Hyperemesis Impact of Symptoms Score Handbook
Zoe Power, Heather Waterman and Henry Kitchener Introduction Hyperemesis gravidarum (HG) is a relatively rare but potentially devastating condition of pregnancy associated with many potential complications i.e. dehydration, electrolyte imbalance, malnutrition, Wernicke‟s encephalopathy, and compromised renal function. While most women experience severe nausea and vomiting, the impact of HG on their daily lives will vary from woman to woman depending on factors relating to the person such as lifestyle, responsibilities, access to help and information, coping ability and severity of symptoms. The purpose of the HIS questionnaire is to assist in planning tailored care for women with HG. Results of the questionnaire provide a guide for practitioners, pointing to where a woman may require the most intervention and advice. In essence the HIS questionnaire is a distilled interview. Questions are focused on areas that have been found by research conducted at St. Mary‟s Hospital, Manchester, to be of most importance to women with HG. The HIS can be used in hospital and community settings by doctors, midwives and nurses. Using the questionnaire The HIS may be self completed by the woman or by a practitioner if the woman feels too unwell. If the questionnaire is to be read out by a practitioner, it can be helpful to give a copy to the woman to read at the same time (unscored) to aid comprehension. The HIS has a simple scoring system and can be scored quickly at the bedside using the scoring guide. All asterisked answers (usually scored 2 or 3) should be investigated by the practitioner and advice and/ or intervention given as required using the handbook as a guide. Other answers may also require follow up if the practitioner feels it is necessary. The numerical result is a guide and a method of quantifying symptoms that may be useful for research or comparison purposes whereas womens‟ individual responses are more useful for clinical purposes. The following are suggestions for follow up to individual answers. However, these suggestions only represent a framework. Advice and support must be tailored to the individual woman and clinical judgement is always required.
Questions 1 and 2
“Are you able to keep small drinks/food down without vomiting?” Box 1: Actions for when women are intolerant of fluids Qu.1 & 2. assess the woman‟s ability to tolerate fluids give anti-emetics as soon as possible administer anti-emetics regularly start IV fluids as per local protocol encourage the woman to drink small amounts regularly explain why it is important to avoid dehydration try ice or lollies monitor the woman‟s body weight
These questions relate to the main symptoms of hyperemesis. They will be important for all women and almost always warrant some discussion because they impact heavily on other symptoms. If a patient says she can never, or only occasionally, keep food or drinks down, establish exactly what she means by this, i.e. how often is she vomiting; how much is she trying to eat or drink? If possible on initial presentation, before anti-emetics are given, assess the woman‟s ability to tolerate fluids by giving her a small drink of water. This does not mean that anti-emetics should be delayed. Anti-emetics should be given as soon as possible and administered regularly as prescribed until no longer necessary. If the woman is dehydrated start IV fluids, prescribed as per local protocol, as soon as possible and maintain them at the prescribed rate. Do not leave time lapses between bags, as this impacts upon rehydration. Some trusts recommend the “stat” administration of 1 litre of appropriate IV fluids over 1 or 2 hrs. Choice of fluid will depend on the individual woman‟s blood results. If a woman is particularly dehydrated, an IV pump to maintain fluid administration more accurately is preferable. Evidence suggests women who eat small amounts more often generally feel better (Motherisk, 2006). Unfortunately, this is not the case for everyone and some women will not even manage the tiniest amount of water. Even so, encourage the woman to drink small amounts of fluid regularly. Fluid, at least initially, is more important than diet. Dehydration itself is nauseating and will make symptoms feel much worse. Ensure the woman understands that it is important to avoid dehydration and that if dehydration has occurred to rehydrate quickly before an uncontrolled downward spiral of symptoms occurs. If even tiny amounts are vomited back try ice or ice lollies.
For most women, periods of respite from symptoms will occur at some point during the day (especially those scoring under 3 on these questions). Encourage capitalising on those moments by eating and drinking a little more, if possible. It is a good idea to have drinks and snacks readily to hand for these times so that women can “seize the moment” without having to move very far and risk triggering further nausea by having to search for and/or prepare food. Encourage women to eat whatever they fancy within the general safety guidelines for eating in pregnancy. Spicy, strong smelling and greasy foods tend to trigger nausea more than plain foods. Cold foods are often better tolerated than hot foods. However, this will not be the case for every woman. Ginger at a therapeutic level (not ginger biscuits) may be helpful but has very limited safety data although there is no evidence of adverse effect either. Monitoring of weight is important for these women as an objective measure of the physical impact of the condition. Women should be weighed on every presentation to health care services and, at least, weekly. Severe hyperemesis with poor weight gain (<7kg) throughout pregnancy is associated with lower birth weight infants (Paauw et al, 2005; Dodds et al, 2006).
