Nausea and vomiting: Information for you (new)
Consumer pilot response received August 2015
88 responses were received in total. 1 hardcopy was received from patients who had been asked to review the
information through their clinic. 87 were from the Women’s Voices Involvement Panel and the wider public through
the online survey.
Of all responders, 93% (representing 70 responses out of 75 patients who provided this information) identified
themselves as having had personal experience of the subject matter of the leaflet. 3% (2 out of 75) said a friend or
family member had had this experience, and 4% (3 out of 75) had no personal experience of it.
If you answered 'no' or 'in parts', please note anything you think could improve the layout.
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Patient comment
Use of bullet points or images/diagrams
Better different ion between HG and normal vomiting.
Make the section about treatment more informative and obvious
The treatment available need to be shown in a ladder so that sufferers can understand all the levels
of medication that is available.
It jumps between severity, so for example discussing the risks of both NVP and HG in the same
section when they carry very different risk levels. Then it goes back to self help for NVP after
discussing HG. I think it would be better to get all the NVP stuff and self help done at the start and
then move onto HG, rather than implying that HG can be helped with Ginger Biscuits.
Nausea should be replaced by feeling sick; reduce the impersonal tense and making it more direct
talking to women as you would face ti face;dehydration is explained twoards the end of the
document, tis should come much earlier on; why not say medicines instead of medications; delete
last paragraph or put it much earlier
Index/table of contents would be useful.
It seems very muddle switching from NVP to HG & back again
It was not clear that you can be offered all that medication outside hospital as the order implied you
got that in hospital.
There's mention of psychiatric treatment before the section dedicated to it.
If there are some phrases that are difficult to understand, what are they?
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Patient comment
Reference to other fact sheet has an acronym that was not explained previously - VRT?
Perhaps a glossary or similar at the start would be useful.
If ‘yes’, what did you learn?
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Patient comment
[Answered ‘no’] But only because I had read up on this before
How to manage symptoms, I was not told this information by my doctor or midwife
It explained the different Meds that would be offered and that they were safe - I had to search
the web to double check for this info after being prescribed by the doctor.
The medication. That you should contact healthcare professional if symptoms persist after self
management
That nausea and vomiting can be caused by a problem with the placenta.
The different types of medications available
More drug options.
Different coping strategies.
That in my second pregnancy , which lead to my baby being still born at 37 weeks , I should have
challenged my midwife more , as I lost 5 stone in pregnancy . I was told that I was big enough and
that the baby would be ok
How to recognise if I am dehydrated and when I should contact my midwife
That I should have had extra vitamin tablets prescribed to me!
The order of the medication
The various options. I have recently suffered with hyperemesis and did not have all those options
in hospital, and I didn't realise what was an unacceptable amount of vomiting.
What foods to eat such as rice potato and pasta
Anti sickness medicine prescribed and safe to use during pregnancy as well as tips on what and
how to eat and drink.
Spacing eating and drinking out by thirty minutes
Basically everything
treatment options, dietary advice
I was not informed of the details of this subject prior to reading
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Treatment of this condition
shocked and dismayed that ginger is marginally better than a placebo. It certainly doesn't taste
better than a placebo when you vomit it back up.
That the medical community is seriously considering recommending ginger as an alternative form
of treatment, when it's an acidic product that can only increase acid reflux and discomfort. The
validity of the studies showing its effectiveness should be reconsidered, but if medical
practitioners feel adamant about recommending it, they should at least favour minuscule extract
tablets in minute amounts, not consumption of the actual food product, which us near
impossible to someone with nausea.
Mostly Caucasian women affected
Q12 Is there anything else you think this information should cover that is not included? If so, please tell us.
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Patient comment
It recognises psychological issues but does not signpost the patient to contact their GP if they
notice persistent low mood.
Just a bit more information about how it can affect you psychologically can cause you to feel very
down, scared to leave the house etc and these feelings are normal your not on your own.
