effects
Physical consequences of HG that have been reported to PSS are tooth enamel eroded by stomach acid requiring major dental work; such severe constipation as to cause fistula; surgery to stretch the oesophagus; re-feeding procedures to prevent re-feeding syndrome;chronic acid reflux; hernia; gall bladder problem sometimes necessitating removal; ruptured blood vessels in the face, neck and chest; sensitivity to hitherto tolerated foodstuffs; worsening of pre-existing Irritable Bowel Syndrome; onset of IBS when not pre-existing; ongoing constipation due to loss of muscle tone. There is a paucity of published research on post-HG sequelae, but the frequency with which such problems are reported to PSS indicates an urgent need for research in this area.
Preparing for the Next Baby
Although it is possible to have a subsequent pregnancy without HG, there is a high recurrence rate so women should be prepared to suffer it again. Many women ask their doctor for a care plan in advance so that they can mentally prepare and have systems in place for the next time. Once a woman is confirmed to be pregnant, there is very little time to prepare – some women are already experiencing symptoms before they have missed their period. The purpose of the care plan is not simply practical, it is for peace of mind; many women do not trust that if a particular sympathetic doctor is unavailable, then another doctor in the practice will take the same attitude towards treatment. Moreover, women want to discuss which treatments worked, which didn’t and what they would prefer to do differently. Women who have had HG and know that they are at high risk of suffering again, can be torn between the thought of going through it again, and the strong desire for another baby. They will have to come to terms with either the terror of going through another HG pregnancy, or grief for the babies they are unable to have. In either case, counselling may be helpful at this point.
Recommendations for HCPs
- Listen to the patient and accept that her account of her symptoms is true. Take into account her quality of life and psychosocial situation when devising a treatment plan.
- Do not recommend ginger, acupressure bands etc.
- Never suggest that her condition is psychosomatic. Be very careful when recommending counselling to emphasise that you know that the condition is not psychosomatic, but that it can cause psychological problems that counselling can assist with.
- Reassure the patient that you will help her and that she will not be left without medication.
- Establish ways in which her need to leave the house can be minimised, by allowing consultations by phone or home visits.
- Set up systems for repeat prescriptions of antiemetics which do not require the women to physically attend the surgery.
- Consider suppositories if she is having trouble keeping oral antiemetics down.
- Monitor her hydration regularly
- Recommend rest and give fit notes for work.
- Reassure the patient that antiemetics are safe, that she needs them and she is not weak for taking them.
- Set up pathways for self referral avoiding A&E for IV fluids. Communicate between all different sectors to make sure she is not left without an avenue for treatment.
- Refer her to perinatal mental health services and charities which provide moral support eg Pregnancy Sickness Support.
- Don’t tell her that it will stop at 12 weeks, it will almost certainly not.
- Reassure her that the baby will almost certainly not suffer ill effects, but do so only in the context of providing her with treatment for her symptoms.
- Be careful about telling a woman that sickness is a sign of a well implanted pregnancy – women with HG do have miscarriages and it is not at all certain that HG does have better outcomes than other severities of NVP.
- Suggest she avoid odours
- Suggest that she stop cooking for the family and that her partner avoids cooking in the house. If this is not practical, suggest that the kitchen is ventilated such that no cooking odours can be detected in the bedroom.
- Suggest she enlists help from anywhere she can to assist with household tasks and childcare.
- Recommend that she rest as much as possible.
- Reassure her that it’s not her fault and she shouldn’t feel guilty.
- Prepare a pre-emptive plan for the next pregnancy, if requested.
Dr Margaret O'Hara 2014
Sources of Further Information
Pregnancy Sickness Support is the only UK charity which provides support and information for women suffering from all severities of pregnancy sickness. They offer online support as well as the opportunity for women to have personal one to one support from a woman who has herself suffered from HG. Support for partners and carers of women with HG is also available. www.pregnancysicknesssupport.org.uk
Pregnancy Sickness SOS is a UK based website giving information about coping with and obtaining treatment for HG www.pregnancysicknesssos.co.uk
The Hyperemesis Research and Education Foundation is a USA based organisation which provides information and conducts research into HG. www.her.org
A guideline document for management of NVP and HG published by the British Medical Journal is a useful source of information about treatments for HG. (Jarvis S, Nelson-Piercy C. Management of nausea and vomiting in pregnancy. British Medical Journal. 2011;342.)
Dr Margaret O’Hara is a former sufferer of HG and runs an information website at www.pregnancysicknesssos.co.uk. She is a member of the Pregnancy Sickness Support national support network and has provided online support for sufferers of HG since 2010. She is currently a member of an RCOG working group which is developing guidelines for the treatment of NVP and HG. She can be contacted at firstname.lastname@example.org and tweets as @Know_HG
Endnote 1. Duration of Symptoms
A study to examine nausea and vomiting in late pregnancy found that 32% of 108 pregnant women questioned still suffered nausea and vomiting after 20 weeks. (Lindseth, G. and Vari, P. (2005) Nausea and Vomiting in Late Pregnancy. Health Care for Women International, 26:372-386). A study comparing the effects of normal versus large doses of a drug called Diclectin (used to treat pregnancy sickess in Canada). It found that in a group of 102 women with HG who were taking large doses of Diclectin, the average week that symptoms stopped was 31.4 +/- 9.5. In a group of 123 women on the standard dose of Diclectin, who had less severe symptoms, the average week that symptoms stopped was 27.5 +/- 10.4. (Atanackovic, G., Navioz, Y., Moretti, M. E. & Koren, G. (2001) The safety of higher than standard dose of doxylamine-pyridoxine (Diclectin (R)) for nausea and vomiting of pregnancy. Journal of Clinical Pharmacology, 41, 842-845.). A study of 201 women with HG found that 63% of them had symptoms till birth. (Mullin, P. M., Ching, C. Y., Schoenberg, F., Macgibbon, K., Romero, R., Goodwin, T. M. & Fejzo, M. S. Risk factors, treatments, and outcomes associated with prolonged hyperemesis gravidarum. Journal of Maternal-Fetal & Neonatal Medicine, 25, 632-636.). An online survey on the HER foundation website found that 45% of women have NVP lasting longer than 30 weeks. ( http://www.hyperemesis.org/mothers/current-research/index.php). An online study found that of 88 women with HG, 68% had symptoms till birth; 65% had improvement in symptoms by 22 weeks; 9% had cessation of symptoms by 22 weeks in 9%; (http://www.pregnancysicknesssupport.org.uk/documents/HCPconferenceslides/womens-experience-2013-MOH.pdf)
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