Hyperemesis gravidarum and subsequent breast cancer risk

Both parity and a young age at first pregnancy are associated with a reduction in breast cancer risk. The hormones involved in this process are not fully investigated. Human chorionic gonadotropin is a placental hormone, which in rats and in human breast cells in vitro has been shown to prevent against breast cancer. Hyperemesis, a severe nausea combined with vomiting during pregnancy, is associated with increased levels of human chorionic gonadotropin. We investigated the possible relationship between hyperemesis and subsequent breast cancer risk in a case-control study based on registry data. Among 13 079 breast cancer cases and 34 348 individually matched controls we found 148 cases and 405 controls who had been hospitalised for hyperemesis. Hyperemesis was not associated with breast cancer risk (adjusted odds ratio 1.05, 95% confidence interval 0.86-1.27), and similar risks were observed regardless of age at diagnosis, number of hospitalisations for hyperemesis or time of follow-up. Our results do not support the hypothesis that human chorionic gonadotropin is responsible for the protective effect of pregnancies upon breast cancer risk.

Transient hyperthyroidism of hyperemesis gravidarum

OBJECTIVE

To characterise the clinical, biochemical and thyroid antibody profile in women with transient hyperthyroidism of hyperemesis gravidarum.

DESIGN

Prospective observational study.

SETTING

Hospital inpatient gynaecological ward.

POPULATION

Women admitted with hyperemesis gravidarum and found to have hyperthyroidism.

METHODS

Fifty-three women were admitted with hyperemesis gravidarum and were found to have hyperthyroidism. Each woman was examined for clinical signs of thyroid disease and underwent investigations including urea, creatinine, electrolytes, liver function test, thyroid antibody profile and serial thyroid function test until normalisation.

MAIN OUTCOME MEASURES

Gestation at which thyroid function normalised, clinical and thyroid antibody profile and pregnancy outcome (birthweight, gestation at delivery and Apgar score at 5 minutes).

RESULTS

Full data were available for 44 women. Free T4 levels normalised by 15 weeks of gestation in the 39 women with transient hyperthyroidism while TSH remained suppressed until 19 weeks of gestation. None of these women were clinically hyperthyroid. Thyroid antibodies were not found in most of them. Median birthweight in the infants of mothers who experienced weight loss of > 5% of their pre-pregnancy weight was lower compared with those of women who did not (P = 0.093). Five women were diagnosed with Graves' disease based on clinical features and thyroid antibody profile.

CONCLUSIONS

In transient hyperthyroidism of hyperemesis gravidarum, thyroid function normalises by the middle of the second trimester without anti-thyroid treatment. Clinically overt hyperthyroidism and thyroid antibodies are usually absent. Apart from a non-significant trend towards lower birthweights in the infants of mothers who experienced significant weight loss, pregnancy outcome was generally good. Routine assessment of thyroid function is unnecessary for women with hyperemesis gravidarum in the absence of any clinical features of hyperthyroidism.

Pneumomediastinum following esophageal rupture associated with hyperemesis gravidarum

A patient was diagnosed with pneumomediastinum caused by an esophageal rupture during hyperemesis gravidarum. The woman, at 15 weeks' gestation, presented with hyperemesis gravidarum complicated by an episode of chest pain and disturbance of consciousness. Radiological examination revealed pneumomediastinum and subcutaneous emphysema. They are normally caused by either pulmonary or esophageal rupture. The esophageal etiology was suspected as more likely because of the severe vomiting accompanied with it. Although the clinical feature was quite complicated and esophageal rupture is generally a life-threatening disease, we chose conservative therapy which resulted in rapid recovery. The final diagnosis was confirmed by endoscopic examination performed after recovery. Pneumomediastinum during pregnancy is rare but it could be lethal. Careful and considerate assessments including surgical treatment should be necessary.

