Hyperemesis Gravidarum and the pelvic floor

May 15th is International Hyperemesis Gravidarum (HG) Awareness Day. Much worse than ‘morning sickness’ HG is characterised by prolonged and severe nausea and vomiting, which can cause dehydration, weight loss and malnutrition. It's not known what causes HG, or why some women get it and others do not, but some experts believe it is linked to the changing hormones in the body that occur during pregnancy. There is also some evidence that it runs in families. In this blog, we want to focus on HG and the pelvic floor.

A refresher on the pelvic floor

You’ll remember that the pelvic floor muscles span the bottom of the pelvis and - among other things - they provide support to the pelvic organs: the bladder, bowel and uterus. They serve almost like a trap door, keeping us continent of urine, faeces and wind. Remember we have loads of easy-to-digest pelvic floor education in our online, foundation course, Essentials by Umi, which is you can access at no cost with our Umi Free membership.

The pelvic floor in pregnancy

During pregnancy, there are many hormonal changes going on, including an increase in relaxin, oestrogen and progesterone. Together, these pregnancy hormones help the connective tissues and ligaments which support your bones and muscles to become softer, to accommodate your pregnancy and prepare for birth. These circulating pregnancy hormones also have an affect on the pelvic floor, leaving them having to work harder for the same pre-pregnancy effect. Bear in mind, too, that as the pregnancy progresses and the uterus gets heavier, this will put additional strain on the pelvic floor muscles.You can learn lots more about pregnancy and the pelvic floor in our online course, Pregnancy by Umi, which you can access via our Umi Plus membership.

Why is HG relevant to the pelvic floor?

Vomiting and heaving can cause downward pressure on the pelvic floor muscles. With HG, this downward pressure is likely to be repetitive and persistent, because of the nature and longevity of the condition. Unlike regular pregnancy sickness, HG may not get better until 16 to 20 weeks' gestation, and may not clear up completely until the baby is born.

If the pelvic floor muscles cannot meet the demands of the downward pressure being generated during episodes of vomiting or heaving, either because they are weak or fatigued or simply because they are overwhelmed by the amount of pressure being placed upon them, you may experience pelvic floor symptoms. These symptoms could be stress urinary incontinence (leaking urine), faecal incontinence (leaking stool), incontinence of flatus (passing wind unintentionally) or symptoms or pelvic organ prolapse (POP). POP is the descent of one or more of the pelvic organs into the vaginal canal. Common symptoms include a feeling of heaviness or dragging in the vagina, pressure in the pelvic area or seeing or feeling a bulge.

What can I do to support my pelvic health with HG?

First off, please seek help if you’re experiencing symptoms of HG. Speak to your GP, midwife or care provider as soon as possible. Anecdotally, lots of people with HG talk of not being taken seriously. If this is your experience, do you have someone who can advocate on your behalf? There are medicines that can be used in pregnancy, including during the first trimester, to help improve the symptoms of HG, for example anti-emetics to relieve the sickness.

If you have had HG in a previous pregnancy, you are more likely to get it in your next pregnancy than someone who has never had it before, so it's worth doing some planning in advance if you are able to. See a pelvic health physio, if possible, prior to a subsequent pregnancy. You can go privately if you have the means, or ask your GP for a referral. A pelvic health physio will be able to assess your muscles and provide you with an individual plan to get your pelvic floor muscles as strong as possible before embarking on another pregnancy. If you have a prolapse, a pelvic health physio could explore whether a pessary might be beneficial for you in offering some more support to the pelvic floor, generally and during a future pregnancy (as long as use of a pessary is approved in your pregnancy). A pessary is like a sports bra for your vagina. They come in different shapes and sizes and fit into your vagina to provide support to the vaginal tissues displaced by the POP. It can take trial and error to find one that feels comfortable and fits well.

If you experience incontinence or prolapse symptoms during vomiting or heaving episodes, please try not to panic, though we know it may feel scary. Don't hesitate to use incontinence pads or pants if you need to. It is worth using proper incontinence products rather than making do with a sanitary pad, as they'll be more effective and will keep your skin more comfortable.

You may find that there are strategies you can use during or between episodes to help provide some additional support to the pelvic floor muscles. Play around with these and see if any of them work for you:

1. Try doing a gentle, conscious pelvic floor squeeze (imagine you’re stopping wind) right before vomiting. This might give you some additional upward support to meet the pressure down on the pelvic floor muscles.

2. See if there is a position which feels more comfortable to you, during episodes of vomiting. You might find that your pelvic floor symptoms are less noticeable in certain positions.

3. Focus on taking some diaphragmatic breaths between episodes of sickness, if you’re able to, inhaling into the ribcage 360 degrees.

4. Apply manual support or pressure to your pelvic floor during vomiting episodes if you're experiencing symptoms of prolapse and you find this helpful.

5. Offload your pelvic floor when you’re able to. Lying on the floor with your legs up the wall or on a chair or sofa can feel really nice.

We understand that when you’re experiencing repeated sickness, you may not have the energy or opportunity to do these things every time or at all, and that is totally ok. This is a gruelling time for you mentally and physically. Do what you need to do to get through it, and please don’t hesitate to seek the support of a pelvic health physio when you feel ready to. It is never too early or too late to seek help.

Image: Megan Rossier, www.birth-ed.co.uk