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Vol. 10 No. 1 Nausea and vomiting are the most common complaints in the first fourteen to sixteen weeks of pregnancy. The term hyperemesis gravidarum should be reserved for the most severe forms of intractable vomiting (Taylor, 1962) when it is associated with signs of disturbed nutritional status-such as dehydration, loss in body weight, elevated temperature, irregular pulse rate, and jaundice (Adams, Gordon, & Combes, 1968). Several cases of death due to hyperemesis gravidarum were reported by Tillman (1934), Merger and Levy (1955), Sheehan (1961), and Von Bayer (1965). On the other hand, Brandes (1967) observed that the absence of vomiting in the first trimester of pregnancy is associated with a higher abortion rate. This finding suggests that the emesis gravidarum (as opposed to hyperemesis gravidarum) is organic in nature. Thus, in most cases of nausea, there is no need for any special treatment. In sever cases, however, the patient needs medical care and sometimes hospitalisation is required. According to Hellman and Pritchard (1971), between one to five patients per 1000 suffering from gravidas vomit so severely that they require hospitalisation. In these sever cases, many different methods of treatment such as vitamins (C, B1, B6, K); steroids; glucose; insulin; antihistamines; chlorpromazine; phenothiazine; meclesine; A.C.T.H.; intravenous administration of calcium; placebo; and gastric tube feeding (Weinfield, Dibay, Burchel, Millerick & Kennedy, 1977) have been advised (Hart, McConnell & Picket, 1944; Kotz & 'Kaufman, 1940; Schoeneck, 1942; Shute, 1941; Sussman, 1937; Weinstein, Mitchell & Sustendal, 1943). Since these treatments have not always given satisfactory results, the present authors decided to use hypnosis, which has been highly recommended (Von Bayer, 1965; Giorlando & Mascola, 1957) in the treatment of severe hyperemesis cases. This method of treatment was introduced in cases where conventional treatment (that is, drug therapy, isolation by hospitalisation, intravenous administration of fluids, and the use of placebo) had failed in the hope of bringing satisfactory results (Fuchs, Brandes, & Peretz, 1963; 1967). Etiology The etiology of hyperemesis is still obscure, but it is interesting to note that in primitive cultures, excessive morning sickness is unknown. It is only after civilization reaches these people that pregnant women start suffering from this complaint (Peretz, 1958). There is little doubt that, in hyperemesis gravidarum, emotional factors may play and important role. According to psychoanalytic theories, hyperemesis gravidarum is an exaggeration of the "oral symptom" in pregnancy. Fairweather (1968), in an excellent review of different theories, discussed the "Reflex-theory" due to uterine displacement; or abnormalities of the ovum such as hydramnion, mole, and twins; or a reflex to inflammation in the cervix. In conclusion he stated that "There seems little doubt that psychiatric factors must be impoicated in at least a proportion of cases of hyperemesis gravidarum, and in the author's opinion the proportion is quite high-even as much as 75-80 per cent of all cases". (p. 164). Copeman (1875) treated severe hypermemesis by cervix dilation. Kaltenbach (1891) concluded that the "vomiting of pregnancy is usually a manifestation of neurosis, somewhat allied to hysteria and readily amenable to suggestive treatment" (Kaltenbach, 1891, cited in Fairweather, 1968, p140). Different explanations were given as background to the psychic reasons for hyperemesis gravidarum. One explanation is derived from the theory of "oral impregnantion". A second explanation is from another analytical theory that explains vomiting as "subconscious suicide." The accepted belief in the Western culture is that expression of disgust and rejection is situated in the digestive tract-therefore, the antagonism to pregnancy is expressed by vomiting. This is also reflected in idioms of everday use such as, "You disgust me," "You make me sick," etc. Confirmation of the existence of a psychic factor can also be found by empirical clinical observation and experience. It is sufficient to admit the patient to the hospital, change her surroundings, and give her any kind of medication causing cessation of nausea and vomiting. As soon as she returns home, however, vomiting will often re-occur (Peretz, 1958). The importance of the psychological factors in the causation of hyperemesis gravidarum is indicated by the disappearance of symptoms when the patient is separated from the