Hyperemesis gravidarum complicated by Wernicke's encephalopathy

BACKGROUND

Wernicke's encephalopathy is usually associated with alcohol abuse, but can also occur with hyperemesis gravidarum. The effect of delay in thiamine replacement on fetal outcomes is unknown. We present a case of this complication.

CASE

A primipara with hyperemesis was admitted for mental status changes in her 14th week of pregnancy. Physical examination revealed a lethargic patient with ophthalmoplegia, ataxia, and hyporeflexia. Parenteral thiamine therapy was started. The patient improved rapidly although the ataxia persisted. A spontaneous abortion occurred 2 weeks later.

CONCLUSION

Wernicke's encephalopathy can complicate hyperemesis gravidarum. Early thiamine replacement may decrease the chances of spontaneous abortion.

Memory loss and ataxia after hyperemesis gravidarum: a case of Wernicke-Korsakoff syndrome

Hyperemesis gravidarum can induce Wernicke-Korsakoff syndrome (WKS), a thiamin deficiency disorder characterized by ocular abnormalities, ataxia and disturbance of consciousness. This should be considered in the differential diagnosis of pregnant patients with persisting vomiting and neurological alterations.

Wernicke's encephalopathy due to hyperemesis gravidarum: an under-recognised condition

We present a case of a 25-year-old woman with drowsiness, nystagmus, severe ataxia and areflexia, which developed six weeks after admission to an obstetric clinic for hyperemesis gravidarum. She had been treated with intravenous dextrose and electrolyte solutions and antiemetics. Magnetic resonance imaging (MRI) performed on the fifth day of her neurologic symptoms showed increased intensity in both thalami, periaqueductal grey matter, the floor of the fourth ventricle and superior cerebellar vermis in T2 weighted and FLAIR images. Clinical signs and MRI findings were consistent with the diagnosis of Wernicke's encephalopathy. On the third day of thiamine replacement, neurologic signs improved dramatically In addition to our case, we review 29 previously reported cases of Wernicke's encephalopathy associated with hyperemesis gravidarum, and emphasize the importance of thiamine supplementation to women with prolonged vomiting in pregnancy especially if they are given intravenous or parenteral nutrition.

Wernicke's encephalopathy in patients with hyperemesis gravidarum

Our two patients presented with Wernicke's Encephalopathy (WE) resulting from prolonged hyperemesis gravidarum. This is an unusual cause of WE, a potentially fatal medical emergency due to thiamine deficiency. We discuss the clinical settings, presentation, diagnosis, neurophysiological and radiological findings, treatment and outcome of WE in these two cases and the neuropathologic correlation of this condition. We stress upon the importance of early diagnosis and prompt treatment of WE.

Hyperemesis gravidarum and the sex of the offspring

Studies have suggested that offspring of women hospitalized for hyperemesis gravidarum have a different sex ratio than those of women without this diagnosis, but little is known of the potential association between fetal gender and variables such as severity of hyperemesis, gestational trimester, and maternal age. Our findings provide evidence that pregnant women with a diagnosis of hyperemesis gravidarum in the first trimester give birth to a higher proportion of female newborns than do all mothers, regardless of whether they are hospitalized.

Psychosocial morbidity among women with nausea and vomiting of pregnancy: prevalence and association with anti-emetic therapy