“How tired do you feel?” Box 2. Actions for when women feel tired Qu 3. Explain why the woman should rest Check that partner / carers also understand the importance of rest Assist the woman in exploring possibilities regarding obtaining help Approach social worker if no help available
Tiredness and exhaustion also impact on other symptoms. Dehydration is very exhausting. Fatigue is a characteristic feature of the first trimester of pregnancy, and nausea and vomiting only serves to compound this. Furthermore, fatigue is associated with increased nausea. Make it clear that rest is important, even if this means taking time off work or from home duties. Insufficient rest appears to jeopardise control over symptoms making dehydration and admission to hospital more likely (Power et al, 2006). If a partner or other support person is present ensure that they understand this too. If necessary make an appointment to see the partner or family to explain or provide written information. Where the woman is unsupported, assist the woman in exploring possibilities regarding obtaining help e.g. other family members, friends, neighbours, community resources etc. This is particularly important where the woman has responsibility for caring for children or other relatives. If no help can be found in this situation, advice from a social worker may be needed.
“Think back to your usual mood/emotional state before you felt sick, how do you feel now in comparison?” Box 3. Actions for when women feel emotional or have a low mood Qu 4. Establish the nature of the condition as the woman experiences it Avoid making under-informed judgements of the cause of HG Identify whether any depression is a result of HG or whether it was present before HG Formulate an action plan with the woman Take the woman‟s condition seriously Advise that severe nausea and vomiting lasts up to around weeks 1314 of pregnancy and that it can suddenly abate Warn that a small number of women have persistent symptoms Suggest that women capitalise on the „good times‟ and be prepared for these with drink and food at hand Reinforce the message to rest
Prolonged severe nausea and vomiting can have a detrimental effect on psychological wellbeing and research has indicated low mood to be a common result of this condition (Mazzotta et al, 2000). Research has not, in general, supported depression as a cause of hyperemesis (Simpson et al, 2001; Mazzotta, 2000) although it is possible that psychological reactions to symptoms may become entrenched or conditioned (Buckwalter and Simpson, 2002). It is also possible that some women may simply be more equipped to cope with symptoms than others from a psychological as well as social and physical point of view. However, it should be borne in mind that “poor coping” as a cause of hyperemesis was found in general to be over emphasised by medical and nursing staff in a recent study (Power et al 2006). It must be stressed that it is important to try to establish the “true” nature of a women‟s condition as she experiences it rather than making under-informed judgements. Establish whether any depression noted is a result of HG or was present prior to the condition. In the case of depression unrelated to hyperemesis the patient should seek help from their GP or be referred to psychiatry where this is appropriate. Where low mood is a result of symptoms, a discussion of symptom management and expected time frame may help. Also, developing an action plan with the woman based on the results of the HIS may facilitate women gaining control over their symptoms, rather than the symptoms controlling the individual. It is important that the woman feels she is being taken seriously, dismissive attitudes are not helpful (Soltani, 2003; Munch, 2000). Many women will ask “how long will their symptoms last?” It is not possible to give a definitive answer to this question. However, women may be advised that most women feel much better by around weeks 13-14 of pregnancy
(Verberg et al, 2005; Attard et al, 2002). Unfortunately, some will have some symptoms for longer and occasionally, women do vomit right up until birth. However, those who do vomit throughout pregnancy rarely vomit more than once or twice a day and in comparison to the more severe symptoms they have experienced, this is usually found to be manageable. Remind women that uncertainty about the length of time that symptoms will remain has a positive side. Symptoms may resolve tomorrow! Symptoms often resolve suddenly and unexpectedly. Also symptoms generally improve after hospital admission and rehydration is achieved, although, symptoms may reoccur after discharge. It is a normal for the symptoms of hyperemesis to come and go, encourage women to capitalise on the “good” times. Advise women to eat and drink if possible and rest and relax without guilt. They should not be rushing around to catch up on jobs etc. as soon as respite from symptoms occurs as this may induce further nausea. Therefore the woman should be encouraged, if at all possible, to take it easy.
