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Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O'Hara M, Hodson K, Nana M. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG 2024; 131:e1-e30. [PMID: 38311315 DOI: 10.1111/1471-0528.17739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
An objective and validated index of nausea and vomiting such as the Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can be used to classify the severity of NVP and HG. [Grade C] Ketonuria is not an indicator of dehydration and should not be used to assess severity. [Grade A] There are safety and efficacy data for first line antiemetics such as anti (H1) histamines, phenothiazines and doxylamine/pyridoxine (Xonvea®) and they should be prescribed initially when required for NVP and HG (Appendix III). [Grade A] There is evidence that ondansetron is safe and effective. Its use as a second line antiemetic should not be discouraged if first line antiemetics are ineffective. Women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed HG. [Grade B] Metoclopramide is safe and effective and can be used alone or in combination with other antiemetics. [Grade B] Because of the risk of extrapyramidal effects metoclopramide should be used as second-line therapy. Intravenous doses should be administered by slow bolus injection over at least 3 minutes to help minimise these. [Grade C] Women should be asked about previous adverse reactions to antiemetic therapies. If adverse reactions occur, there should be prompt cessation of the medications. [GPP] Normal saline (0.9% NaCl) with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, is the most appropriate intravenous hydration. [Grade C] Combinations of different drugs should be used in women who do not respond to a single antiemetic. Suggested antiemetics for UK use are given in Appendix III. [GPP] Thiamine supplementation (either oral 100 mg tds or intravenous as part of vitamin B complex (Pabrinex®)) should be given to all women admitted with vomiting, or severely reduced dietary intake, especially before administration of dextrose or parenteral nutrition. [Grade D] All therapeutic measures should have been tried before considering termination of pregnancy. [Grade C].
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Hu Y, Yang Q, Hu X. The efficacy and safety of acupuncture and moxibustion for the management of nausea and vomiting in pregnant women: A systematic review and meta-analysis. Heliyon 2024; 10:e24439. [PMID: 38298660 PMCID: PMC10828706 DOI: 10.1016/j.heliyon.2024.e24439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 02/02/2024] Open
Abstract
Background Nausea and vomiting, which cause considerable multifaceted effects, are commonly experience in early pregnancy. Various therapeutic strategies are employed, including both conventional agents and complementary medicine. However, the effectiveness of complementary medicine remains controversial. The objective of this meta-analysis is to evaluate efficacy and safety of acupuncture and moxibustion in pregnant women. Methods We conducted a comprehensive search using electronic databases such as PubMed, Embase, ISI Web, Medline, Cochrane, clinicaltrial.gov, and several Chinese databases. A total of 21 randomized controlled trials were included in this study for quantitative analysis. Forest plots were utilized to evaluate the efficacy and safety of acupuncture and moxibustion. Egger's test was employed to assess publication bias. Results The pooled analysis revealed that the acupuncture/moxibustion group was more effective than control group in alleviating nausea and vomiting in early pregnant women (RR: 0.28; 95%CI: 0.21, 0.37). Similar results were observed when comparing the acupuncture group to traditional herbs (RR: 0.08; 95 % CI: 0.01, 0.60), conventional therapy (RR: 0.15; 95 % CI: 0.04, 0.57), and the blank control group (RR: 0.33; 95 % CI: 0.22, 0.51). Moxibustion also exhibited the ability to alleviate nausea and vomiting compared with the blank control group (RR: 0.21; 95 % CI: 0.08, 0.52). As for safety, there were no significant differences in severe adverse events between the acupuncture group and the control group (RR: 0.77; 95%CI: 0.52, 1.14), the blank control group (RR: 0.61; 95%CI: 0.34, 1.10), the sham acupuncture group (RR: 1.05; 95%CI: 0.63, 1.73), or the conventional therapy group (RR: 0.32; 95%CI: 0.06, 1.55). Conclusion Acupuncture and moxibustion might be effective for the management of nausea and vomiting in early pregnant women. Moreover, acupuncture might be a relatively safe treatment for pregnancy.
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Affiliation(s)
- Yao Hu
- Department of Traditional Chinese Medicine, Xiang He Community Healthcare Center, Chengdu, Sichuan, China
| | - Qian Yang
- Science and Education Department, Chengdu Eighth People's Hospital (Geriatric Hospital of Chengdu Medical College), Sichuan, China
| | - Xianjin Hu
- Department of Cardiology, West China Hospital, Sichuan University, China
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El-Skaan RGA, Abdelrahman RM, Hassan AMA. Retrospective Analysis of Hyperemesis Gravidarum and Its Psychological Impact during Hospital Admission. J Obstet Gynaecol India 2023; 73:19-24. [PMID: 37916005 PMCID: PMC10615969 DOI: 10.1007/s13224-023-01787-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 05/30/2023] [Indexed: 11/03/2023] Open
Abstract
Background The aim of this study was to evaluate hyperemesis gravidarum in pregnant women and its psychological impact. Methods This retrospective study included 109 pregnant females suffering from hyperemesis gravidarum admitted during 2019-2020 at Maternity Ain shams university hospital. Results Disease severity and laboratory investigations such as Na and K levels (P = 0.007 and < 0.001, respectively) and serum creatinine level (P < 0.001) were significantly positively correlated. Depressive symptoms included guilt feeling for leaving family (49.5% patients), suicidal thoughts (9.2%), crying (56.9%) and lost concentration (33.9%). Conclusions Medical staff should be aware of psychological impact of the disease and refer to specialists if needed.
