At first, it seemed like normal morning sickness. But within days, the nausea became relentless. Getting out of bed felt impossible, every sip of water came back up, and daily life quickly turned into a cycle of vomiting, weakness and hospital visits. For around 1% of pregnant women in Australia, Hyperemesis Gravidarum (HG) is a debilitating condition that goes far beyond typical pregnancy sickness. It can lead to severe dehydration, weight loss, electrolyte imbalances and hospitalisation, impacting physical health, mental wellbeing, family life and work. From early recognition to compassionate management, midwives are essential in ensuring the best possible care and outcomes.

Hyperemesis Gravidarum (HG) is a severe form of nausea and vomiting in pregnancy (NVP) that goes beyond typical morning sickness. While up to 80% of pregnant women experience some degree of nausea and vomiting, HG affects approximately 0.3–1.5% of pregnancies in Australia.

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HG typically presents before 16 weeks’ gestation, with:

• Severe nausea and vomiting occurring multiple times a day
• Inability to keep food and fluids down
• Loss of more than 5% of pre-pregnancy body weight
• Signs of dehydration such as dizziness, dry mucous membranes, and reduced urine output
• Electrolyte imbalances and ketonuria

Unlike typical NVP, which tends to peak by 9 weeks and resolves by 12–14 weeks, HG is prolonged and far more severe, often requiring medical intervention, including intravenous fluids, and hospitalisation.

The Pregnancy-Unique Quantification of Emesis and Nausea (PUQE-24) scoring system is widely used in Australian practice to assess the severity of NVP and HG. It evaluates:

• Duration of nausea in the past 24 hours
• Number of vomiting episodes in the past 24 hours
• Number of retching episodes in the past 24 hours

Midwives should also carry out a thorough clinical assessment, including their history, assess for signs of dehydration, hypotension, tachycardia, and weight loss and exclusion of other causes, such as urinary tract infections, gastroenteritis, thyroid disorders and more.

Managing Hyperemesis Gravidarum requires a multidisciplinary approach that addresses both physical symptoms and psychosocial impacts. Midwives are central to coordinating this care.

Many women with HG feel dismissed or misunderstood. Midwives can advocate by educating women and families about HG, its causes, and treatment options and providing clear information on when to seek urgent medical care (e.g. signs of dehydration or inability to keep fluids down). It’s also important to ensure workplace and home support through medical certificates, letters for employers, and practical advice for managing daily life. By combining clinical expertise with compassionate support, midwives can make a profound difference in the experiences and outcomes of women living with Hyperemesis Gravidarum.

For women with mild to moderate symptoms, non-pharmacological strategies may provide some relief, including:

• Dietary modifications: Encouraging small, frequent meals; avoiding strong odours and trigger foods; eating dry biscuits before rising.
• Ginger supplementation: Evidence supports the use of ginger to reduce nausea in pregnancy.
• Acupressure or Acupuncture: Some women find wrist acupressure bands helpful in alleviating symptoms.
• Hydration: Encouraging hydration with electrolyte-rich fluids, ice chips, or ice blocks if tolerated.

When symptoms are severe, medication may be required. The Society of Obstetric Medicine of Australia and New Zealand recommended treatment protocol is as follows:

• One of the following taken orally up to three times daily: Doxylamine 6.25-25mg, Prochlorperazine 5mg, Promethazine 25mg, Metoclopramide 10mg, Ondansetron 4-8mg taken orally two to three times daily.
• Nighttime dosing with one of the following: Metoclopramide 10mg, Prochlorperazine 5-10mg IV, Doxylamine 12.5-50mg IV, Cyclizine 12.5-50mg IV or orally (if tolerating orally).
• Consider adding: Prednisone: commence 40-50mg daily or hydrocortisone 100mg IV twice daily and wean Prednisone over 7-10 days to minimal effective dose. May need to continue until symptoms resolve.
• IV fluids 1-3 x per week as required. Add IV thiamine if poor oral intake or administering dextrose.

Hyperemesis Gravidarum can also have a huge psychological impact, often leaving women feeling isolated, anxious and overwhelmed. Midwives are ideally placed to recognise and respond to these psychosocial challenges.

Studies have shown that HG is associated with an increased risk of:

• Depression and anxiety: Due to prolonged illness, social isolation, and disruption to daily life and work.
• Post-traumatic stress: Some women report trauma-like symptoms following severe HG, especially if they felt unsupported or dismissed during care.
• Attachment concerns: The illness can affect bonding with the baby during pregnancy, with some women feeling disconnected due to their distress.

Midwives can step in and normalise these emotional responses, offering reassurance that their feelings are understandable and valid. Connecting women with support groups, such as Hyperemesis Australia, where they can share experiences with others who understand the challenges of HG. And of course, it’s important to refer on for extra support from a psychologist or psychiatrist if needed. By addressing both physical and psychological needs, midwives can help reduce the long-term mental health impact of HG and support women towards a more positive pregnancy experience.

Although HG typically resolves by birth, its impacts may extend into the postpartum period. Midwives can:

• Assess for ongoing nutritional deficits or dehydration in the immediate postnatal period.
• Monitor mental health closely, as women with HG have an increased risk of postnatal depression and anxiety.
• Discuss birth experiences, providing an opportunity for debriefing if the pregnancy was particularly traumatic due to HG.

Women with a history of HG are at high risk of recurrence in subsequent pregnancies. Midwives can assist by:

• Providing pre-conception counselling, discussing the likelihood of HG returning and management options.
• Planning proactive care, including early review, preventative medications if indicated, and referral pathways.
• Ensuring women know when to seek help early in future pregnancies to minimise the severity and impact of symptoms.

Hyperemesis Gravidarum is a debilitating condition that extends far beyond typical morning sickness, affecting the physical, emotional and social well-being of pregnant women. As primary caregivers, midwives play an important role in early recognition, assessment, management, and providing compassionate, holistic care.