family and its influences and the frequent relapses caused by her returning to this environment. While emesis in pregnancy is regarded primarily as organic-physiologic in background, many authors point out the role of psychic factors involved in severe vomiting in pregnancy. According to Hellman and Pritchard (1971), the etiology of hyperemesis is based on the continuous flow of chorionic gonadotropin into the bloodstream combined with the metabolic and endocrinological changes in normal pregnancy. These authors also observe, however, that most cases of severe nausea and vomiting in pregnancy are neuroses as a result of emotional imbalance. Chertok (1965) publishes an excellent paper of historical importance on placebo effects in the vomiting of pregnancy (Chertok, Mondzain & Bonnau, 1963). Heineman (1965) connected vomiting in pregnancy to an oral symptom and regression. According to Willson, Beecham and Carrington (1963), the etiology is not clear. The symptoms appear at a time when the trophoblastic tissue activity reaches its peak and are severe, while the level of gonadotropins is highest-in normal pregnancy-and will increase with higher gonadotropin activity in hydatiform mole. It is possible that "several substances appearing during growth and destruction" (p. 343) are responsible for the vomiting. At the same time, Willson et al (1963) think that severe hyperemesis may develop as a result of emotional involvements that intensify ordinary nausea. G. Farkas and G. Farkas, Jr. (1972) summarize their views on the etiology as follows:
METHODS Subjects During the years 1965 to 1977, 204 patients with severe hyperemesis gravidarum were referred to the present authors for treatment. Of the 204 patients, 201 patients started on conventional medical therapy. (The pregnancy of three patient was terminated prior to treatment because of psychotic disease). The criteria for admission for treatment were as follows: (a) sever vomiting (fifteen to twenty times per day); (b) fluid and electrolytes imbalance expressed by increased hematocrit, alkalosis, hypokalemia, urine ketosis (2 + acetone), and/or clinical dehydration; and (c) loss of weight (5-10kg.) Out of 201 patients treated by drugs, 36 were cured, 5 improved significantly, while 160 failed to respond adequately. Thus, the favourable response to drugs was 20.4 percent. Out of the 160 patients where conventional medical treatment failed, 22 patients (13.7%) refused hypnotherapy and the pregnancy was terminated in 4 of the 22 cases because of severity of symptoms. The remaining 138 patients (86.3%) up to gestational age of sixteen weeks were treated with hypnotherapy. Out of 138 patients, 64 women were primipara and 74 multipara. Out of 138 patients, 87 were treated in groups together with women preparing for natural childbirth. Out of the fifty-one patients treated by hypnosis individually, twenty-four patients were primiparas and twenty-seven patients were multiparas. In the group hypnotherapy, eighty-seven patients were treated; out of these, forty patients were primparas and forty-seven were multiparas. Twenty-five patients were under twenty years of age; forty-six patients were between ages of twenty-one and twenty-five; forty-eight patients were between the ages of twenty-six and thirty; and only nineteen were over the age of thirty. The selection of patients for hypnotherapy was based on (a) exclusion of psychotic patients, (b) the agreement or refusal of the patient of hypnotherapy, and (c) a simple suggestions test like the postural sway test or the semaphore arm test (imagination of one arm being light and lifting up while the other arm is heavy and dropping down). In this clinical study, standard suggestibility scales were not used. Procedure Trance was induced by permissive approaches, such as relaxation, arm levitation or eye fixation, suggesting relaxation, comfort, and general well being. Negative ideas, i.e. pain, vomiting, nausea, were never mentioned during the hypnotic sessions. In most cases, one to three sessions lasting 45 to 60 minutes each brought the desired results. In very rare cases, a more authoritative approach was used. There were cases in which the patient was suffering with severe vomiting, depression and despair, and only after a single session the patient improved considerably. Several patients continued ambulatory hypnotherapy after a successful first treatment in the hospital. Group treatment was used for patients who admitted while the present authors were working with a group. If the patient was admitted at a time when the present authors