Unlike severe nausea and vomiting of pregnancy (NVP), it is not known whether milder forms of NVP have been associated with psychosocial morbidity. We undertook the study to explore the prevalence of psychosocial morbidity by severity of NVP, and determine whether, after correction for severity of nausea/vomiting, there is a relationship between psychosocial morbidity and women's decisions to take anti-emetics as a reflection of their distress due to NVP. From 1996-97, an NVP Healthline was advertised. Callers underwent semi-structured interviews about both their NVP and associated psychosocial morbidity in a previous pregnancy. Most of the 3201 callers resided in Canada, worked outside the home, reported on planned pregnancy (a median of) 4 years before, and described severe (> 5 episodes/day of) nausea and vomiting. More severe nausea/vomiting was associated with more frequent feelings of depression, consideration of termination of pregnancy, adverse effects on women's relationships with their partners or their partners' everyday lives, and the perceived likelihood that NVP would harm their baby (p < 0.0001). However, all psychosocial factors were reported by a clinically important proportion of women with mild nausea/vomiting (0-1 episodes/day). The severity of vomiting was most closely related to women's decisions to take anti-emetics, but other psychosocial factors were also independently associated with anti-emetic therapy. We conclude that psychosocial morbidity is evident across the spectrum of severity of nausea and vomiting among women with NVP. The severity of nausea or vomiting does not appear adequately to reflect the distress caused by NVP, as reflected by women's decisions to take anti-emetic therapy.

Hyperemesis gravidarum in a contemporary population in Oslo

BACKGROUND

Sociodemographic studies of hyperemesis gravidarum are conflicting. During the last few years, there has been a clinical impression in Norway that immigrants are more afflicted than ethnic Norwegians.

METHODS

Of 175 patients hospitalized with the diagnosis hyperemesis gravidarum 1993-1997, 120 had complete records and were compared to a control group of 115 patients without hyperemesis gravidarum, drawn at random from the labor ward protocol.

VARIABLES

Ethnicity, age, height, weight at the beginning and at the end of pregnancy, body mass index, gravidity, parity, smoking, gestational age at labor, birth weight, placental weight. The patient's first name was used as an indication of ethnicity. Having a non-Norwegian name means, in the majority of cases, being a first generation immigrant from a developing country.

STATISTICS

SPSS statistical package for regression analyses, the chi-square test with Yates correction and the Mann-Whitney U-test.

RESULTS

Risk factors for hyperemesis: non-Norwegian name (OR 3.4, 95% CI 1.5-7.6), female sex of the infant (OR 2.6, 95% CI 1.3-5.3), gravidity number (OR 1.4, 95% CI 1.1-1.9). These two last variables were of significance only in patients with a Norwegian name. The hyperemesis group had a lower weight gain and birth weight. In a stepwise multiple regression birth weight (g) was dependent on weight increase (kg) (B=19.0, p=0.001), weight in early pregnancy (kg) (B=8.0, p =0.02) and parity (B= 107.1, p=0.02). Hyperemesis, when corrected for weight increase, did not influence birth weight.

CONCLUSIONS

Risk factors vary between different populations. Hyperemesis patients are at risk of having infants with reduced growth.

Transient hyperthyroidism of hyperemesis gravidarum: a sheep in wolf's clothing

BACKGROUND

Transient hyperthyroidism of hyperemesis gravidarum (THHG) is a self-limiting hyperthyroidism occurring in the context of hyperemesis gravidarum.

METHODS

A literature search of MEDLINE was undertaken, and a case report of a woman with THHG in pregnancy is described.

RESULTS AND CONCLUSIONS

Because thyroid function tests cannot distinguish Graves disease from THHG, the diagnosis of THHG rests largely on the concurrent development of hyperemesis and hyperthyroidism and the absence of signs and symptoms of hyperthyroidism before and during pregnancy. THHG might be responsible for 40% to 70% of thyroid function abnormalities in pregnancy. Both the thyroid function abnormalities and hyperemesis are related to elevated levels of human chorionic gonadotropin. THHG resolves by 18 weeks of pregnancy without sequelae. No treatment is required. Diagnosis of THHG by the primary care provider can prevent unnecessary treatment or referral for specialty care.

Thyroid function during pregnancy

BACKGROUND

This Case Conference reviews the normal changes in thyroid activity that occur during pregnancy and the proper use of laboratory tests for the diagnosis of thyroid dysfunction in the pregnant patient.

