Excessive vomiting in pregnancy

by Dr. Vijith Vidyabhushana

Consultant Obstetrician and Gynaecologist Teaching Hospital, Kalubowila

Nausea and vomiting can be one of the first signs of pregnancy and usually begins around the 6th week of pregnancy.

About 50-75% of pregnant women feel nausea or vomit during early pregnancy. It is often called ‘morning sickness’, but symptoms can occur at any time - not just in the morning and also it may start as early as 4-5 weeks or later with in first 12 weeks of pregnancy.

Symptoms are mild in most cases. Feelings of sickness (nausea) typically come and go. They usually last between 1 and 4 hours at a time. Some women have more severe symptoms and have frequent and/or longer bouts of vomiting. In most cases the symptoms have gone by 12-14 weeks of pregnancy. However, about 10% of pregnant women have some nausea throughout their pregnancy.

If you experience excessive vomiting and cannot keep your food down, you may have ‘hyperemesis gravidarum’ i.e. severe vomiting specific for the pregnancy.* *Hyperemesis gravidarum can be harmful to you and your baby if severe and left untreated. This is due to the possible lack of nutrients and electrolyte imbalance. The most important thing is to inform your health care provider when these symptoms appear and discuss possible options for treatment.

The cause of the sickness is not known. It is probably due to the hormone changes of pregnancy. Some think that it is related to the amount of a hormone produced by the placenta called Human Chorionic Gonadotrophin (hCG) and hence excessive vomiting is commonly seen in twins where the placental mass is more.

This is a reason for every pregnant woman who has severe vomiting to undergo an ultrasound scan to see if she is carrying twins.

But it not usual to get excessive vomiting for the first time after 12 weeks of pregnancy. If you get excessive vomiting for the first time after 12 weeks it may be due to hidden infection like a urine tract infection.

Here are some frequently ask questions.

Does it affect my baby?

Not usually. The baby gets nourishment from your body’s reserves even though you may not eat well when you are vomiting. The effort of retching and vomiting does not harm your baby or cause a miscarriage.

The only time your baby may be affected is if you become very ill with dehydration which is not treated, resulting in accumulation a harmful substance called ketones in blood and urine. When there is dehydration and lack of energy, the liver produces this substance (ketones) to provide energy, but this substance can be harmful to the baby.

Other causes

Remember, not all vomiting may be due to the pregnancy - you can still get other illnesses. For example diarrhoea, blood in vomit, jaundice (yellow skin and eyes), high temperature (fever), and stomach pains may be due to an infection or some other problem unrelated to pregnancy. See your family doctor or Gynaecologist if these symptoms occur, or if the vomiting is severe and you suspect that you are becoming dehydrated.

Even urinary tract infection, respiratory tract infection can give rise to vomiting. Hepatitis is another cause for vomiting. Hyperemesis gravdarum should be diagnosed after exclusion of above causes for vomiting.

There are a number of do’s and don’ts you can try to help alleviate your symptoms.

When do I have to seek medical help?

If you are experiencing excessive nausea and vomiting that prevents you from keeping any food down.

If vomiting is accompanied by pain or fever.

If nausea and vomiting persists well into the second trimester (after 13th week). If you just don’t feel right. ‘Morning sickness’ is the nauseated feeling you experience in your first trimester. It usually starts out in the morning and wears off as you become active throughout your day. Not all morning sickness remedies will work for you, but these are just a few remedies and comforts that have helped other women get through their day.

‘Hyperemesis gravidarum’ is a condition characterized by severe nausea, vomiting, weight loss, and sometimes electrolyte disturbance. Mild cases are often treated with dietary measures, rest and antacids. Severe cases often require a stay in the hospital so that the mother can receive fluid and nutrition through an intravenous line. DO NOT take any medications to solve this problem without consulting your health care provider first.

Do I need any treatment?

‘No treatment’ is needed in most cases as the symptoms are often mild.