were not working with a group, individual therapy was used. The severity of the case played no role in deciding whether group or individual hypnotherapy was needed. The following three cases illustrate the different hypnotic methods used-hypnotic relaxation, hypnotic imagination, and group hypnotherapy. CASE HISTORIES Case 1 (Hypnotic Relaxation Method) The patient, aged thirty-five, had two normal deliveries, the last one occurring twelve years earlier, followed by five therapeutic abortions because of severe hyperemesis. Upon admission at eight weeks pregnant, she was again suffering from severe hyperemesis and had lost 11 kg during the previous three to four weeks. According to the patient, "no treatment had brought any relief," and she was not prepared to continue with the pregnancy. In the hope to gain time and delay the patient's final decision for an abortion, the present authors explained to her that in her present condition there was no possibility of performing a therapeutic abortion. Treatment by hypnosis was suggested for one week in order to give her time to regain her strength and enable her at a later stage to decide to undergo a D and C. Because the patient had no hypnotherapy in the past, it was decided to try this approach in order to dissuade her from the course of abortion. She had three hypnotic sessions during that one week. The induction was passive-permissive relaxation method by arm levitation and the suggestion given to the patient was only relaxation, calm and well-being. At the end of one week her physical condition improved and she stated that, since she was feeling well, she wishes to continue the pregnancy. The patient had a normal delivery under self-hypnosis. Case 2(Group Hypnotherapy) A patient, aged twenty-one, primigravida, was sent to the hospital because of abdominal pain, vomiting, and fainting and was referred to the present authors as a suspected ectopic pregnancy. Upon examination, the patient was found to be in a very bad general condition, weighing 40kg. From her past history, it was learned that she had been married for one year and had suffered from dyspareunia. Her last menstrual period was two months prior to admission. She had been unwell for the last month, and, ten days before her admission, low abdominal pain had occurred and had worsened. Upon examination, a normal intrauterine pregnancy of seven weeks was found. No acute abdominal pathology was found. Ambulatory treatment by hypnosis was decided upon, and the patient took part, on the same day, in a group session of pregnant women being prepared for natural childbirth. She integrated easily into the group, entered a medium trance, and received the same positive suggestions as the other members of the group. The induction was performed by the eye fixation method. The suggestions given were the same as those given for natural childbirth: You are happy to be pregnant…..your pregnancy is progressing well…….watch your breathing…..in and out………relax……count your breathing………that is right…………you are going deeper and deeper…………you are looking forward to your delivery……….it will be a beautiful experience………. The next day she reported considerable improvement and after one more session, one week later, she was completely free of vomiting and abdominal pain. At the beginning of week fifteen of gestation, slight vomiting re-occurred. At her request, she participated in one more group session. This time vomiting ceased immediately and she felt well up to the time of delivery. She was delivered of a boy weighing 3900 gms. Delivery was by forceps because of a prolonged second stage. RESULTS The hypnotherapeutic response was graded on a four-point scale as (a) excellent: no vomiting, no nausea; (b) good: no vomiting, nausea present; (c) poor: vomiting less than six times a day, nausea improvement; or (d) failure: no improvement. The results are summarized in Table 1. Out of fifty-one gravidas patients treated individually, thirty-five (68.5%) showed excellent and two (3.9%) good response to treatment by hypnosis. Fourteen (25.5%) patients showed poor response to treatment and one patient (2.3%) could not be hypnotized in spite of repeated trial sessions. Out of eighty-seven gravida patients treated in groups, excellent results were obtained with sixty-one patients (70.1%), good with twenty-four patients (27.6%), and poor with two patients (2.3%). It is obvious from these results that there is no significant influence of parity, age, or number of sessions upon the therapeutic effect. The Psychodynamics of Hyperemesis Gravidarum The psychological processes of pregnancy take place on three levels: the biological level, the emotional level, and within the boundaries of the outside world surrounding the expectant mother. The psychic mechanism uses the organic processes of pregnancy to give an outlet to emotional tensions existing in the woman before her pregnancy. Each woman brings into pregnancy certain emotional factors and conflicts related to her condition as a whole and with the organic manifestations characteristic of pregnancy. On the other hand, various typical groups of organic pregnancy processes also mobilize definite emotional attitudes that now emerges openly. table 1.
