Nausea and vomiting in pregnancy (Hyperemesis gravidarum)
Nausea and vomiting in pregnancy (NVP) is common and affects up to 70% of women, While most cases settle down by 16 weeks, up to 13% of women have ongoing symptoms. Hyperemesis gravidarum is the more severe form of NVP and can result in dehydration, imbalances in body salts and significant weight loss. Luckily less than 3% of women are affected to this severity.
What is the cause of NVP?
NVP appears to be linked to the hormone beta human chorionic gonoadotrophin (BhCG) which is at its highest levels in the first trimester of pregnancy. This means that women with a twin pregnancy (and who have higher levels of BhCG) are more likely to suffer from NVP. There is also a suggestion that NVP has a genetic basis, women whose mothers or sisters had NVP are much more likely to also suffer in their pregnancy.
Other causes of NVP may include urinary infections, thyroid abnormalities or gastroenteritis and your doctor may perform some investigations to help rule these out.
What is the treatment for NVP?
Luckily, there are a number of simple ways to manage the symptoms of NVP. Dietary changes such as “grazing” or eating small quantities of food more frequently throughout the day may help. Avoiding food preparation and strong food smells can also be beneficial and for this reason some women prefer eating cold or even frozen foods.
It is important to keep up your intake of fluids, and this can include sports drinks or soft drinks which may provide some extra calories and salts to replace what is being lost.
You may find that you are not able to tolerate your usual pregnancy multivitamins. It is important to at least take a folate supplement as this will help to reduce the risk of your baby developing a neural tube defect (spina bifida). Vitamin B1, B6 and B12 supplements are also recommended as they can help reduce nausea.
Other simple measures can also help your symptoms. Ginger can be brewed into a tea, or purchased as a supplement from your chemist or health food store. When taken four times daily, it can help relieve some of the nausea.
If you are vomiting you may need to take prescription anti-nausea medications prescribed by your GP or Obstetrician. These may include metoclopramide, doxylamine, prochlorperizine and ranitidine. Ondansetron may also be used if these medications don’t work, however this causes constipation and is not usually a first line medication. All of these medications have been used safely in pregnancy for many years.
If you are unable to tolerate anything orally including fluids, and have severe vomiting, you may need to have fluids for dehydration. Contact your Alana Doctor or present to your local Emergency Department for assistance.
Bleeding and pain during early pregnancy
Bleeding in the first trimester can be very upsetting and is very common. It does not always mean you are having a miscarriage, and many women go on to have a normal, healthy baby. It does need to be investigated by your doctor though, as it can be a warning sign of miscarriage, ectopic pregnancy (where the pregnancy is in the tube rather than the uterus), or molar pregnancy (a genetic problem with the pregnancy where there is an overgrowth of placental tissue and cannot result in a baby).
Bleeding can also be arising from another location such as the cervix from polyps or infection. Not uncommonly, no cause for the bleeding is found.
What should I do about the bleeding?
If the bleeding is heavy and you are passing clots, you have significant pain or are feeling dizzy you need to seek urgent medical advice from your local Emergency Department. Otherwise make an appointment with your GP to arrange initial investigations and referral to the Alana Bleeding Clinic.
How is bleeding investigated?
When a woman has bleeding during her pregnancy her doctor will need to take a history of when the bleeding occurred and whether there are other symptoms such as pain. An examination will be performed which will include a speculum (like having a Pap smear) to look at the cervix and an internal examination to see if the uterus is the expected size and whether pain can be elicited.
Blood tests will be performed which will include a BhCG level (pregnancy hormone) and a blood count as well as the blood group if this is not already known. If you are a negative blood group you will be offered Anti-D which helps to prevent against the development of antibodies.
An ultrasound will also be performed to assess the pregnancy. In particular we will be looking for the pregnancy in the right location, that there is a fetus present and whether the fetus has a heartbeat (seen from 6 weeks of the pregnancy).
What is a subchorionic haematoma?
A subchorionic haematoma is a blood clot present behind the placenta. This is sometimes seen when a woman has had bleeding in early pregnancy. Pregnancies with a subchorionic haematoma can progress normally but have an increased likelihood of miscarriage, premature rupture of the membranes and ongoing bleeding. Your Alana Obstetrician will discuss this result with you in more detail.