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Wu XK, Gao JS, Ma HL, Wang Y, Zhang B, Liu ZL, Li J, Cong J, Qin HC, Yang XM, Wu Q, Chen XY, Lu ZL, Feng YH, Qi X, Wang YX, Yu L, Cui YM, An CM, Zhou LL, Hu YH, Li L, Cao YJ, Yan Y, Liu L, Liu YX, Liu ZS, Painter RC, Ng EHY, Liu JP, Mol BWJ, Wang CC. Acupuncture and Doxylamine-Pyridoxine for Nausea and Vomiting in Pregnancy : A Randomized, Controlled, 2 × 2 Factorial Trial. Ann Intern Med 2023; 176:922-933. [PMID: 37335994 DOI: 10.7326/m22-2974] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND An effective and safe treatment for nausea and vomiting of pregnancy (NVP) is lacking. OBJECTIVE To assess the efficacy and safety of acupuncture, doxylamine-pyridoxine, and a combination of both in women with moderate to severe NVP. DESIGN Multicenter, randomized, double-blind, placebo-controlled, 2 × 2 factorial trial. (ClinicalTrials.gov: NCT04401384). SETTING 13 tertiary hospitals in mainland China from 21 June 2020 to 2 February 2022. PARTICIPANTS 352 women in early pregnancy with moderate to severe NVP. INTERVENTION Participants received daily active or sham acupuncture for 30 minutes and doxylamine-pyridoxine or placebo for 14 days. MEASUREMENTS The primary outcome was the reduction in Pregnancy-Unique Quantification of Emesis (PUQE) score at the end of the intervention at day 15 relative to baseline. Secondary outcomes included quality of life, adverse events, and maternal and perinatal complications. RESULTS No significant interaction was detected between the interventions (P = 0.69). Participants receiving acupuncture (mean difference [MD], -0.7 [95% CI, -1.3 to -0.1]), doxylamine-pyridoxine (MD, -1.0 [CI, -1.6 to -0.4]), and the combination of both (MD, -1.6 [CI, -2.2 to -0.9]) had a larger reduction in PUQE score over the treatment course than their respective control groups (sham acupuncture, placebo, and sham acupuncture plus placebo). Compared with placebo, a higher risk for births with children who were small for gestational age was observed with doxylamine-pyridoxine (odds ratio, 3.8 [CI, 1.0 to 14.1]). LIMITATION The placebo effects of the interventions and natural regression of the disease were not evaluated. CONCLUSION Both acupuncture and doxylamine-pyridoxine alone are efficacious for moderate and severe NVP. However, the clinical importance of this effect is uncertain because of its modest magnitude. The combination of acupuncture and doxylamine-pyridoxine may yield a potentially larger benefit than each treatment alone. PRIMARY FUNDING SOURCE The National Key R&D Program of China and the Project of Heilongjiang Province "TouYan" Innovation Team.
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Affiliation(s)
- Xiao-Ke Wu
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine, and Heilongjiang Provincial Hospital, Harbin, China (X.-K.W.)
| | - Jing-Shu Gao
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China, and College of Pharmacy, The Department of Medicine, Hangzhou Normal University, Hangzhou, China (J.-S.G.)
| | - Hong-Li Ma
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China (H.-L.M., Y.W., J.C., X.-M.Y., L. Liu)
| | - Yu Wang
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China (H.-L.M., Y.W., J.C., X.-M.Y., L. Liu)
| | - Bei Zhang
- Department of Obstetrics and Gynecology, Xuzhou Central Hospital, Xuzhou, China (B.Z.)
| | - Zhao-Lan Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China (Z.-L. Liu)
| | - Jian Li
- Department of Obstetrics & Gynaecology, Affiliated Hospital, Guizhou Medical University, Guiyang, China; First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China; and Department of Obstetrics & Gynecology, The Chinese University of Hong Kong, Hong Kong, China (J.L.)
| | - Jing Cong
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China (H.-L.M., Y.W., J.C., X.-M.Y., L. Liu)
| | - Hui-Chao Qin
- Heilongjiang Provincial Hospital, Harbin Institute of Technology, Harbin, China (H.-C.Q., L.-L.Z.)
| | - Xin-Ming Yang
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China (H.-L.M., Y.W., J.C., X.-M.Y., L. Liu)
| | - Qi Wu
- Heilongjiang Province "TouYan" Innovation Team, Heilongjiang University of Chinese Medicine, Harbin, China, and Department of Obstetrics & Gynaecology, The Chinese University of Hong Kong, Hong Kong, China (Q.W.)
| | - Xiao-Yong Chen
- Jiangxi Maternal and Child Health Hospital, Nanchang, China (X.-Y.C.)
| | - Zong-Lin Lu
- Luoyang Hospital of Chinese Medicine, Luoyang, China (Z.-L. Lu)
| | - Ya-Hong Feng
- Ningxia Hui Autonomous Region Hospital of Chinese Medicine, Yinchuan, China (Y.-H.F.)
| | - Xue Qi
- Jixi Maternal and Child Health Hospital, Jixi, China (X.Q.)
| | - Yan-Xiang Wang
- Jiamusi Maternal and Child Health Hospital, Jiamusi, China (Y.-X.W.)
| | - Lan Yu
- Hegang Maternal and Child Health Hospital, Hegang, China (L.Y.)
| | - Ying-Mei Cui
- Mudanjiang Maternal and Child Health Hospital, Mudanjiang, China (Y.-M.C.)
| | - Chun-Mei An
- Shuangyashan Maternal and Child Health Hospital, Shuangyashan, China (C.-M.A.)
| | - Li-Li Zhou
- Heilongjiang Provincial Hospital, Harbin Institute of Technology, Harbin, China (H.-C.Q., L.-L.Z.)
| | - Yu-Hong Hu
- First Affiliated Hospital of Jiamusi University, Jiamusi, China (Y.-H.H.)
| | - Lu Li
- Pharmaceutical Informatics Institute, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China, and Department of Obstetrics & Gynaecology, The Chinese University of Hong Kong, Hong Kong, China (L. Li)
| | - Yi-Juan Cao
- Centre of Reproductive Medicine, Xuzhou Central Hospital, Xuzhou, China (Y.-J.C.)
| | - Ying Yan
- Department of Gynecology, First Affiliated Hospital, Tianjin University of Chinese Medicine, Tianjin, China (Y.Y.)
| | - Li Liu
- First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China (H.-L.M., Y.W., J.C., X.-M.Y., L. Liu)
| | - Yu-Xiu Liu
- Data and Statistics Division, Department of Critical Care Medicine, Jinling Hospital, and Department of Biostatistics, Public Health School, Nanjing Medical University, Nanjing, China (Y.-X.L.)
| | - Zhi-Shun Liu
- Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China (Z.-S.L.)
| | - Rebecca C Painter
- Amsterdam University Medical Center, Reproduction and Development, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands (R.C.P.)
| | - Ernest H Y Ng
- Department of Obstetrics & Gynaecology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China (E.H.Y.N.)
| | - Jian-Ping Liu
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China, and National Research Center in Complementary and Alternative Medicine (NAFKAM), Department of Community Medicine, Faculty of Health Science, UiT The Arctic University of Norway, Tromsø, Norway (J.-P.L.)
| | - Ben Willem J Mol
- Monash Medical Centre, Monash University, Melbourne, Victoria, Australia (B.W.J.M.)
| | - Chi Chiu Wang
- Department of Obstetrics & Gynaecology, Li Ka Shing Institute of Health Sciences; School of Biomedical Sciences; and The Chinese University of Hong Kong-Sichuan University Joint Laboratory in Reproductive Medicine, The Chinese University of Hong Kong, Hong Kong, China (C.C.W.)