Otherwise it's a very good leaflet!
Reassurance that you can be off work with HG and not be expected to function normally, people
think oh it's only morning sickness and do not take it seriously. Expectation of this reaction from
others.
If suffering from sever nausea and/or vomiting rest is important as you do not have the same
calorie intake as usual.
That it's ok to feel low during this time, make women know it's hard but you will feel better I am
a hyperemisis sufferer currently pregnant with my second baby an reassurance when you feel
low is what is needed
Encourage women that although normal, to speak to doctor/midwife. I suffered very badly to the
point of being admitted to hospital but felt that it was normal so didn't seek help early on. Had I
have done, things may have been different.
More about the low mood and desperate situation suffers feel they are in. Would love to see
more support for the mums suffering. But understand this is not easy to add to a leaflet.
Tolerating foods also linked to heightened smell sensitivity, so easier to tolerate bland,
unfragrant foods
I suffered with hyperemesis and was admitted to hospital 11 times whilst pregnant. The effect it
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has on a woman's mental health is maybe worth a mention. It can make you feel depressed, it's
not nice to spend a lot of time alone in a gynae ward with older patients
Yes, what to do if you don't get support or recognition from your GP about HG. Detail of where to
get further information in tips on how to manage it. Leaving the part about accepting help till
end isn't right - needs to be highlighted much earlier.
A reassurance statement that advises women to seek advice from their midwife and not struggle
unnecessary! I knew sickness was expected but persisted in trying to manage this without
medication I should have gone sooner! Perhaps also just a statement that medications may be
give for just a couple of weeks if that's what's needed?
That some GPs/medical professionals don't take it seriously enough which can be scary and
stressful.
Maybe that a GP might not know how to manage HG. That HG will start before you meet your
midwife. That going to a&e in reality might be the best way to see a Dr who knows how to treat
HG. (Personal experience)
During my pregnancy I suffered with Hyperemesis Gravidarum, but managed to avoid hospital
admission. I feel a short paragraph about the psychological element involved with severe
sickness is needed, as I and many other women, felt like giving up and that we couldn't cope with
the situation. Including in the article that feeling down and even depressed is normal when
you're going through such a hard time, would be good for newly pregnant ladies to read!
I am suffering with this currently and what always worries me and what I find little information
on is the effect it may have on my baby... It's very worrying and you want to reassured or advised
or little things you could try to try and help yourself like trying to eat ice cubes if sipping water is
difficult and so forth.
Maybe explain about what keytones mean in your urine as that's what is said a lot in hospital.
More information about HG would be useful.
Being sick the whole way through your pregnancy is very isolating. I had it twice
H.G and employment.
More specific statistics need to be added; 86% of women who have had HG in a previous
pregnancy will experience it again. Approx 9000 cases of HG across the country every year
NVP/HG symptoms have a pattern of reducing around 16-20 weeks but can continue until birth
'Will it harm me?' needs to be included. HG was the leading cause of death in early pregnancy
before IV's. It still causes maternal deaths - complications and risks need to be explained. Full
risks to baby need to be explained more fully. Rest needs to be included in the 'What can i do to
help' section. Ginger and acupressure info needs to be removed as this is more than just normal
morning sickness. This doesn’t help with this condition. Within the medication section it either
needs to state than no medications are licensed to take in pregnancy but that medications have
been used for 20-45 years with increasing amounts of research and data being collected to show
that these medications are safe to take in pregnancy - or take out the licensing information as it
is misleading to talk about it in relation to one of the medications available.The section on after
discharge i feel undermines the seriousness of the condition and the level of follow up treatment
and care required for a sufferer of this condition. A detailed discharge plan needs to be drawn up
and agreed by HCP's so that the patient knows exactly what is in place and what will be done if
symptoms persist or increase. There needs to be a detailed monitoring plan agreed with the GP
to insure hydration and medication is correct. There needs to be a link at the end of the
information to pregnancy sickness support (www.pregnancysicknesssupport) who can offer
information and support to sufferers, their families and Health Care Professionals. This
information leaflet needs to be written using the knowledge and experience of Pregnancy
Sickness Support who are the experts in the field.