Miscarriage is common and occurs in one in five pregnancies in the first trimester. It occurs when the pregnancy stops growing and results in pain and bleeding as the pregnancy tissue passes out of the body. There is nothing that can be done to prevent a miscarriage occurring.
What is the cause of miscarriage?
Miscarriage is most often caused by a chromosomal abnormality. This is usually due to the incorrect exchange of genetic material when the egg and sperm came together, and represents nature’s way of dealing with an abnormal embryo. The majority of the time this is a random event, not something which is passed from you or your partner. As a result, it is uncommon for another miscarriage to occur and subsequent babies will be expected to be normal.
Miscarriage is more common as women get older due to an increased likelihood of chromosomal abnormalities. Women who smoke or drink in the first trimester are also more likely to miscarry in their pregnancy.
Occasionally, medical illnesses which aren’t controlled like diabetes or thyroid problems can be related to miscarriage, as can clotting problems.
It is normal to have one or two miscarriages, however if you have three miscarriages your doctor may investigate to see if there is an underlying cause.
Types of miscarriage
Miscarriage is defined as complete, incomplete or missed depending on the ultrasound findings:
Complete miscarriage – is where the pregnancy tissue has completely passed from your body and the uterus is empty. Usually no further treatment is required.
Incomplete miscarriage – is where part of the pregnancy has passed however there are still some pregnancy products remaining in the uterus. A number of different management options are available including a wait and see approach, medical management of miscarriage and surgical management (suction evacuation/curette). Your Obstetrician will discuss the results with you and talk about which option is best for you.
Missed miscarriage – is where there has been no pain or bleeding but the pregnancy has stopped growing. Again, this can be managed in a number of ways that your Alana Obstetrician will explain to you.
Going through a miscarriage is a distressing time and it can be important to get emotional or psychological support. Your GP or Alana Obstetrician can help to refer you to someone who you can talk to at this time.
Ectopic pregnancy is where the developing pregnancy is outside the cavity of the uterus. The most common place for an ectopic pregnancy to occur is in the fallopian tube. There are other places where an ectopic pregnancy can occur including on the ovary, in the wall of the uterus or caesarean scar, in the cervix or attached to other organs in the pelvis or abdomen including the lining of the abdomen. Tubal pregnancy makes up about 98% of all ectopic pregnancies, the other sites are all rare. Ectopic pregnancy occurs in approximately 1/100 pregnancies. It does appear to be increasing, probably due to better treatments for pelvic infections, and a higher rate of surgery performed in the pelvis and the abdomen.
How do I know if I have an ectopic pregnancy?
The most common symptoms arising from ectopic pregnancy are pain and/or vaginal bleeding during early pregnancy. The pain associated with an ectopic pregnancy can be mild or severe. The absence of pain does not exclude an ectopic pregnancy and occasionally they are found during a routine early ultrasound. The pain can be present in the centre of the pelvis or to the side of the abdomen. The other common symptom that may occur is vaginal bleeding. If you are in the early part of your pregnancy and there is vaginal bleeding or pain, then you should seek medical advice at the earliest possible time. Whilst a more common possibility with pain and bleeding in the early part of pregnancy is miscarriage, diagnosis of an ectopic pregnancy is important because it can be dangerous.
The main risk from an ectopic pregnancy is that the pregnancy may outgrow the site that it has settled and cause damage to that site and heavy bleeding. Such an event can be life-threatening and always requires immediate surgery. This is not common and most ectopic pregnancies are diagnosed and treated before they burst (or rupture).
How is an ectopic diagnosed?
If you have pain and bleeding in early pregnancy (usually between 4-12 weeks), then you should consult a medical professional at the soonest possible time. For severe pain you should always present to the Emergency Department of your nearest hospital if you cannot contact your doctor. A history of your symptoms will be taken and your doctor will perform an examination of the cervix and the uterus (womb) by gently feeling them. If there is still doubt about the diagnosis then an ultrasound will often be performed. This is usually done with a thin probe that is gently inserted into the vagina. This allows better pictures to be taken and can diagnose a pregnancy inside the uterus, or elsewhere (an ectopic) more easily than an ultrasound performed through the abdomen.