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Jansen LAW, Nijsten K, Limpens J, van Eekelen R, Koot MH, Grooten IJ, Roseboom TJ, Painter RC. Perinatal outcomes of infants born to mothers with hyperemesis gravidarum: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2023; 284:30-51. [PMID: 36924660 DOI: 10.1016/j.ejogrb.2023.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND Hyperemesis gravidarum is the severe form of nausea and vomiting during pregnancy and can lead to undernutrition and low maternal weight gain. Previous epidemiologic and animal studies have shown that undernutrition and low maternal weight gain in pregnancy can increase the risk of unfavorable perinatal outcomes, like shorter gestational age, small for gestational age and lower weight at birth. OBJECTIVE To evaluate the effect of hyperemesis gravidarum on perinatal outcomes. SEARCH STRATEGY OVID Medline and Embase were searched from inception to February 9th, 2022. STUDY ELIGIBILITY Studies reporting on perinatal outcomes of infants born to mothers with hyperemesis gravidarum or severe nausea and vomiting in pregnancy were included. Case reports, case series, animal studies, reviews, editorials and conference abstracts were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently selected and extracted data. Risk of bias was assessed by the Newcastle-Ottawa Quality Assessment Scale. We conducted meta-analyses where possible. RESULTS Our search yielded 1387 unique papers, of which 61 studies (n = 20,532,671 participants) were included in our systematic review. Meta-analyses showed that hyperemesis gravidarum was associated with preterm birth < 34 weeks (2 studies n = 2,882: OR 2.81, 95 %CI: 1.69-4.67), birth weight < 1500 g (2 studies, n = 489,141: OR 1.43, 95 %CI: 1.02-1.99), neonatal resuscitation (2 studies, n = 4,289,344: OR 1.07, 95 %CI: 1.05-1.10), neonatal intensive care unit admission (7 studies, n = 6,509,702: OR 1.20, 95 %CI: 1.14-1.26) and placental abruption (6 studies, n = 9,368,360: OR 1.15, 95 %CI: 1.05-1.25). Hyperemesis gravidarum was associated with reductions in birthweight > 4000 g (2 studies, n = 5,503,120: OR 0.74, 95 %CI: 0.72-0.76) and stillbirth (9 studies, n = 3,973,154: OR 0.92, 95 %CI: 0.85-0.99). Meta-analyses revealed no association between hyperemesis gravidarum and Apgar scores < 7 at 1 and 5 min; fetal loss, perinatal deaths and neonatal deaths. CONCLUSION Hyperemesis gravidarum is associated with several adverse perinatal outcomes including low birth weight and preterm birth. We also found that pregnancies complicated by hyperemesis gravidarum less frequently were complicated by macrosomia and stillbirth. We were unable to investigate underlying mechanisms.
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Affiliation(s)
- Larissa A W Jansen
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Obstetrics and Gynecology, Amphia Hospital, Breda, The Netherlands; Department of Obstetrics and Gynecology, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
| | - Kelly Nijsten
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Obstetrics and Gynecology, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Jacqueline Limpens
- Medical Library, Research Support - Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rik van Eekelen
- Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands
| | - Marjette H Koot
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Iris J Grooten
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Tessa J Roseboom
- Department of Obstetrics and Gynecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Obstetrics and Gynecology, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands; Department of Epidemiology & Data Science, Amsterdam UMC, Vrije Universiteit Medical Centre, Amsterdam, The Netherlands
| | - Rebecca C Painter
- Department of Obstetrics and Gynecology, Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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Olmsted A, DeSimone A, Lopez-Pastrana J, Becker M. Fetal demise and Wernicke-Korsakoff syndrome in a patient with hyperemesis gravidarum: a case report. J Med Case Rep 2023; 17:32. [PMID: 36726136 PMCID: PMC9893614 DOI: 10.1186/s13256-022-03748-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/28/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Wernicke-Korsakoff syndrome is a neuropsychiatric disorder caused by thiamine deficiency composed of two related disorders accounting for an acute presentation and chronic progression. Hyperemesis gravidarum presents a significant risk factor for Wernicke-Korsakoff syndrome as symptoms may rapidly progress in the setting of pregnancy. We present the first-reported case of hyperemesis-gravidarum-associated Wernicke encephalopathy in a patient in the first half of pregnancy in which a missed diagnosis led to septic shock, fetal demise, and eventual profound Korsakoff syndrome. CASE PRESENTATION We present the case of a 33-year-old primigravid African American woman at 15 weeks gestational age who initially presented at a community emergency department with nausea and vomiting that ultimately progressed to severe hyperemesis-gravidarum-associated Wernicke-Korsakoff syndrome, fetal demise, and septic shock. The patient received a total of 6 weeks of high-dose parenteral thiamine. Magnetic resonance imaging of the head and formal neuropsychological assessment following treatment plateau confirmed the diagnosis of Wernicke-Korsakoff syndrome. CONCLUSIONS The multisystem complications seen in severe thiamine deficiency can delay timely administration of high-dose thiamine, particularly in pregnancy, in which the classic triad of Wernicke-Korsakoff syndrome may not raise clinical suspicion due to rapid progression of neurological sequelae in this population. We advise a low threshold for parenteral thiamine repletion in pregnant women with persistent vomiting as hyperemesis gravidarum-induced severe thiamine deficiency can result in Wernicke-Korsakoff syndrome, sepsis, and fetal demise.