My experience of HG was really awful. Being sick was actually a relief as the constant nausea
every second of every day was unbearable. It was so back that I started to think about a
termination. I would be helpful to recognise impact and that it can be more about the constant
nausea than the vomiting itself.
How long in hospital for? I was always five days each visit - is that typical? Also, I had to go back
to hospital three times - should be made clearer that this could happen and is not rare. Options
for meds - could say that liquids / suppositories may be more suitable than tablets. Really really
don't like ginger advice as when have HG it is very bitter to sick back up. More advice in foods to
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try would be good, and that liquids drunk very hot or very cold are more likely to stay down.
A better definition on HG with more of an emphasis on the mental toll as well as the physical
symptoms. It states in severe cases vomiting can continue until 20 weeks and rare for it to
continue for rest of pregnancy. No mention of the crippling nausea that can last longer once the
vomiting has stopped and can be more distressing than the vomiting. My vomiting stopped at 25
weeks, nauseous until baby was born although managed to stop taking anti - emetic at 35 weeks.
Also that it can take time to find medication that has effect and a combination of the mentioned
drugs may be an option.
I find it helpful to view a table with the symptoms for usual pregnancy sickness compared with
symptoms for HG making it clearly visible which you are experiencing. If I had had information
like that to hand from the midwife /doctor when I first became pregnant I may not have got as ill.
Maybe some information that is more visual would be useful in this leaflet.
The mental effects of Hyperemesis and ways family and friends could be supportive.
Risks of HG for the mother... currently implies that only possible harm to the baby matter and
their live is therefore more valuable. The risks of poorly managed HG are not covered
sufficiently. Rest should be mentioned as a self-help strategy as many women find this hard to
do without "permission". When discussing ondansetron the leaflet specifies "it is not licensed
in pregnancy" this implies that the other medications are licensed, which they are not. Either
specify that none are licensed or don't get into the whole issue of licenses in pregnancy,
otherwise it looks manipulative. At the end you mention support from family and friends but
you need to add in Pregnancy Sickness Support which has a peer support network which has
been shown to significantly improve women's experiences of HG. Some information on the
mental health impact of HG and how isolating it can be would be a very valuable addition.
Additional sources of support for sufferers, eg pregnancy sickness support.
Side effects of the medication. I couldn't tolerate one type so had to be put on another.
The emotional impact which has a direct link to the physical effects and the effect it has on your
everyday life and ability to function.
Some reassurance that hyperemesis gravidarum is not a psychological/mental condition, as this
is an attitude often encountered by women seeing their doctor or midwife.
Please make it clear that ginger is not an appropriate treatment for HG. I feel you would be
better to have a section for NVP & a subsection for HG to make the differences clearer
It needs to be made clear that hyperemesis is different to NVP and that treatments like ginger
and acupuncture are largely ineffective with HG.
A table of what is normal pregnancy sickness and what is hyperemesis, I don't think this info is
clear enough.
Please stop telling women who suffer with HG to try ginger biscuits! They don't work!!! Trust me,
been there done it, tried it, doesn't work.
How much weight loss is medically relevant Mental health / quality of life - what to do if it
makes you depressed Mention of caring for dependents when sick
It should seek to give women advice without scaremongering about other conditions.