Eating small but frequent meals may help. Foods high in carbohydrate are best, such as bread, crackers, etc. Some people say that sickness is made worse by not eating anything at all. If you eat some food regularly, it may help to ease symptoms. Eating a plain (or ginger) biscuit about 20 minutes before getting up is said by some women to help.

Some women find that a ‘trigger’ can set off the sickness. For example, a smell or an emotional stress. If possible, avoid anything that may trigger your symptoms.

Have lots to drink to avoid dehydration (low body fluid). Drinking little and often rather than large amounts may help to prevent vomiting.

Try to aim to drink at least two litres a day. Water is probably the best drink if you are feeling sickly. ‘An anti-sickness medicine’ may be advised if symptoms are severe, or do not settle.

It is generally best to avoid medicines when you are pregnant (including herbal remedies as the contents are often uncertain).

However, most medicines that have been used for morning sickness or hyperemesis have been used for a number of years and are thought to be safe.

For example, many women have used promethazine, cyclizine, metoclopromide etc and there is no evidence that they harm a developing baby. Always see a doctor before taking an anti-sickness medicine when you are pregnant.

‘Hospital care’ is needed to give fluids by a ‘drip’ in small number of women who become quite ill and dehydrated (low in body fluid).

Lifestyle-related maladies, bane of society

“Cancer, diabetes, heart and brain diseases are lifestyle-related diseases. People can prevent contacting those diseases by practising health-conscious living,” said Dr. Hiroshi Kobayashi, Chairman of the Japan Sapporo Cancer Seminar Foundation recently.

He was addressing a one-day workshop on “Prevention of lifestyle-related Diseases in Sri Lanka” held in Colombo. He also said that the recurrence of lifestyle-related diseases are increasing in Sri Lanka and these diseases are the main causes of death in the country.

Dr. Kobayashi said “We have to pay attention to the gradual increase amongst the Sri Lankan people of such lifestyle related diseases as cancer, heart attacks, cerebrovascular diseases, and diabetes.

Since people’s prolonged life-span will render them more susceptible to such diseases, it is likely that in the near future such a development will have a marked effect upon the already critical condition of the national budget.

“Some of my Sri Lankan friends have suggested that we might overcome the difficulty through the early detection of diseases, and it is right that such early detection is something that we ought to seek to achieve.

Yet since the budgetary resources required for the early detection of cancer, for example, are extremely limited, and because the cost of the advanced medical equipment required for the early detection of cancer is prohibitive, only a small number of potential patients will be able to benefit from such ‘early detection’ procedures.

“How, in the future, will Sri Lanka be able to cope with this problem? To put it simply, I believe that we have, as individuals, to be responsible for our own health, particularly with regards to the prevention of disease.

No one is able to escape death, but we are all anxious to live as long as possible in the best possible state of health. If we hope to do so, we need to look again at the social environment and the way in which we live our daily lives.

“I would like here to propose six topics that I have myself chosen, with reference to certain guidelines laid down by WHO (World Health Organisation) and UICC (Union Internationale Contre le Cancer), under which we may find the most reliable evidence of ways towards the achieving of healthy longevity.

“Surprisingly, perhaps, a campaign to prevent cancer is also applicable to the prevention of other lifestyle-related diseases.

Prof. Kono added, while the overall incidence of cancer shows a relatively small geographical variation worldwide, the international variation is phenomenal when cancer is seen by site or type. For example, male lung cancer shows a 30-fold difference between the regions with the lowest and highest rates.

Colorectal cancer incidence rates are highest in Japan, Australia/New Zealand, North America and Western Europe. The rates in these regions are approximately ten fold higher than reported for the South Central Asia. Japan, Korea and North China have the highest rates of gastric cancer in the world.

Again, a 10-fold difference is noted between Japan and South Central Asia for gastric cancer incidence. Oral and oesophageal cancers are much less than gastric and colorectal cancers in the world, but oral cancer incidence is the highest in South Asia, probably due to betel chewing.”