Pregnancy phantasies fill the psychic life of children from earliest childhood. These phantasies in pregnancy, generated from ideas in childhood and puberty that are connected with oral intake and expulsion, can be revived through the psychologically determined proneness to nausea which is, in certain cases, pathologically exaggerated. This exaggeration of the "oral symptom" in pregnancy (hyperemesis) may appear in cases where there are overt or covert negative feelings towards the husband, parents, the pregnancy as a whole, or the fetus specifically. Together and as a result of these hostile feelings, the patient will also form deep-seated guilt feelings with tendencies toward self-punishment. If the unconscious tendencies are accompanied by a conscious counter-wish to keep the child, there develops an inner conflict that transforms the psychosomatic process into neurosis, usually hysterical (Deutsch, 1945). The other oral symptoms-excessive intake of food (which usually alternates with complete lack of appetite), heart-burn, extreme sensitivity to disgust to certain food and on the other hand, the craving of the pregnant woman for special dishes (Thretowan, 1972)-also express the same inner ambivalent conflict between her wish to destroy and her wish to preserve her child. The excessive eating of food such as fruit, cucumbers, fish etc., in pregnancy is a symbolic unconscious repetition of the act of fruition with the reserve aim of the wish for cannibalistic destruction. In some women, the conflict between the aims of rejection and preservation is postponed to a later phase of pregnancy and takes place in different organs (anal, genital). Constipation and diarrhea in pregnancy, as well as prolonged second stage delivery are part of this conflict. On the other hand, if the rejection symptoms increase, they may bring about premature birth or abortion. In her subconscious, the woman identifies her child as a parasite-"endoparasite" as quoted by Ferenczi (1952)-using her body as host, and she refuses to be exploited by its existence. As long as the mother is not willing to give-in a positive masochistic sense-out of love and identification with the fetus, she is not yet capable of cancelling the parasitic conception of the fetus (the "masochistic giving" is here a typical sign of femininity and motherhood in all phases of fruition). If the pregnant woman is deprived of love and unfulfilled, her willingness to give might deteriorate to the extent that her somatic feelings will take on the form of rejection. Her early engrams will decide whether the rejection will be oral, anal, or genital. The protest against biological" giving" may take many different forms. If it is accompanied by aggressive aims, rejection will be of a severe aggressive character and will threaten the lives of both the foetus and the mother. DISCUSSION Analyzing the age influence on the present results, it was found that there was no pattern in hypnotherapeutic response that could be attributed to a specific age group. Analyzing the influence of parity, and equal distribution of positive and negative results was found. It was expected that the primipara patients would be more susceptible to treatment because of no previous negative experiences and memories. Surprisingly, this point could not be proved from the data. The number of sessions per patient had no significant influence on the hypnotherapeutic results. Patients were observed who were almost cured in their first two sessions while other patients showed a poor response to treatment even after three or four sessions. The most significant single result found in the analysis of the present data appears to be the surprising difference in group therapy success rate versus individual treatment. Of patients who received individual hypnotherapy, 25.5 percent showed poor response as compared to 2.3 percent of patients who received group hypnotherapy. Some procedural