Hyperemisis gravidarum should have more information and not be in the same category as 'try
ginger'
The information in the leaflet could be misleading for women as the steps in which referral is
made or hospital admission is dependent on ketones in urine at most gp/ hospitals and therefore
just because they are vomiting and feeling really rough will this mean they will be referred at the
gp or admitted to hospital?
lots more about severe nausea. I didn't have much vomiting in my pregnancy - mostly because
PSS helped me to self manage, but by about 15 weeks I had lost almost 3 stone, and I was only
offered cyclizine after mentioning it to a dr at a walk in when i went for something else. It's
important to know about keeping hydrated even when not vomiting and to know that you will be
supported in pregnancy without having the constant vomiting. The ptylatism was a huge problem
as well as very intense sense of smell, which led to vomiting. Not sure if appropriate (or too scary
to add) but mentioning monitoring MMH may be helpful? Isolation and not being able to be
excited about being pregnant (not societal norms) can have such a massively detrimental affect
this reads like a morning sickness leaflet. Morning sickness is very different from both severe NVP
and HG, and needs to be treated as such.
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To begin with, the guidelines should have begun with a section stating there are ongoing studies
involving the genetic factors determining HG. Any mention of psychosomatic factors should be
eliminated, unless the info is backed up with real data. The section on advice for psychiatric
treatment should be formulated differently. Wanting to terminate an HG pregnancy is not a sign
of 'mental disease', as hinted at here. It's a natural reaction to being on the brink of survival.
Counselling should be offered, not psychiatric treatment. Also, there is no mention of what
happens to doctors who take HG lightly and hint at psychosomatic factors. These practitioners
should be given counselling, as well, because they clearly have reasons of their own to deny their
patients the care they deserve.
I personally didn't lose lots of weight but I was being sick up to 20 times a day. I didn't read about
the amount of times you're being sick as an indicator to being treated. I wold want that
Q15 Please make any additional comments you have about this information:
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Patient comment
Fab!
More women need to know that it really common and this will help so many feel better
Very informative unfortunately I won't benefit from it now as I have had 2 children as a sufferer
and couldn't go through this again. I would certainly recommend this leaflet if I knew someone
suffering.
Anti-sickness medication needs to be emphasised safe during pregnancy otherwise despite no
longer in use patients may automatically think of thalidomide and won't pursue
I suffered HG and was admitted to hospital, I spent from 6weeks -39+5 weeks on medication and
continued to be sick thought my pregnancy; we found travel bands helped! Lots of people are
advised ginger, this made me feel hot & therefore more sick!! It's also a shame my MW never
acknowledged I had HG & how much I was suffering, information/ support around HG would
have been great!
Much needed information. Wish it was available when I had HG.
Great that the leaflet explains what will happen if you have to go into hospital, not great that
that isn't always the case.
I think all GP's and midwives should be reading this. I feel my vomiting wasn't monitored
correctly. I lost 20lb in weight and struggled to even keep water down. I had ketones in my urine
on occasions and was then prescribed anti sickness tablets. I was never sent to hospital to be re
hydrated nor was I given thiamine. I just had responses like; 'isn't it awful' and 'it will pass'.
Again I feel that in order to create the best possible information leaflet it needs to be written
with the experts from Pregnancy Sickness Support who have been working on and researching
this condition as well as supporting sufferers for the past 13 years
I think the leaflet is good, however I think it seems quite short and could maybe go into more
detail, for instance the mental health aspects of the condition.
I suffered hg in both my pregnancies...the first from 13 weeks to full term. My baby boy was
healthy but small...5 lb 12 oz and I lost 2.5 stone. My second pregnancy vomiting started at 5
weeks and again continued to full term. This time I received various medications to try and
control the condition which I remained on up to giving birth. I was told on numerous occasions it
was in my head or I was making myself sick. The ignorance of health professionals needs
addressing as when you are told that there is the possibility of your baby being terminated you
need support and not patronising comments from people who have no idea what you are going
through.