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Affiliation(s)
- Alisa Olmsted
- grid.412726.4Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, Philadelphia, PA USA ,grid.280747.e0000 0004 0419 2556Present Address: Stanford University and the Sierra-Pacific Mental Illness Research, Education, and Clinical Center (MIRECC), VA Palo Alto Health Care System, Palo Alto, USA
| | - Andrea DeSimone
- Department of Psychiatry, Bayhealth Medical Center, Dover, DE USA
| | - Jahaira Lopez-Pastrana
- grid.412726.4Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, Philadelphia, PA USA
| | - Madeleine Becker
- grid.412726.4Department of Psychiatry and Human Behavior, Thomas Jefferson University Hospital, Philadelphia, PA USA ,grid.412726.4Department of Integrative Medicine and Nutritional Sciences, Thomas Jefferson University Hospital, Philadelphia, USA
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Mohd Nafiah NA, Chieng WK, Zainuddin AA, Chew KT, Kalok A, Abu MA, Ng BK, Mohamed Ismail NA, Nur Azurah AG. Effect of Acupressure at P6 on Nausea and Vomiting in Women with Hyperemesis Gravidarum: A Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10886. [PMID: 36078602 PMCID: PMC9518577 DOI: 10.3390/ijerph191710886] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/26/2022] [Accepted: 08/30/2022] [Indexed: 06/15/2023]
Abstract
Hyperemesis gravidarum is characterized by severe nausea and vomiting. This study aims to illustrate the efficacy of acupressure at P6 in treating nausea and vomiting in hyperemesis gravidarum. This parallel randomized controlled trial was conducted from 2016-2017 in a tertiary hospital. Hospitalized women with ≤16 weeks of gestation and moderate to severe nausea and vomiting classified using a modified PUQE score were randomly assigned in a 1:1 ratio to either apply an acupressure wristband at the P6 point three times daily or to receive regular doses of intravenous antiemetics. The primary outcome was differences in modified PUQE scores among the groups. The secondary outcomes were differences in the rate of urine ketone clearance and the frequency of requiring rescue antiemetics. Ninety women were equally randomized into two groups, with no dropout. There was a statistically significant difference in the degrees of nausea and vomiting between the groups at 8, 16, and 24 hours post-admission (p8hours= 0.001, p16hours = 0.006, and p24hours = 0.001). The requirement of antiemetics and the rate of urine ketone clearance between the two groups were also statistically significant, at p = 0.001 and p = 0.02 respectively. There were no side effects in either group. The P6 acupressure was efficacious in alleviating nausea and vomiting among hyperemesis gravidarum women. The trial was retrospectively registered on ClinicalTrials.gov (NCT05175079).
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Affiliation(s)
| | | | | | | | | | | | | | | | - Abdul Ghani Nur Azurah
- Department of Obstetrics and Gynaecology, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur 56000, Malaysia
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Mares R, Morrow A, Shumway H, Zapata I, Forstein D, Brooks B. Assessment of management approaches for hyperemesis gravidarum and nausea and vomiting of pregnancy: a retrospective questionnaire analysis. BMC Pregnancy Childbirth 2022; 22:609. [PMID: 35915406 PMCID: PMC9341047 DOI: 10.1186/s12884-022-04922-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/15/2022] [Indexed: 11/28/2022] Open
Abstract
Background Hyperemesis gravidarum is the most severe form of nausea and vomiting of pregnancy, or morning sickness. 2% of pregnancies in the United States are affected by hyperemesis gravidarum. The condition is characterized by severe vomiting in pregnant people, especially during the first trimester, often leading to hypovolemia and weight loss. The standard of care for hyperemesis and nausea and vomiting of pregnancy is commonly ineffective. We hypothesize that based on patient experience; the current treatment guidelines for hyperemesis are not clinically effective. Our objective was to identify the efficacy of the various management approaches that are currently in place for hyperemesis and nausea and vomiting of pregnancy. Methods A questionnaire was designed based on diagnostic criteria, standard demographic identifiers, and common medications for the treatment of hyperemesis gravidarum. This questionnaire was distributed online to through hyperemesis and nausea and vomiting of pregnancy support groups, personal social media, and institutional email. Results In our study, most participants diagnosed with hyperemesis gravidarum trialed at least three medications, most of which were ineffective and/or had severe side effects. The most used medication for treatment of hyperemesis gravidarum is ondansetron, a standard antiemetic, with fatigue and constipation being the most reported side effects. All data in the dataset was coded as categorical and analyzed using contingency tables using Mantel-Haenszel Chi square tests. Conclusions The data presented in this research provides insight into the suffering that patients with these diagnoses face day-to-day due to the lack of efficacious, well-tolerated treatment options. Establishing this gap in treatment can facilitate the development of effective treatments that will provide relief for thousands of patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04922-6.
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Affiliation(s)
- Rachel Mares
- Department of Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, 255 E. Center St, Ivins, UT, 84738, USA
| | - Adelene Morrow
- Department of Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, 255 E. Center St, Ivins, UT, 84738, USA
| | - Haley Shumway
- Department of Obstetrics, Central Michigan University, Mount Pleasant, MI, 48859, USA
| | - Isain Zapata
- Department of Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, Parker, CO, 80134, USA
| | - David Forstein
- Rocky Vista University College of Osteopathic Medicine, Office of the President, Parker, CO, 80134, USA
| | - Benjamin Brooks
- Department of Biomedical Sciences, Rocky Vista University College of Osteopathic Medicine, 255 E. Center St, Ivins, UT, 84738, USA.
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Robson S, McParlin C, Mossop H, Lie M, Fernandez-Garcia C, Howel D, Graham R, Ternent L, Steel A, Goudie N, Nadeem A, Phillipson J, Shehmar M, Simpson N, Tuffnell D, Campbell I, Williams R, O'Hara ME, McColl E, Nelson-Piercy C. Ondansetron and metoclopramide as second-line antiemetics in women with nausea and vomiting in pregnancy: the EMPOWER pilot factorial RCT. Health Technol Assess 2021; 25:1-116. [PMID: 34782054 DOI: 10.3310/hta25630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Around one-third of pregnant women suffer from moderate to severe nausea and vomiting, causing physical and emotional distress and reducing their quality of life. There is no cure for nausea and vomiting in pregnancy. Management focuses on relieving symptoms and preventing morbidity, and often requires antiemetic therapy. National guidelines make recommendations about first-, second- and third-line antiemetic therapies, although care varies in different hospitals and women report feeling unsupported, dissatisfied and depressed. OBJECTIVES To determine whether or not, in addition to intravenous rehydration, ondansetron compared with no ondansetron and metoclopramide compared with no metoclopramide reduced the rate of treatment failure up to 10 days after drug initiation; improved symptom severity at 2, 5 and 10 days after drug initiation; improved quality of life at 10 days after drug initiation; and