CASE

A woman in the 18th week of pregnancy presented with tachycardia, increased blood pressure, severe vomiting, increased total and free thyroid hormone concentrations, a thyroid-stimulating hormone (TSH) concentration within the reference interval, and an increased human chorionic gonadotropin (hCG) beta-subunit concentration.

ISSUES

During pregnancy, normal thyroid activity undergoes significant changes, including a two- to threefold increase in thyroxine-binding globulin concentrations, a 30-100% increase in total triiodothyronine and thyroxine concentrations, increased serum thyroglobulin, and increased renal iodide clearance. Furthermore, hCG has mild thyroid stimulating activity. Pregnancy produces an overall increase in thyroid activity, which allows the healthy individual to remain in a net euthyroid state. However, both hyper- and hypothyroidism can occur in pregnant patients. In addition, two pregnancy-specific conditions, hyperemesis gravidarum and gestational trophoblastic disease, can lead to clinical hyperthyroidism. The normal changes in thyroid activity and the association of pregnancy with conditions that can cause hyperthyroidism necessitates careful interpretation of thyroid function tests during pregnancy.

CONCLUSION

Assessment of thyroid function during pregnancy should be done with a careful clinical evaluation of the patient's symptoms as well as measurement of TSH and free, not total, thyroid hormones. Measurement of thyroid autoantibodies may also be useful in selected cases to detect maternal Graves disease or Hashimoto thyroiditis and to assess risk of fetal or neonatal consequences of maternal thyroid dysfunction.

[Central pontine myelinolysis induced by hyperemesis gravidarum]

An 18-year-old woman in her first pregnancy with hyperemesis gravidarum, presented dehydration, without hyponatremia. She was confused with profound disorientation, apathy, and drowsiness. She presented upbeating nistagmus on upward gaze and gate ataxia recognised as Wernicke's encephalopathy. Laboratory tests demonstrated hypokalemia, hypernatremia and aminotransferase elevation. The serum osmolality was 319 mOsm/kg and the water deficiency 2.73 l. The patient developed weakness in the four limbs, with hypotonicity, absence of tendon reflexes and showed bilateral Babinski signs. A T2 weighted sagittal cranial-magnetic resonance imaging revealed a high signal within mid-pons suggesting central pontine myelinolysis. In this case we highlight the absence of hyponatremia. Furthermore, the central pontine myelinolysis was probably secondary to hypokalemia, hypernatremia and hyperosmolality.

Pregnancy outcome in patients requiring parenteral nutrition

OBJECTIVE

The purpose of this retrospective study was to evaluate maternal and perinatal outcomes and complications of parenteral nutrition during pregnancy in our institution.

METHODS

This study was a review of medical records of all women who required parenteral nutrition during pregnancy at our institution from 1990-1997. The frequency of maternal and perinatal complications was calculated.

RESULTS

Twenty-six pregnancies required parenteral nutrition for the following indications: hyperemesis gravidarum (n = 16), cholecystitis/pancreatitis (n = 3), small bowel obstruction (n = 2), intracranial bleed (n = 2), ulcerative colitis (n = 1), and other (n = 2). The mean gestational age at initiation of therapy was 16.2 weeks and the mean duration of therapy was 30.6 days. Five pregnancies were terminated prior to fetal viability. Of the remaining pregnancies, obstetric complications occurred in 11, including two cases of idiopathic preterm labor resulting in preterm deliveries. Maternal complications resulting from the central venous catheters included four infections, two thromboses, one occlusion, one pneumothorax, and one catheter dislodgment. The complication rate for centrally inserted central catheters (50%) was significantly greater than the rate for peripherally inserted central catheters (9%).

CONCLUSIONS

Successful outcomes can be achieved in obstetric patients requiring parenteral nutrition. In this group of patients, the frequency of maternal complications secondary to centrally inserted central venous catheters was greater than that reported in nonpregnant patients. Peripherally inserted central catheters may be preferable when parenteral nutrition is required during pregnancy.