I've made a number of comments on the last page but would also like to suggest that you take
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out the suggestion of ginger or specify that for women with HG ginger may make symptoms
worse. Dr Margaret O'Hara is part of the Green Top Guideline committee and she and I have a
paper which has been accepted for publication which shows that in just over 500 women
admitted with HG over 50% found that ginger caused pain, worsening of symptoms and
increased acid. Furthermore, when a healthcare professional suggested it the trust in their
professional ability was totally eroded. Women get suggested ginger by anyone and everyone
and there is almost 100% knowledge of it in the general population so there really is no need to
include it in the leaflet and may serve only to undermine the rest of the information in the
leaflet. I think you should put the "what can I do to help" information before the section on
"What is Hyperemesis Gravidarum". I also think you should separate risk discussion so that
before the HG section you discuss "will NVP harm my baby" with the reassuring line that no it
won't and then after the HG section have a section on "Will HG harm my baby" with the risks and
that's why it's important to get treatment. And then also have a section "Will HG Harm Me?"
because the mother's health is just as important as the baby's and again here you can reiterate
the need for treatment to prevent oesophageal damage, wernike's and mental health problems.
Otherwise it's a pretty good leaflet.
Very patient-friendly and clearly written.
Really not keen on the suggestion that ginger helps. There is no evidence of this.
Ginger biscuits do not help women who are suffering with HG. It is soul destroying to see this on
a leaflet produced by the RCOG. It makes me feel like you don't really understand the condition
at all.
It's a general overview of the condition but feel that the level of care described in the leaflet may
not be received by every women which may lead them to feel alone and not helped?
Thank you for creating this leaflet - i think if i'd seen it when i first was pregnant it would have
been very helpful. I'm sure it will help a lot of people
It needs clear distinctions between morning sickness (can be managed by the woman without
medical help, small regular meals help, no impact on ability to work, look after children, QoL,
stops around 12-14 weeks), severe NVP (weight loss, dehydration, medication needed, lack of
ability to work, impacts QoL, may last around 20 weeks) and HG (as NVP but severe illness,
mental health impact, physical health impact, serious QoL consequences). By starting a leaflet
called 'NVP' by talking about morning sickness it negates the experience that women with NVP
and HG go through
While I'm grateful that guidelines are finally being drawn out, I don't feel they truly dismiss the
preconceived notions that most doctors have with regard to NVP and HG. There is no mention of
any penalties for doctors who persist in disregarding the severity of these conditions. Also, the
guidelines should clearly state that wanting to terminate an HG pregnancy is a natural reaction,
not a sign of 'mental disease', and while counselling should be offered to mothers who cannot
carry an HG pregnancy to term, the involvement of psychiatric personnel should only be
recommended when the termination has affected the mother irreparably, not the pregnancy.
Wanting to survive when your very existence is threatened, and taking drastic steps to ensure
your survival is not a sign of mental disease, and patients should be absolved of any such
judgement. Furthermore, seeing as there are ongoing studies concerning the genetic factors
behind HG, I don't feel that the guidelines should give medical practitioners the impression that
any of the medication suggested is an actual treatment for HG. While they may alleviate some of
the symptoms, they will NOT treat the condition. I feel patients should also be made aware of
this from the very beginning. Another point is that the onset of HG or NVP should be
acknowledged and recorded as soon as the patients have their first GP antenatal visit. There is no
mention in these guidelines as to when a doctor should start taking the condition seriously. Mine
waited until I was 6 months pregnant and denied me any medication throughout my 9-month
ordeal with HG. I fear that unless the guidelines specifically state that doctors all doctors tending
to a pregnancy have an obligation to acknowledge, report and record HG symptoms from the
time they first set eyes on a patient, even if these signs should turn out to be inconclusive,
medical personnel will ignore the condition for the sake of their hospital budgets. That's been my
experience, and I don't think these guidelines address this risk.
I would want to know that any Medical practitioner I was speaking to had read, understood but
also BELIEVED in this information. As that is not the experience I had so was never diagnosed but
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looking back I know what I had.
Anti-embolism stockings not worn in Hyperemisis day unit and no heporin injections given either,
only given if patient is an in-patient, not out-patient.