(c) 2017. Miriam Erick, MS, RDN, CDE
Poster presented in 2017 

The “Nightmare” (1781), a renowned painting of Anglo-Swiss artist, Henri Fuseli, depicts a sleeping young woman surrounded by ghoulish creatures. Her expression reflects distress. Whether Fuseli knew any women with hyperemesis gravidarum (HG) when he conceived this scene is unknown but possible.

Investigating nightmares is complicated and content is unpleasant. Why nightmares are included in post-traumatic stress syndrome (PTSS) in the HG population is unclear. (1)

The Nightmare
The Nightmare
(Courtesy of the Detroit Institute of Arts, Detroit, MI. Accession #: 55.5 A. Used with permission)

Altered mental status (AMS) encompasses agitation, deliria, dementia, delusions, apparitions, illusions, confusion, Wernicke’s, metabolic encephalopathy, psychosis, mirage, night terrors, Charles Bonnet syndrome, hallucinations, and autoscopy. Etiologies include drugs, alcohol, polypharmacy, infections, organ failure, stroke, brain bleeds and seizures. Hypoglycemia, hypoxia, electrolyte abnormalities (sodium, calcium, magnesium, potassium and phosphorous), pain, fecal impaction/urinary retention, and sensory deficits can also contribute to AMS. Iatrogenic causes include dehydration, malnutrition, and sleep deprivation. (2)

AMS is often thought a problem of the elderly or the infirmed however in a popular book, 22 women describe HG. (3) Five stories feature elements of AMS: Ashli, Ginger, Kricket, Courtney, and Dr. Lana. Historically, Charlotte Bronte’s diary describes a gradual onset of severe “wandering” delirium before her death in 1855 from nausea and vomiting of pregnancy.(4) Features of HG common to overall delirium include malnutrition (starvation), dehydration, altered electrolytes, pain, constipation, sleep deprivation and/or polypharmacy. Sleep deprivation causes hallucinations. Charles Lindbergh’s flight diary of May 20-21, 1927 provides evidence. “Last night couldn’t sleep — tonight can barely stay awake…great black mass ahead … its jaw gap wide … it’s a cloud — or — maybe it’s…not a cloud…it could be a dragon … or a python…..” “These phantoms speak with human voices …” (5)

Deliria occur in explorers who exhaust provisions (nutrition): from modern day adventurer Benedict Allen (6), to pioneers of the Donner Pass.

We have found women with HG often have horrific dreams/nightmares they are reluctant to share. The HG suffers dehydration, malnutrition, altered electrolytes, constipation, polypharmacy, sleep deprivation as well as pain from poorly managed retching, gagging and vomiting. Malnutrition, dehydration and altered electrolytes all known to adversely impact cognitive function. Nightmares may be a unique expression of HG-trauma in a form of “Altered Sensorium Gestosis”. More research is needed.

References:

  1. Christodoulou-Smith J, Gold JL, et al. Post-traumatic stress symptoms following pregnancy complicated by hyperemesis gravidarum. J Matern Fetal Neonatal Med. 2011; 24 (11): 1307-1311.
  2. Brigham and Women’s Hospital Delirium Task Force. BWH Delirium Guidelines. June 2008
  3. Foshee-McCall, A. Beyond Morning Sickness: battling hyperemesis gravidarum. Book Surge. 2006
  4. Smith, M (ed). The Letters of Charlotte Bronte: with a selection of Letters by Family and Friends. Volume III: 1852-1855. Claredon Press. Oxford UK. 1995.
  5. Lindbergh, CA. The Spirit of St. Louis. Charles Scribner’s Sons. NY. 1953. Pages 338-9, 389.
  6. “I shouldn’t be alive.” Darlow Smithson Production: Alone in the Amazon. Season 7, series 37
Brigham and Women's Hospital
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