had an acceptable side effect and safety profile. To estimate the incremental cost per treatment failure avoided and the net monetary benefits from the perspectives of the NHS and women. DESIGN This was a multicentre, double-dummy, randomised, double-blinded, dummy-controlled 2 × 2 factorial trial (with an internal pilot phase), with qualitative and health economic evaluations. PARTICIPANTS Thirty-three patients (who were < 17 weeks pregnant and who attended hospital with nausea and vomiting after little or no improvement with first-line antiemetic medication) who attended 12 secondary care NHS trusts in England, 22 health-care professionals and 21 women participated in the qualitative evaluation. INTERVENTIONS Participants were randomly allocated to one of four treatment groups (1 : 1 : 1: 1 ratio): (1) metoclopramide and dummy ondansetron; (2) ondansetron and dummy metoclopramide; (3) metoclopramide and ondansetron; or (4) double dummy. Trial medication was initially given intravenously and then continued orally once women were able to tolerate oral fluids for a maximum of 10 days of treatment. MAIN OUTCOME MEASURES The primary end point was the number of participants who experienced treatment failure, which was defined as the need for further treatment because symptoms had worsened between 12 hours and 10 days post treatment. The main economic outcomes were incremental cost per additional successful treatment and incremental net benefit. RESULTS Of the 592 patients screened, 122 were considered eligible and 33 were recruited into the internal pilot (metoclopramide and dummy ondansetron, n = 8; ondansetron and dummy metoclopramide, n = 8; metoclopramide and ondansetron, n = 8; double dummy, n = 9). Owing to slow recruitment, the trial did not progress beyond the pilot. Fifteen out of 30 evaluable participants experienced treatment failure. No statistical analyses were performed. The main reason for ineligibility was prior treatment with trial drugs, reflecting an unpredicted change in prescribing practice at several points along the care pathway. The qualitative evaluation identified the requirements of the study protocol, in relation to guidelines on anti-sickness drugs, and the diversity of pathways to care as key hurdles to recruitment while the role of research staff was a key enabler. No important adverse events or side effects were reported. LIMITATIONS The pilot trial failed to achieve the recruitment target owing to unforeseen changes in the provision of care. CONCLUSIONS The trial was unable to provide evidence to support clinician decisions about the best choice of second-line antiemetic for nausea and vomiting in pregnancy. TRIAL REGISTRATION Current Controlled Trials ISRCTN16924692 and EudraCT 2017-001651-31. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 63. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Stephen Robson
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine McParlin
- Department of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Helen Mossop
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Mabel Lie
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Cristina Fernandez-Garcia
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Ruth Graham
- School of Geography, Politics and Sociology, Newcastle University, Newcastle upon Tyne, UK
| | - Laura Ternent
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Alison Steel
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola Goudie
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Afnan Nadeem
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Julia Phillipson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Manjeet Shehmar
- Gynaecology Secretaries Department, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Nigel Simpson
- Leeds Institute of Medical Research, Department of Women's and Children's Health, School of Medicine, University of Leeds, Leeds, UK
| | - Derek Tuffnell
- Department of Obstetrics, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ian Campbell
- Pharmacy Department, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | | | - Elaine McColl
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
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Abstract
Hyperemesis gravidarum (HG) is a condition at the extreme end of the pregnancy sickness spectrum, estimated to affect 1-2 % of pregnant women. This narrative review provides an overview of the current literature concerning the nutritional implications and management of HG. HG can persist throughout pregnancy, causing malnutrition, dehydration, electrolyte imbalance and unintended weight loss, requiring hospital admission in most cases. In addition to its negative effect on maternal, physical and psychological wellbeing, HG can negatively impact fetal growth and may have adverse consequences on the health of the offspring. HG care and research have been hampered in the past due to stigma, inconsistent diagnostic criteria, mismanagement and lack of investment. Little is known about the nutritional intake of women with HG and whether poor intake at critical stages of pregnancy is associated with perinatal outcomes. Effective treatment requires a combination of medical interventions, lifestyle changes, dietary changes, supportive care and patient education. There is, however, limited evidence-based research on the effectiveness of dietary approaches. Enteral tube feeding and parenteral nutrition are generally reserved for the most intractable cases, where other treatment modalities have failed. Wernicke encephalopathy is a rare but very serious and avoidable consequence of unmanaged HG. A recent priority-setting exercise involving patients, clinicians and researchers highlighted the importance of nutrition research to all. Future research should focus on these priorities to better understand the nutritional implications of HG. Ultimately improved recognition and management of malnutrition in HG is required to prevent complications and optimise nutritional care.
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11
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The Contribution of Registered Dietitians in the Management of Hyperemesis Gravidarum in the United Kingdom. Nutrients 2021; 13:nu13061964. [PMID: 34201043 PMCID: PMC8226879 DOI: 10.3390/nu13061964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 02/07/2023] Open
Abstract
Hyperemesis Gravidarum (HG) is a condition at the extreme end of the pregnancy sickness spectrum, which can cause poor oral intake, malnutrition, dehydration and weight loss. The aim of this study is to explore the role of Registered Dietitians (RD) in the management of HG in the United Kingdom (UK). A survey was designed and distributed electronically to members of the British Dietetic Association. There were 45 respondents, 76% (n = 34) worked in secondary care hospitals, 11% (n = 5) were in maternal health specialist roles. The most commonly used referral criteria was the Malnutrition Universal Screening Tool (40%, n = 18), followed by second admission (36%, n = 16). However 36% (n = 16) reported no specific referral criteria. About 87% (n = 37) of respondents did not have specific clinical guidelines to follow. Oral nutrition supplements were used by 73% (n = 33) either ‘sometimes’ or ‘most of the time’. Enteral and parenteral nutrition were less commonly used. There was an inconsistent use of referral criteria to dietetic services and a lack of specific clinical guidelines and patient resources. Further training for all clinicians and earlier recognition of malnutrition, alongside investment in the role of dietitians were recommended to improve the nutritional care of those with HG.
