WOMEN WHO EXPERIENCE severe sickness and vomiting during pregnancy should be routinely and periodically screened for emotional distress during and after pregnancy, according to new clinical guidelines for hyperemesis gravidarum (HG).

The new HSE guidelines, published last week, also highlight how “almost 5% of women with HG will terminate a wanted pregnancy due to severity of symptoms”. 

HG can profoundly debilitate those who suffer with it.

The condition received a lot of attention when Kate Middleton was expecting her first child. Her condition was so severe it resulted in her hospitalisation.

While the majority of women experience regular ‘morning sickness’ (which can actually occur at any time of the day) during pregnancy, HG is a lot more serious and can often result in multiple hospitalisations.

It can leave women unable to eat, drink or carry out everyday activities.

For over a 10-year period, there has been a campaign for better access to drugs and support for women experiencing this illness. 

The HSE has now moved to update its guidelines for clinicians, recommending that where indicated, psychiatric assessment and intervention should be offered to women. 

The guidelines state that doctors should refer women to a psychologist within the perinatal mental health services, which provide support for women who are experiencing moderate to severe depression during pregnancy and after giving birth or a community setting, if deemed necessary. 

The document also points to research that HG can escalate to the point that a woman may consider a termination of pregnancy and suicidal ideation.

“Healthcare professionals should adopt a holistic and compassionate approach to assessment of HG,” states the report, which also suggests further education being required to improve practitioner awareness and management of the condition. 

Trauma-sensitive training

Trauma-sensitive staff training is recommended for staff interacting with women experiencing HG.

In cases where clinicians do not have access to such training, management should be informed so that funding can be obtained and trauma-sensitive training prioritised, state the HSE guidelines. 

“Patients report a large contributor to distress is difficulty accessing treatment or feeling to have to fight for adequate treatment of their condition.

“Practitioners should address the severity of a woman’s symptoms in relation to her quality of life and social situation and offer adequate treatment of HG that is acceptable to the patient to ease and avoid psychological distress,” states the guideline document, which spans 129 pages. 

It goes on to state: “Women who undergo termination of pregnancy due to HG have been found to be three times more likely to describe their healthcare providers as uncaring compared to those who do not terminate.” 

HG alone is not an indication for early delivery or induction of labour, note the guidelines; however, they say an individualised approach taking the woman’s preferences into account is recommended. 

The issue of termination has previously been raised by consultant obstetrician at the National Maternity Hospital and assistant professor at University College Dublin (UCD), Prof Mary Higgins, in 2023. 

As reported by The Journal at the time, she said many women find themselves in a very “dark place” when suffering with HG. 

She said she knows of women who have contemplated suicide while others chose not to continue with their pregnancy. 

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Standardising care for women

The guidelines, which contain 40 new recommendations aimed at improving the treatment of HG have been welcomed by Hyperemesis Ireland, the patient organisation which supports women and families affected by the condition.

Our hope is that the new guidelines will standardise care for HG in Ireland; help women to access appropriate treatment earlier; and reduce the risk of severe illness and complications for both mother and baby,” said Professor Brian Cleary of the Rotunda Hospital – a trustee of Hyperemesis Ireland

He said the updated guidelines offer a significant opportunity for standardising care and improving experiences and outcomes for women. 

Health Minister Jennifer Carroll MacNeill told The Journal that the new clinical guideline on hyperemesis gravidarum and nausea/vomiting in pregnancy are an important addition to the suite of guidelines developed by the National Women and Infants Health Programme and the Institute of Obstetricians and Gynaecologists of the Royal College of Physicians in Ireland.

“Pregnancy can be a challenging time, and for women experiencing severe nausea, vomiting, or hyperemesis, the physical and emotional impact can be overwhelming.

“This guideline will help ensure that women receive consistent, evidence-based care and have clear information about where to seek support throughout their pregnancy journey,” said the minister. 

Aside from recommendations around mental health supports for women, the clinical guidelines recommend a standardised severity assessment tool to gauge and track women’s symptoms. 

It also encourages institutions and health professionals to develop and undertake regular audits of the women attending for treatment for nausea and vomiting, stating that medication prescribing practices and the number of women with HG attending the perinatal mental health team should be tracked. 

The number of attendances to the emergency department and other admissions should also be documented. 

The report calling for women to be referred to their hospital’s perinatal mental health team comes at a time when recent reporting by The Journal Investigates reveals that pregnant women are experiencing restricted access to such supports.