Management of severe pregnancy sickness and hyperemesis gravidarumBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k5000 (Published 30 November 2018) Cite this as: BMJ 2018;363:k5000
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I was very pleased to read the excellent article regarding 'Management of Severe Pregnancy Sickness & Hyperemesis Gravidarum' published in the BMJ on 30/11/18 , which highlights this under appreciated & under researched condition .
However, as a retired GP who has been interested in Pregnancy Sickness for over 50yrs, I would disagree with the authors & say I feel moderate nausea & vomiting of Pregnancy (NVP) may often need treatment with anti-Sickness medication.
Moderate pregnancy sickness may be characterised by NVP causing an inability to shop, maintain relationships with husband or child & lose time from employment.The PUQE scoring system for moderate pregnancy sickness would be equivalent to total daily nausea for 4-6 hrs with or without 1-2 vomits per day. This level of symptoms should surely be considered for anti-sickness medication. Early effective management of moderate NVP may also prevent deterioration to severe symptoms and hyperemesis gravidarum.
A.M. Barnie-Adshead FRCGP
Patron of Pregnancy Sickness Support Charity
Competing interests: No competing interests
Dean et al discussed severe pregnancy sickness and hyperemesis gravidarum but did not address the related issue of the effect of cannabis on the mother and future child.(1) Nausea and vomiting are much more common than hyperemesis but all may be worsened secondary to the increasing use of cannabis which has potentially devastating consequences.
Professional associations warned about the teratogenicity of cannabis a decade ago with ventricular septal defect and Ebstein's syndrome.(2) Moreover, animal and human evidence shows adverse impacts of cannabinoid receptors’ stimulation on fetal brain development.(3) Shockingly, two thirds of Colorado’s cannabis dispensaries recommend marijuana for first trimester nausea,(4) when chronic cannabis use is actually associated with nausea and vomiting leading to emergency department visits.(5) The documented cannabinoid hyperemesis syndrome is associated with severe cyclical abdominal pain, nausea and vomiting, and compulsive bathing behaviors.(6,7)
More public awareness is required, as cannabis has a very long duration of activity due to extensive distribution and accumulation in fatty tissues. As many pregnancies are unplanned, stopping when becoming aware of pregnancy is far too late.
Considering the global use of marijuana, we believe all women of reproductive age, especially those considering pregnancy, as well as pregnant women suffering from nausea, vomiting or hyperemesis, should be asked about, and warned against, cannabis use.
1 Dean CR, Shemar M, Ostrowski GAU, Painter RC. Management of severe pregnancy sickness and hyperemesis gravidarum. BMJ 2018;363:k5000.
2 Jenkins KJ, Correa A, Feinstein JA, et al. Noninherited risk factors and congenital cardiovascular defects: current knowledge: a scientific statement from the American Heart Association Council on Cardiovascular Disease in the Young: endorsed by the American Academy of Pediatrics. Circulation 2007;115:2995-3014.
3 Higuera-Matas A, Ucha M, Ambrosio E. Long-term consequences of perinatal and adolescent cannabinoid exposure on neural and psychological processes. Neurosci Biobehav Rev 2015;55:119-46.
4 Dickson B, Mansfield C, Guiahi M Recommendations from cannabis dispensaries about first-trimester cannabis use. Obstet Gynecol 2018;131:1031-1038.
5 Bollom A, Austrie J, Hirsch W et al. Emergency Department burden of nausea and vomiting associated with Cannabis Use Disorder: US trends from 2006 to 2013. J Clin Gastroenterol.2018;52:778-783.
6 Habboushe J, Rubin A, Liu H, Hoffman RS. The prevalence of cannabinoid hyperemesis syndrome among regular marijuana smokers in an urban public hospital. Basic Clin Pharmacol Toxicol 2018;122:660-662.
7 Wallace EA, Andrews SE, Garmany CL, Jelley MJ. Cannabinoid hyperemesis syndrome: literature review and proposed diagnosis and treatment algorithm. South Med J 2011;104:659-64.
Competing interests: SB chairs the TSC of EMPOWER (an RCT of secondary care treatment of severe pregnancy sickness, HTA project ref 16/15/03, EudraCT number 2017-001651-31, IRAS 227 986)