The inquest into the deaths of Jess Cronshaw and subsequently her daughter, Elsie, in East Lancashire was reported earlier this year. Jess died as a result of taking her own life due to poorly controlled Hyperemesis Gravidarum. This has highlighted within pharmacy that we may need to do more to support pregnant women who struggle with this condition.
The Royal College of Obstetricians and Gynaecologists have a very detailed ‘Green-top Guideline No. 69’ which covers the ‘Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (HG)’. Nausea and Vomiting in Pregnancy (NVP) affects up to 90% of pregnant women and is one of the most common indications for hospital admission among pregnant women, with the estimated cost to the NHS of £62million per year. The lay term for NVP is often ‘morning sickness’, which can be felt to trivialise the condition. HG is a severe form of NVP which affects about 3.6% of pregnant women, but this figure may be an underestimate.
Since the Medicines and Healthcare products Regulatory Agency (MHRA) alert in January 2020, which stated that there is an increased risk of the baby having a cleft lip and/or palate if ondansetron is used within the first trimester, there is a fear in non-specialist primary or secondary care of prescribing and dispensing this medication for pregnant women. However, the UK Teratology Information Service said in January 2025 that, as ondansetron is one of the most studied antiemetics in pregnancy, we can interrogate the data and have more certainty in the pregnancy safety profile. They noted that the cleft palate data is conflicting, and the highest quality study suggests that the absolute risk is very low with a background rate of 11 per 10,000 versus the ondansetron-exposed rate of 14 per 10,000.
Relating back to the case of Jess Cronshaw, the Royal College of Obstetricians and Gynaecologists (RCOG) guideline has a section on the effect of HG on mental health, so we can see that what Jess was feeling was not an isolated case. A UK-wide survey of 5071 participants found that a quarter of those with HG occasionally reported suicidal ideation and 6.6% regularly considered taking their own life due to the severity of their condition. Added to that, 4.9% had a termination of a wanted pregnancy (TOP) due to HG, and 52.1% had considered TOP due to HG. Both suicidal ideation and TOP of a wanted pregnancy were associated with perceived poor care from their healthcare provider. Those reporting extremely poor perception of both primary and secondary care were less likely to have been offered medication compared with those reporting excellent care. When the risk of suicide and TOP is so closely related to the lack of medication being offered, and considering we have excellent, safe choices available, should we be asking our profession ‘What are we doing to help these women?’
Supporting pregnant women
So, what does excellent care look like?
- An objective tool to classify the severity of the HG can be used, such as Hyperemesis Level Prediction (HELP) or the Pregnancy-Unique Quantification of Emesis (PUQE).
- Women who have nausea and vomiting but are not dehydrated can be cared for in the community with antiemetics, reassurance, oral hydration and dietary advice (eat little and often). Areas that have ‘Hospital at Home’ services available may be able to provide IV treatment in the community. Women should be counselled that the benefits of antiemetics outweigh the risks, and that the absolute risk is low.
- Women should be asked about previous adverse reactions to antiemetic therapies. A combination of different antiemetics may be needed for those who do not respond to a single agent. If women are unable to tolerate orals, then ambulatory care or ‘Hospital at Home’ management could be offered with intravenous fluids, vitamins (especially thiamine as stores can deplete rapidly) and parenteral antiemetics as needed.
- Thiamine should be given to all women with HG with severe vomiting or severely reduced dietary intake.
- For those who do not respond to antiemetics, steroids may be prescribed under Secondary Care Consultant care.
How does that work in practice for the different areas of pharmacy? There are many roles that have a direct impact on the care of these patients, such as obstetric or formulary pharmacists, who could ensure that, for example, the necessary guidelines are in place. However, there are many other non-specialist pharmacy roles where we may encounter these patients, and by knowing where to signpost them, we could minimise their distress. These include GP pharmacists, community pharmacists and Emergency Department pharmacists, who may not be the experts in this area, but may be the first port of call for those who do not know where else to turn.
The deaths of Jess and Elsie Cronshaw were tragic, as they may have been preventable if Jess’s HG had been controlled. Pharmacists have regular contact with pregnant patients in many different settings, and although we may not all have direct influence on prescribing, we all have the ability to support the patient with knowing that there are many options available and to signpost to the best care.
The PDA’s view
The ongoing variation in care for women suffering from NVQ and HG is a cause for concern for all healthcare professionals, and there are actions which pharmacists can take in every sector to help improve outcomes and ensure appropriate care to reduce the poor quality of life and health risks associated with NVP and HG.
Suggested actions:
- Pharmacists in all settings should be aware of the basic principles of treatment, familiarising themselves with the key points of the RCOG treatment guideline.
- Antiemetic therapy has proved to be effective, and pharmacists should familiarise themselves with the drug groups included in the treatment pathway, including side effects and the real-world practical implications and be able to discuss these with patients and clinical colleagues.
- Whilst MHRA issued an alert in 2020 regarding the use of ondansetron in the first trimester, the RCOG guideline produced in 2024 does recommend its use as a second-line agent. Pharmacists should familiarise themselves with the visual patient decision aid in the guideline, which looks at the incidence of cleft palate and be able to discuss the absolute risk of a baby having cleft palate and the benefits of effective antiemetic therapy with pregnant patients and clinical colleagues if appropriate.
- The RCOG has also produced a patient information guide on pregnancy sickness (nausea and vomiting of pregnancy and hyperemesis gravidarum) which pharmacists can provide.
By Siobhan Abrahams, advanced pharmacist for Virtual Wards, pharmacist advisor, and PDA NAWP Network member
Learn more
- Information for you, Pregnancy sickness (nausea and vomiting of pregnancy and hyperemesis gravidarum)
- Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy
- The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69)
- USE OF ONDANSETRON IN PREGNANCY
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