Sometimes there can be doubt as to whether there is an early pregnancy inside the uterus or an ectopic pregnancy. If there is a low risk for complications such as bleeding, then a blood test may be performed to observe the pregnancy hormone level and/or further blood tests and an ultrasound may be arranged at a later time to observe what the likely diagnosis is. The diagnosis can take a few days to a few weeks and it is important to tell your doctor if there are any changes to your symptoms. If you have severe pain or heavy bleeding during this time of observation, then you should present immediately to the Emergency Department of your nearest hospital for assessment.
What are the treatments for ectopic pregnancy?
There are three possible types of treatment for ectopic pregnancy:
- Conservative treatments (observation)
- Medical treatments (medications such as methotrexate)
- Surgical treatments
Conservative treatments: Conservative treatment is not often recommended, since the risk of having a significant complication such as rupture of the ectopic pregnancy and life-threatening bleeding is present. It is possible for an ectopic pregnancy to resolve spontaneously, though there are certain predictive factors that make this course of action more favourable, such as a low pregnancy hormone level, a small ectopic size (< 2 cm) and no obvious signs of bleeding (such as the diagnosis of blood in the pelvic cavity on ultrasound).
If you and your Alana Doctor decide to adopt conservative management, then it is important to have a follow-up plan involving blood tests and/or ultrasounds. If you have severe pain or heavy bleeding during this time of observation, then you should present to the Emergency Department immediately for assessment.
Medical treatments: Medical treatments such as methotrexate are suitable for some women with an ectopic pregnancy. Such treatment will depend on a number of factors including:
- The level of the pregnancy hormone
- Whether there are signs of rupture (such as fluid in the pelvis)
- Whether the pregnancy is alive or not
- The desire for pregnancy 6 months after treatment
Should you and your Alana Doctor decide on this treatment then it will be given to you as a single injection into the muscle of your buttock and you will require follow-up with blood tests and/or ultrasounds. It is important to follow the pregnancy hormone level to < 5 units to ensure that the treatment has been effective. Side effects that can occur after treatment with methotrexate include stomach upset and nausea, hair loss and skin rash. Local effects around the injection site such as pain and swelling may occur. It is possible for an ectopic pregnancy to rupture even after treatment with methotrexate and if there is a sudden increase in pain or change in symptoms then you should immediately present to the Emergency Department.
Surgical treatments: Surgery for an ectopic pregnancy will usually involve a laparoscopy. This is where a thin telescope is placed into the umbilicus (belly button) under general anaesthetic to look at the inside of the abdomen and pelvis.
The first step in the laparoscopy is to assess the pelvis, at which time the best treatment will be decided upon. Generally, if there is an ectopic in one fallopian tube, and the other is normal, then the tube with the ectopic in it will be surgically removed. This will ensure that there is a reduced chance of a further ectopic pregnancy and that all the pregnancy tissue is removed. Most women and their families are concerned that the loss of one of their tubes will mean a decreased chance of pregnancy. Research to date has shown that there is no change in the chance for a normal pregnancy if the tube with an ectopic is removed completely or if it is surgically opened, the pregnancy removed and the tube is left to heal.
If the tube is opened (called a salpingotomy), then there is an increased chance for a further ectopic pregnancy to occur in the same tube. The chance of an ectopic pregnancy occurring in the other (normal) tube is unchanged. If a salpingotomy is performed then it is possible that not all of the pregnancy tissue will be removed and further treatments, such as methotrexate or more surgery may be required. For these reasons, when the tube without the ectopic is normal then the best treatment appears to be removing the tube with the ectopic completely.
If the ectopic pregnancy has burst (ruptured), then there may be significant bleeding into the abdomen. This can be life-threatening. In such circumstances, the abdomen is usually opened through a large incision to control the bleeding. If there are no signs of shock due to large blood loss, then laparoscopy is a better form of treatment as there is less pain, a quicker recovery, fewer days in hospital, smaller scars and less risk of adhesions (scar tissue in the abdomen).