“Do you worry about the health of your unborn baby?” Box 4. Action for when the woman is worried about the effect of HG on the unborn baby Qu. 5. Point out that so long as the woman is gaining weight satisfactorily and is not dehydrated there is no evidence that the baby will be harmed Explain the need to monitor body weight Provide urinalysis sticks for home testing to reassure women or to alert them that they should contact a health professional Some women will come to hospital to seek reassurance that vomiting is not harmful to their baby. Assuming that the woman is not dehydrated and is gaining weight sufficiently there is no evidence to suggest adverse effects on the baby. In fact some researchers suggest a protective effect, linked to high pregnancy hormones and other theories re: avoidance and ejection of harmful toxins (Weigel & Weigel, 1989; Sherman & Flaxman, 2002). However, dehydration is of course a risk, as are low thiamine levels, (potential risk of Wernicke‟s encephalopathy) as a result of prolonged, excessive vomiting. Severe hyperemesis with poor weight gain throughout pregnancy is also reported to be associated with low birth weight and pre-term infants (Paauw et al, 2005; Dodds et al, 2006). Although, it is not known if there are any long term effects on the infant. Weight loss (or insufficient weight gain) should be monitored. Occasionally, urinalysis sticks have been given to women to test their urine at home. This has been successful in reassuring women by enabling them to test for the presence of ketones. Presence of ketonuria is often used as an indication for hospital admission.
“Do you feel defeated by your nausea and vomiting and that nothing will work to make you feel better?” Box 5. Action for when a woman feels defeated by HG Qu 6. Encourage a proactive response to HG as in the advice for Qu 3 & 4. Follow-up women at home via a telephone call Ensure the woman has informed GP and an ante-natal appointment booked Arrange midwife to support the woman
Women sometimes describe the experience of hyperemesis as a “vicious circle” or “downward spiral”. The “downward spiral” can spiral out of control and some women need the help of health care practitioners to “lift the burden” and “break the cycle”. This may not necessarily mean hospitalisation, in some cases good advice and anti-emetics will be all that is necessary. However, some women may require follow up, this may be in the form of a return visit, a follow up phone call or simply ensuring the woman is booked into ante-natal services. If a patient has not yet seen her GP regarding the pregnancy, this should be encouraged as soon as possible in order to access ante-natal services. Women with hyperemesis often access maternity services late due to hospitalisation or being housebound. In fact these women would benefit from early access to midwifery support. There is evidence to support the view that where symptoms are not unmanageable, given the appropriate explanation, information, reassurance and support, women are able to rationalise their symptoms and deal with them in a more positive way (Soltani, 2003; Munch, 2000). See also advice for responses to Q3 and Q4.
“Do people understand how ill you are feeling?” Box. 6 Actions for when women feel they are not understood Qu 8. Listen to womens‟ experiences of HG Avoid pre-juding the cause of HG
Research has shown that many women with hyperemesis meet disbelieving and dismissive attitudes (Soltani, 2003; Power et al 2006). This is an issue as research also shows that this impacts on depression and anxiety levels and general ability to cope with symptoms (Soltani, 2003; Munch, 2002). For many women understanding and validation is an important part of the burden lifting referred to in question 6 and impacts upon the woman‟s quality of life and satisfaction with their care (Munch, 2006). Dismissive attitudes can have the opposite effect, making the woman feel more isolated in managing unmanageable symptoms (Power et al 2006).
Questions 7, 9 and 10
Do your symptoms effect your ability to look after your home and/or family? Do your symptoms effect your worklife? Do your symptoms effect your ability to look after yourself? Box 7. Actions for when …Qu 7,9 and 10 Assess whether the woman needs anymore support to reduce stress eg a sick note Help the woman to maintain her physical needs and dignity
See question 3 also: Does this person need a sick note? Re-emphasise the importance of rest and help. Are there any specific issues re: home life and help that need addressing? If the woman is hospitalised, help will be required with self care until feeling well, some women will be very debilitated and may even find it difficult to stand or go to the toilet. Ensure that all help is given in order to maintain physical needs and dignity whilst recovering and regaining independence.
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