details should be kept in mind: (a) the group and individual hypnotherapy was done in all cases by the same therapist; (b) the decision for individual or group hypnotherapy was made only by the therapist; (c) the patient chosen for group hypnotherapy was never told of the possibility of individual hypnotherapy, and vice versa; and (d) in both kinds of treatment, the patient was given the same introduction and explanation about the nature of hypnosis, and the same induction method was used. This uniform introduction and induction given to all patients, in both kinds of treatment, prevented the shaping of patients' preference to one or the other possibility. These facts support the present authors' presumption that the only reason for the differences was group therapy versus individual therapy. King (1955) suggests the following treatment formula, which also points to the emotional factor: Cure = t + u+ x t = time (spent by physician) (it is always time-consuming for the doctor, but it is his most effective weapon to date). u = understanding (of the patient by the physician, sympathy and support). x = medication (one of the many drugs, inclusive placebos). ph = physiological factor (nature as yet unknown). ps = psychic factor (adverse psychological factors). Theoretically, the best treatment for hyperemesis could be psychotherapy by an experienced psychiatrist, which would require many sessions extending over weeks or even months. Practically, however, the patient suffering from severe hyperemesis requires instant treatment and should be treated as an emergency and helped in a matter of days or even hours to avoid complications which might endanger her well-being or even her life. Treatment by medication presents a certain danger, and warnings are voiced, more and more often, about possible drug related teratogenic influence in the first trimester of pregnancy (Sadusk, 1966; as opposed by Yerushalmy & Milkovich, 1965). Hypnosis, on the other hand, is a treatment that brings the desired results in a very short time, and contrary to treatment by medication, presents no danger to the pregnant woman or to her foetus. Naturally, treatment with hypnosis will relieve the symptoms only, but symptom substitution rarely, if ever, occurs (Kline, 1956; Shaffer, 1956). Remy, Wolff, Gillet, Ritter and Muller (1972) conclude that "Hyperemesis gravidarum constitutes one of the most frequently encountered symptoms in the first three months of pregnancy. A psychological method of approach, more specifically, hypnosis is worth attempting….. The action of the treatment is relatively rapid" (p. 170). According to Giorlando (1962), the suggestions given in hypnosis last for a period of a month or two or even longer, He mentioned as disadvantage of this method, the time required for treatment (a session lasts for about an hour or more), as opposed to treatment by medication which is administered in a matter of minutes, sometimes by nurses or other auxiliary personnel. He also stated that hypnosis may cause apprehension in the pregnant women. During recent years, by including these women suffering from hyperemesis gravidarum in ambulatory group hypnotherapy sessions, the present authors were able to overcome this and other disadvantages since (a) very often hospitalisation was not necessary; (b) treatment was given to a number of patients simultaneously; (c) the women feels safer, less lonely, and the common motivation of the patients consolidated the psychotherapeutic effects, making treatment easier and more efficient. In conclusion, the present authors believe that hypnotherapy should be regarded as the treatment of choice in hyperemesis gravidarum. The method can be easily practiced by any skilled physician who has been trained in medical hypnosis. REFERENCES Adams, R.H., Gordon, J., & Combs, B. (1968). Hyperemesis gravidarum: I. Evidence of Hepatic dysfunction. Obstetrics and Gynecology, 31, 659-664. Brandes, J.M. (1967). First-trimester nausea and vomiting as related to outcome of Pregnancy. Obstetrics and Gynecology, 30, 427-431. Chertok, L.A. (1965). A historical note on placebo effects in vomiting of pregnancy. Journal of the American Medical Association, 194. 473. Chertok, L., Mondzain, M.L., & Bonnaud, M. (1963). Vomiting and the wish to have a child, Psychosomatic Medicine, 24, 13-18. Copeman, E.A. (1875). A novel treatment of obstinate vomiting in pregnancy. British Medical Journal, May, 637-638. Deutsch, E. (1945). Psychology of women (vol. II). New York: Grune & Stratton Inc., 126-201. 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