Immunologic and biochemical factors in hyperemesis gravidarum with or without hyperthyroxinemia

OBJECTIVE

This study was set up to investigate the relationship between immune process and high levels of human chorionic gonadotropin-beta (betahCG) in hyperemesis patients with or without hyperthyroxinemia.

METHODS

betahCG, immune parameters and thyroid related hormones were assayed in hyperemesis patients and in controls.

RESULTS

Mean serum betahCG, fT4 and TSH levels were significantly higher in hyperemesis patients than in controls (p<0. 01, p<0.01, p<0.05, respectively). Further, immune parameters regarding IgG, IgM, C3, C4 and lymphocyte count were significantly higher in patients than in controls (p<0.05, p<0.01, p<0.01, p<0.05, p<0.01, respectively). In hyperemesis patients with hyperthyroxinemia, mean serum betahCG, IgG and IgM were significantly higher than in hyperemesis women without hyperthyroxinemia (p<0.001, p<0.05, p<0.05, respectively). BetahCG was positively correlated with fT4 (r = 0.45, p<0.05), with lymphocyte count (r = 0.47, p<0.01), with IgM (r = 0.38, p<0.05) and with C3 (r = 0.40, p<0.05) in hyperemesis patients. A negative correlation between betahCG and TSH (r = -0.43, p<0.05) was noted in the hyperemesis group. Free T4 showed a positive association to IgM (r = 0.49, p<0.01), to IgG (r = 0.40, p<0.05), to lymphocyte count (r = 0.45, p<0.05).

CONCLUSION

Immunologic activity in pregnancy may have an effect or role on the stimulatory mechanism of betahCG in hyperemesis patients with or without hyperthyroxinemia.

Incidence of postpartum depression in Olmsted County, Minnesota. A population-based, retrospective study

OBJECTIVE

To provide population-based data on the recognition of postpartum depression by reviewing diagnostic and treatment practices of all physicians caring for pregnant and postpartum women in Olmsted County, Minnesota.

STUDY DESIGN

We reviewed the medical charts of a random sample of 403 Olmsted County women who gave birth in 1993. Using outpatient and hospital medical records, we recorded all documented symptoms and diagnoses of depression, drug therapy for depression and variables that were previously associated with postpartum depression, during pregnancy and for one year postpartum.

RESULTS

Fifteen (3.7%) of the women were identified as having postpartum depression during the year following delivery. Two (0.5%) other women had preexisting depression that did not remit before delivery. We found significant associations between postpartum depression and young maternal age, single marital status, hyperemesis gravidarum, tobacco or illegal drug use during pregnancy, history of substance abuse, high utilization of emergency department services and previous affective disorder. Using multivariate analysis with stepwise logistic regression, only single marital status, previous affective disorder and high utilization of emergency services remained associated with postpartum depression.

CONCLUSION

The incidence of postpartum depression was significantly below incidences seen in prospective studies. Systematic screening for postpartum depression may be appropriate in this population.

Wernicke's encephalopathy induced by hyperemesis gravidarum

A report is presented on a patient with Wernicke's encephalopathy secondary to hyperemesis gravidarum. The 25-year-old female presented 11 weeks into pregnancy with prolonged vomiting. Neurological examination 8 weeks later demonstrated obtunded sensations, nystagmus and ataxia of gait. MR imaging revealed bilateral lesions in the mediodorsal nuclei of thalami, in the hypothalamus and in the periaqueductal gray matter (1). The neurological signs and the MRI findings pointed to a diagnosis of Wernicke's encephalopathy. The patient was treated with intramuscular vitamin B1 followed by oral thiamine until the end of pregnancy. The subsequent course of the pregnancy was uncomplicated, and resulted in the delivery of a healthy 2970 g male infant. A review of the literature published during the last 30 years revealed an additional 20 cases of Wernicke's encephalopathy induced by hyperemesis gravidarum. Only half of these pregnancies resulted in the birth of a normal infant.