“Obesity and lack of physical activity have prevailed massively across the world with exception in areas suffering poverty and starvation. Many epidemiologic and laboratory studies have accumulated substantial evidence that obesity and lack of physical activity confer increased risk of colorectal cancer.

As regards foods, high consumption of vegetables and low intake of red meat are recommended for the prevention of colorectal cancer. Calcium, vitamin D and folate seem to be important in the prevention of colorectal cancer, but consolidating evidence deems to be waited for.

Helicobacter pylori infection is a causal agent for gastric cancer, but the infection is so ubiquitous, i.e., 50-60% in developed countries and 70-80% in developing countries. There is no sex-difference in the infection of this bacterium.

Thus factors other than Helicobacter pylori infection play an important role in the development of gastric cancer. In East Asia with the highest rates of gastric cancer, high intake of salt-preserved foods are traditional. High intakes of salt or salty foods considered to probably increase the risk of gastric cancer.

daily amount of 6 g is recommended internationally, but 10 g per day is a guideline in Japan. High intake of vegetables and fruits are important in the prevention of gastric cancer. Limited evidence indicates that chili may increase gastric cancer risk and that tea may be protective. Tobacco and alcohol are major causes of oral and oesophageal cancers, but high intake of vegetables and fruits are protective against these cancers as well.”

Compiled by L. S. A. Wedaarachchi

Psychological rehabilitation after a heart attack or a bypass

By Dr. R.A.R. Perera

Consultant Clinical Psychologist, Asiri Hospital, Colombo.

The current criteria to diagnose a heart attack require two out of three from; chest pain, ECG changes and an enzyme rise to twice the laboratory upper limit of normal.

Reactions to the unexpected onset of a heart attack or bypass surgery can be generally explained using a ‘loss model’. The possible losses include life, health, independence, social role, sexual activity, employment, leisure activities and financial security. The possibility of future loss produces anxiety and depression. Observed anxiety tends to be more pronounced than self reported anxiety because of denial.

As a result of selective attention, a person after a heart attack or bypass surgery, subsequently notices and worry about a number of different chest pains, which they would have previously ignored. The pulse, and its irregularities, is noticed by feeling the pulse or hearing when the ear is on the pillow at night. Simple reassurance is the only therapy required.

Depressed mood is very common in these patients and tends to occur later in the recovery phase after a heart attack or bypass surgery. It is mainly an adjustment disorder with a depressed mood. One third of patients have been demonstrated to have significant depression persisting one year after a heart attack or a bypass surgery. It is often the cause of fatigue, irritability and reduced concentration and sleep disturbance.

Cognitive behavioral therapy programs have been demonstrated to reduce depression and anxiety in patients after a heart attack or bypass surgery.

Very occasionally patients may need medications for depression. But care is needed when antidepressant drugs are given to heart patients. Non treatment of depressed mood can cause repeated hospital admission of a heart patient.

When a heart patient is discharged home from hospital, the partner perceives responsibility to have been transferred to them from the hospital doctors. This can result in close scrutiny, which can be quite disruptive.

For the first time partners notice normal pauses in respiration during sleep. More often, the patient is woken to see whether or not they are still alive.

Over protectiveness can result in patients being restrained from activities for which they are already fit. Normal sexual activity can be resumed when the patient is able to walk briskly up two flights of stairs. This is usually possible within two weeks of their heart event. Special care should be taken of those who are socially isolated or have poorer levels of education.

Many of these patients can return to driving within four weeks after the heart attack or bypass surgery.

Employers fear continuing the employment of those who have had heart attacks or undergone bypass surgery. They need the responsibility to be taken by the doctor. The medical certificate needs to state that the patient can return to work ‘without any limitation of any kind. If there is any limitations, it needs to be specified.

Rehabilitation programs after a heart attack or bypass surgery should include physical, psychological and social recovery. It assists the secondary prevention of heart disease through identification and modification of risk factors and by improving compliance with medical therapies.