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12
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Nijsten K, Koot MH, van der Post JAM, Bais JMJ, Ris-Stalpers C, Naaktgeboren C, Bremer HA, van der Ham DP, Heidema WM, Huisjes A, Kleiverda G, Kuppens SM, van Laar JOEH, Langenveld J, van der Made F, Papatsonis D, Pelinck MJ, Pernet PJ, van Rheenen-Flach L, Rijnders RJ, Scheepers HCJ, Siegelaar SE, Vogelvang T, Mol BW, Roseboom TJ, Grooten IJ, Painter RC. Thyroid-stimulating hormone and free thyroxine fail to predict the severity and clinical course of hyperemesis gravidarum: A prospective cohort study. Acta Obstet Gynecol Scand 2021; 100:1419-1429. [PMID: 33606270 PMCID: PMC8360038 DOI: 10.1111/aogs.14131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/12/2021] [Accepted: 02/15/2021] [Indexed: 11/30/2022]
Abstract
Introduction Little is known about the pathophysiology of hyperemesis gravidarum (HG). Proposed underlying causes are multifactorial and thyroid function is hypothesized to be causally involved. In this study, we aimed to assess the utility of thyroid‐stimulating hormone (TSH) and free thyroxine (FT4) as a marker and predictor for the severity and clinical course of HG. Material and methods We conducted a prospective cohort study including women admitted for HG between 5 and 20 weeks of gestation in 19 hospitals in the Netherlands. Women with a medical history of thyroid disease were excluded. TSH and FT4 were measured at study entry. To adjust for gestational age, we calculated TSH multiples of the median (MoM). We assessed HG severity at study entry as severity of nausea and vomiting (by the Pregnancy Unique Quantification of Emesis and nausea score), weight change compared with prepregnancy weight, and quality of life. We assessed the clinical course of HG as severity of nausea and vomiting and quality of life 1 week after inclusion, duration of hospital admissions, and readmissions. We performed multivariable regression analysis with absolute TSH, TSH MoMs, and FT4. Results Between 2013 and 2016, 215 women participated in the cohort. TSH, TSH MoM, and FT4 were available for, respectively, 150, 126, and 106 of these women. Multivariable linear regression analysis showed that lower TSH MoM was significantly associated with increased weight loss or lower weight gain at study entry (ΔKg; β = 2.00, 95% CI 0.47‐3.53), whereas absolute TSH and FT4 were not. Lower TSH, not lower TSH MoM or FT4, was significantly associated with lower nausea and vomiting scores 1 week after inclusion (β = 1.74, 95% CI 0.36‐3.11). TSH and FT4 showed no association with any of the other markers of the severity or clinical course of HG. Twenty‐one out of 215 (9.8%) women had gestational transient thyrotoxicosis. Women with gestational transient thyrotoxicosis had a lower quality of life 1 week after inclusion than women with no gestational transient thyrotoxicosis (p = 0.03). Conclusions Our findings show an inconsistent role for TSH, TSH MoM, or FT4 at time of admission and provide little guidance on the severity and clinical course of HG.
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Affiliation(s)
- Kelly Nijsten
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development research institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Marjette H Koot
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development research institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Joris A M van der Post
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development research institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Joke M J Bais
- Department of Obstetrics and Gynecology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Carrie Ris-Stalpers
- Laboratory of Reproductive Biology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Christiana Naaktgeboren
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development research institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Bremer
- Department of Obstetrics and Gynecology, Reinier de Graaf Hospital, Delft, The Netherlands
| | - David P van der Ham
- Department of Obstetrics and Gynecology, Martini Hospital, Groningen, The Netherlands
| | - Wieteke M Heidema
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Anjoke Huisjes
- Department of Obstetrics and Gynecology, Gelre Hospital, Apeldoorn, The Netherlands
| | - Gunilla Kleiverda
- Department of Obstetrics and Gynecology, Flevo Hospital, Almere, The Netherlands
| | - Simone M Kuppens
- Department of Obstetrics and Gynecology, Catharina Hospital, Eindhoven, The Netherlands
| | - Judith O E H van Laar
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynecology, Zuyderland Hospital, Heerlen, The Netherlands
| | - Flip van der Made
- Department of Obstetrics and Gynecology, Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Dimitri Papatsonis
- Department of Obstetrics and Gynecology, Amphia Hospital, Breda, The Netherlands
| | - Marie-José Pelinck
- Department of Obstetrics and Gynecology, Scheper Hospital, Emmen, The Netherlands
| | - Paula J Pernet
- Department of Obstetrics and Gynecology, Spaarne Gasthuis, Haarlem, The Netherlands
| | | | - Robbert J Rijnders
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Sarah E Siegelaar
- Department of Internal Medicine, Endocrinology and Metabolism, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tatjana Vogelvang
- Department of Obstetrics and Gynecology, Diakonessenhuis, Utrecht, The Netherlands
| | - Ben W Mol
- Department of Obstetrics and Gynecology, Monash University, Clayton, Victoria, Australia
| | - Tessa J Roseboom
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development research institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.,Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Iris J Grooten
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development research institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Rebecca C Painter
- Department of Obstetrics and Gynecology, Amsterdam Reproduction & Development research institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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13
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Dean CR, Bierma H, Clarke R, Cleary B, Ellis P, Gadsby R, Gauw N, Lodge K, MacGibbon K, McBride M, Munro D, Nelson-Piercy C, O'Hara M, Penny H, Shorter K, Spijker R, Trovik J, Watford E, Painter RC. A patient-clinician James Lind Alliance partnership to identify research priorities for hyperemesis gravidarum. BMJ Open 2021; 11:e041254. [PMID: 33452191 PMCID: PMC7813320 DOI: 10.1136/bmjopen-2020-041254] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE There are many uncertainties surrounding the aetiology, treatment and sequelae of hyperemesis gravidarum (HG). Prioritising research questions could reduce research waste, helping researchers and funders direct attention to those questions which most urgently need addressing. The HG priority setting partnership (PSP) was established to identify and rank the top 25 priority research questions important to both patients and clinicians. METHODS Following the James Lind Alliance (JLA) methodology, an HG PSP steering group was established. Stakeholders representing patients, carers and multidisciplinary professionals completed an online survey to gather uncertainties. Eligible uncertainties related to HG. Uncertainties on nausea and vomiting of pregnancy and those on complementary treatments were not eligible. Questions were verified against the evidence. Two rounds of prioritisation included an online ranking survey and a 1-hour consensus workshop. RESULTS 1009 participants (938 patients/carers, 118 professionals with overlap between categories) submitted 2899 questions. Questions originated from participants in 26 different countries, and people from 32 countries took part in the first prioritisation stage. 66 unique questions emerged, which were evidence checked according to the agreed protocol. 65 true uncertainties were narrowed via an online ranking survey to 26 unranked uncertainties. The consensus workshop was attended by 19 international patients and clinicians who reached consensus on the top 10 questions for international researchers to address. More patients than professionals took part in the surveys but were equally distributed during the consensus workshop. Participants from low-income and middle-income countries noted that the priorities may be different in their settings. CONCLUSIONS By following the JLA method, a prioritised list of uncertainties relevant to both HG patients and their clinicians has been identified which can inform the international HG research agenda, funders and policy-makers. While it is possible to conduct an international PSP, results from developed countries may not be as relevant in low-income and middle-income countries.
