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Sickness In Pregnancy

Dr Roger Gadsby, Institute of Clinical Education

Published August 2010

'Morning sickness' is generally accepted as a normal part of pregnancy. For some women this nausea can prove very disruptive and result in having to take a significant amount of time off work. Dr Roger Gadsby, Institute of Clinical Education, who has been studying the condition for thirty years, tends to find that people underestimate the seriousness of the condition. He would like to see pharmacological treatment which has been developed, but is not licensed for the UK, be made available for women here too.

Nausea and vomiting during pregnancy is culturally accepted as part and parcel of the trials of the gestational period, an effect casually known as ‘morning sickness’. Actually this phenomenon, which is particularly acute between 6-14 weeks, is a medical condition and pharmacological treatment is available, just not in the UK. In short, the degree of suffering is chronically underestimated and the condition itself is under researched, but that is not to say undiagnosed. In times past women have died from dehydration brought about by the regular induced vomiting. Charlotte Bronte is reported to have died because of it - some of her letters have survived where she documents the details of the paralysing symptoms - and the last official death was recorded in the 1930s.

A pregnancy bumpPerhaps part of the problem is that the term ‘sickness’ trivialises the condition. Sickness is a term used to describe a wide variety

circumstances when an individual feels unwell. Actually the particular nausea brought about by pregnancy has several distinctive features; it is episodic - nausea builds up and often ends in a vomit after which the symptoms subside for a short while and then the cycle repeats. Aromas from hot food aggravate the condition and eating whenever the sick feeling goes away is advised to limit the discomfort of the next episode.

Dr Roger Gadsby, of Warwick Medical School, has been studying the condition for over thirty years and published the first paper describing the natural history of the condition in 1992, ‘A prospective study of nausea and vomiting during pregnancy’. The research documented the experience of 363 pregnant women and found that 80% had symptoms. 52% suffered the more severe discomfort of regular vomiting; one woman recorded 246 vomits in total. Around 1/150 women develop the extreme version of the condition, hyperemisis grivadarum, where the severity of symptoms result in admission to hospital. The socio-economic impact is not trivial; 35% of the working women had to take an average of 62 hours off work because of the symptoms - “Employers are not always very sensitive. Given it is a known side-effect of pregnancy the general attitude is ‘Buck up. Get on with it’.”

In short, the degree of suffering is chronically underestimated and the condition itself is under researched...

The immediate question, then, is why women continue to suffer from the condition - is there nothing they can do? There is a pharmacological treatment that is effective and safe, used regularly in Canada, called Diclectin. This is a generic form of another drug, Debendox, that was used worldwide in 1960s but was subsequently voluntarily withdrawn by its manufacturer from the market. It transpires that the annual revenue generated from the drug was around five million dollars. In the 1980s a woman tried to sue the company for ten million dollars when her baby was born with an abnormality. The court case later concluded that there was no link between the drug and the foetal abnormality but the threat of such litigation prevented the drug being returned to the market.

The anxiety of the drug company can be understood in the context of the aftermath of the thalidomide tragedy - many babies suffered severe physical abnormalities as a result of their mothers taking the drug thalidomide while pregnant. The drug was prescribed for sleeping issues but reduced nausea as well: “Before this happened testing drugs to find out about the effect on foetuses was not routinely done. The repeated warning that now appears on various medications - ‘Do Not Use When Pregnant’ - is a direct result of drug companies having to become very cautious. ”The cost of necessary testing to clear drugs for use by pregnant women is very expensive. It has prevented drugs that are safe and effective in treating pregnancy sickness from being licensed in the UK.”

He felt that if this had been something men suffered from, a solution would have been found earlier.

Given the lack of experimental research into the condition the potential underlying causes are based on anecdotal evidence only. “There is intense immuno-suppression that goes on at the foetus/mother interface, necessary for the body to not reject the developing baby as a foreign body. We think that the sickness is caused by a hormone which is a bi-product of this process. At 14 weeks the foetus starts producing enough progesterone to ‘turn-off’ this effect.” In the 1960s it was assumed that the sickness was psychosomatic: “Journal articles at that time suggested that it was caused by a woman unconsciously rejecting her unborn child. These theories are not only wrong but offensive to women.”

Relatively little progress has been made since then: “The perception of the condition has not changed in 30 years. There is a case to suggest that this is discriminatory. I think we need to accept that safe treatment is available outside of the UK, generate better awareness of the condition and hopefully in the next five years we could see a pharmacological treatment available here too.” Dr Gadsby held a conference in July at Warwick Medical School to raise awareness and one male delegate expressed a genuine outrage that so little is known about the condition: “He felt that if this had been something men suffered from, a solution would have been found earlier.”

Dr Rodger GadsbyDr Gadsby has been a Senior Clinical Lecturer at the University of Warwick Medical School since 1992, and Associate Clinical Professor since 2007 where he has run short courses on primary care topics, developed the Certificate in Primary Diabetes Care and other diabetes courses,and taught on the Primary Care Management programme. Dr Gadsby continues to teach and advise on the content of the Warwick Diabetes Care Certificate as Primary Care Medical Advisor. His main interest and publications are in the area of diabetes and Pregnancy Sickness Symptoms. He is active on national working groups on diabetes care, including NICE guidelines for diabetes,and was a founding member and treasurer of the Primary Care Diabetes Society. He is clinical lead for NHS Evidence - diabetes. He is chairman of the trustees for Pregnancy Sickness Support, a small Charity given information and support to women with nausea and vomiting of pregnancy.

Image: Counting down by Marius Waldal (via Flickr)