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Affiliation(s)
- Caitlin R Dean
- Pregnancy Sickness Support, Bodmin, UK
- Obstetrics and Gynecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Hyke Bierma
- Obstetrics and Gynecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Ria Clarke
- Obstetrics and Gynaecology, Frimley Park Hospital, Frimley, UK
| | - Brian Cleary
- Hyperemesis Ireland, Dublin, Ireland
- School of Pharmacy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Roger Gadsby
- Pregnancy Sickness Support, Bodmin, UK
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Kimber MacGibbon
- Hyperemesis Education and Research Foundation, Damascus, Oregon, USA
| | - Marian McBride
- Hyperemesis Ireland, Dublin, Ireland
- Strategic Planning and Transformation, Health Service Executive, Dublin, Ireland
| | - Deirdre Munro
- Hyperemesis Ireland, Dublin, Ireland
- Portiuncula University Hospital Galway, Galway, Ireland
| | | | | | - Helen Penny
- School of Psychology, Cardiff University, Cardiff, UK
| | - Katherine Shorter
- Early Pregnancy Unit, QMC, Nottingham University Hospital Trust, Nottingham, UK
| | - René Spijker
- Medical Library, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, Netherlands
| | - Jone Trovik
- Department Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway
| | | | - Rebecca C Painter
- Obstetrics and Gynecology, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
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Mitchell-Jones N, Lawson K, Bobdiwala S, Farren JA, Tobias A, Bourne T, Bottomley C. Association between hyperemesis gravidarum and psychological symptoms, psychosocial outcomes and infant bonding: a two-point prospective case-control multicentre survey study in an inner city setting. BMJ Open 2020; 10:e039715. [PMID: 33051235 PMCID: PMC7554497 DOI: 10.1136/bmjopen-2020-039715] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/19/2020] [Accepted: 08/28/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES To assess if there is any association between hyperemesis gravidarum (HG), psychological morbidity and infant bonding and to quantify any psychosocial consequences of HG. DESIGN Two-point prospective case-control, multicentre survey study with antenatal and postnatal data collection. SETTING Three London hospitals. PARTICIPANTS Pregnant women at ≤12 completed weeks gestation recruited consecutively over 2 years. Women with HG were recruited at the time of admission; controls recruited from a low risk antenatal clinic. 106 women were recruited to the case group and 108 to the control. Response rates at antenatal data collection were 87% and 85% in the case and control groups, respectively. Postnatally, the response rate was 90% in both groups. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcomes were psychological morbidity in the antenatal and postnatal periods, infant bonding in the postnatal period and psychosocial implications of HG. Secondary outcomes were the effects of severity and longevity of HG and assessment of correlation between Edinburgh Postnatal Depression Scale scores and maternal-to-infant bonding scores. RESULTS Antenatally, 49% of cases had probable depression compared with 6% of controls (OR 14.4 (5.29 to 39.44)). Postnatally, 29% of cases had probable depression versus 7% of controls (OR 5.2 (1.65 to 17.21)). There was no direct association between HG and infant bonding. 53% of women in the HG group reported needing four or more weeks of sick leave compared with 2% in the control group (OR 60.5 (95% CI 8.4 to 2535.6)). CONCLUSIONS Long-lasting psychological morbidity associated with HG was evident. Significantly more women in the case group sought help for mental health symptoms in the antenatal period, however very few were diagnosed with or treated for depression in pregnancy or referred to specialist perinatal mental health services. HG did not directly affect infant bonding. Women in the case group required long periods off work, highlighting the socioeconomic impact of HG.
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Affiliation(s)
- Nicola Mitchell-Jones
- Department of Surgery and Cancer, Imperial College London, Imperial College NHS Trust, St Mary's Hospital and Queen Charlotte's and Chelsea Hospital, London, UK
- Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, Chelsea and Westminster NHS Trust, London, UK
| | - Kim Lawson
- Department of Surgery and Cancer, Imperial College London, Imperial College NHS Trust, St Mary's Hospital and Queen Charlotte's and Chelsea Hospital, London, UK
- Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, Chelsea and Westminster NHS Trust, London, UK
| | - Shabnam Bobdiwala
- Department of Surgery and Cancer, Imperial College London, Imperial College NHS Trust, St Mary's Hospital and Queen Charlotte's and Chelsea Hospital, London, UK
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's Hospital, Imperial College NHS Trust, London, UK
| | - Jessica Alice Farren
- Department of Surgery and Cancer, Imperial College London, Imperial College NHS Trust, St Mary's Hospital and Queen Charlotte's and Chelsea Hospital, London, UK
- Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, Chelsea and Westminster NHS Trust, London, UK
| | - Aurelio Tobias
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | - Tom Bourne
- Department of Surgery and Cancer, Imperial College London, Imperial College NHS Trust, St Mary's Hospital and Queen Charlotte's and Chelsea Hospital, London, UK
- Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, Chelsea and Westminster NHS Trust, London, UK
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's Hospital, Imperial College NHS Trust, London, UK
| | - Cecilia Bottomley
- Department of Surgery and Cancer, Imperial College London, Imperial College NHS Trust, St Mary's Hospital and Queen Charlotte's and Chelsea Hospital, London, UK
- Department of Gynaecology, University College Hospital, University College London Hospital NHS Foundation Trust, London, UK
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15
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Gunay T, Turgut A, Ayaz Bilir R, Hocaoglu M, Demircivi Bor E. Comparative Analysis of Maternal and Fetal Outcomes of Pregnancies Complicated and Not Complicated with Hyperemesis Gravidarum Necessitating Hospitalization. Medeni Med J 2020; 35:8-14. [PMID: 32733744 PMCID: PMC7384498 DOI: 10.5222/mmj.2020.57767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 01/24/2020] [Indexed: 12/02/2022] Open
Abstract
Objective: To compare maternal and fetal outcomes of pregnancies complicated and not complicated with hyperemesis gravidarum (HG) necessitating hospitalization. Method: A total of 386 women with singleton deliveries between March 2015 and January 2018 were included in this retrospective single-center study. Of 386 women, 186 women (mean±SD age: 30.7±5.9 years) who were hospitalized with HG within the first 20 weeks of gestation comprised the hyperemetic pregnancy group, while 200 women without HG during pregnancy served as a control group. Results: No significant difference was noted between the HG and control groups in terms of maternal characteristics, gestational age (median 38.6 and 39.0 weeks, respectively), type of delivery (normal spontaneous delivery in 78.0% vs 80.0%), fetal gender (female: 53.2% vs 48.5%), birthweight (median 3250 g vs 3275 g) and 5-min APGAR scores (≥7 in 97.3% vs 97.5%, respectively). Adverse pregnancy outcomes were also similar between groups including preterm birth (8.1% vs 11.0%, respectively), SGA (5.9% vs 9.5%), hypertensive disorder (5.4% vs 7.5%), placental abruption (1.1% vs 0.5%,), stillbirth (0.0% vs 0.5%) and GDM (3.8%vs 2.5%). Weight loss during pregnancy was evident in 91.3% of women in the HG group, while none of women in the control group had weight loss during pregnancy (p<0.001). Conclusions: The findings of this study indicate that HG may not be related with adverse fetal and prenatal outcomes and this conclusion needs to be clarified with large-scale investigations.
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Affiliation(s)
- Taner Gunay
- Istanbul Medeniyet University, Goztepe Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
| | - Abdulkadir Turgut
- Istanbul Medeniyet University Goztepe Research and Training Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
| | - Reyhan Ayaz Bilir
- Istanbul Medeniyet University Goztepe Research and Training Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
| | - Meryem Hocaoglu
- Istanbul Medeniyet University Goztepe Research and Training Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
| | - Ergul Demircivi Bor
- Istanbul Medeniyet University Goztepe Research and Training Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
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Dinberu MT, Mohammed MA, Tekelab T, Yimer NB, Desta M, Habtewold TD. Burden, risk factors and outcomes of hyperemesis gravidarum in low-income and middle-income countries (LMICs): systematic review and meta-analysis protocol. BMJ Open 2019; 9:e025841. [PMID: 30948589 PMCID: PMC6500362 DOI: 10.1136/bmjopen-2018-025841] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Hyperemesis gravidarum (HG) is a pregnancy condition characterised by excessive nausea and vomiting resulting in dehydration, weight loss and serious adverse pregnancy outcomes including termination of pregnancies. Even though evidence in low-income and middle-income countries (LMICs) is limited, the prevalence of HG in pregnancy ranges from 0.3% to 10.8%. With this systematic review and meta-analysis, we aim to determine the prevalence/burden, risk factors, and maternal and perinatal outcomes of HG in LMICs. METHODS PubMed, CINAHL, EMBASE, EBSCO, Ovid maternity and infant care databases, Cochrane Database of Systematic Reviews, Web of Science and SCOPUS databases will be searched. Reference lists of selected articles will be assessed in order to identify other potential studies of interest. Observational studies and (non) randomised controlled trials conducted from January 2000 to September 2018 in LMIC will be included. A weighted inverse-variance meta-analysis using fixed-effects and random-effects model will be done to generate a pooled estimate. Funnel plot and Egger's regression statistical test will be applied to check publication bias. Heterogeneity among studies will be checked using Τ2 to determine dispersion. Moreover, meta-regression analysis will be performed to investigate the source of heterogeneity. STATA V.14 will be used to analyse the data. ETHICS AND DISSEMINATION Formal ethical approval and patient consent are not required; as primary data collection will not be employed. The result will be published in a peer-reviewed scientific journal and will be presented at scientific conferences and public press. PROSPERO REGISTRATION NUMBER CRD42018096284.
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Affiliation(s)
| | | | - Tesfalidet Tekelab
- Department of Nursing and Midwifery, Wollega University, Nekemte, Ethiopia
| | - Nigus Bililign Yimer
- Department of Midwifery, College of Medicine and Health science, Woldia University, Woldia, Ethiopia
| | - Melaku Desta
- Department of Midwifery, Debre Markos University, Debre Markos, Ethiopia
| | - Tesfa Dejenie Habtewold
- Department of Nursing, Debre Berhan University, Debre Berhan, Ethiopia
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Medley N, Vogel JP, Care A, Alfirevic Z. Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2018; 11:CD012505. [PMID: 30480756 PMCID: PMC6516886 DOI: 10.1002/14651858.cd012505.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB. OBJECTIVES We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update. METHODS We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI. MAIN RESULTS We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB. OUTCOME preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions. OUTCOME perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources. OUTCOMES preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm. AUTHORS' CONCLUSIONS Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.
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Affiliation(s)
- Nancy Medley
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Joshua P Vogel
- Burnet InstituteMaternal and Child Health85 Commercial RoadMelbourneAustralia
| | - Angharad Care
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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van Vliet R, Bink M, Polman J, Suntharan A, Grooten I, Zwolsman SE, Roseboom TJ, Painter RC. Patient Preferences and Experiences in Hyperemesis Gravidarum Treatment: A Qualitative Study. J Pregnancy 2018; 2018:5378502. [PMID: 30515329 PMCID: PMC6234451 DOI: 10.1155/2018/5378502] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 10/04/2018] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Hyperemesis gravidarum (HG) medical therapies are currently of limited effect, which creates a larger role for patient preferences in the way HG care is arranged. This is the first study using in-depth interviews to investigate patients' preferences and experiences of HG treatment. MATERIALS AND METHODS We conducted individual in-depth interviews among women who had been hospitalized for HG in North Holland at least once in the past 4 years. We asked them about their experiences, preferences, and suggestions for improvement regarding the HG treatment they received. The sample size was determined by reaching data saturation. Themes were identified from analysis of the interview transcripts. RESULTS AND DISCUSSION 13 women were interviewed. Interviewees emphasized the importance of early recognition of the severity of HG, increasing caregivers' knowledge on HG, early medical intervention, and nasogastric tube feeding. They valued a single room in hospital, discussion of treatment options, more possibilities of home-treatment, psychological support during HG and after childbirth, and more uniform information and policies regarding HG treatment. CONCLUSION Further research is needed to establish whether the suggestions can lead to more (cost) effective care and improve the course of HG and outcomes for HG patients and their children.
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Affiliation(s)
- Relin van Vliet
- University Medical Centers Amsterdam, University of Amsterdam, Amsterdam, Netherlands
| | - Marieke Bink
- Department of Gynaecology and Obstetrics, Noordwest Ziekenhuisgroep, Alkmaar, Netherlands
| | - Julian Polman
- University Medical Centers Amsterdam, University of Amsterdam, Amsterdam, Netherlands
| | - Amaran Suntharan
- University Medical Centers Amsterdam, University of Amsterdam, Amsterdam, Netherlands
| | - Iris Grooten
- Department of Obstetrics and Gynaecology, University Medical Centers Amsterdam, Amsterdam, Netherlands
| | - Sandra E. Zwolsman
- Department of Obstetrics and Gynaecology, University Medical Centers Amsterdam, University of Amsterdam, Amsterdam, Netherlands
| | - Tessa J. Roseboom
- Departments of Obstetrics and Gynaecology, Public Health & Epidemiology, University Medical Centers Amsterdam, University of Amsterdam, Amsterdam, Netherlands
| | - Rebecca C. Painter
- Department of Obstetrics and Gynaecology, University Medical Centers Amsterdam, University of Amsterdam, Amsterdam, Netherlands
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Mitchell-Jones N, Farren JA, Tobias A, Bourne T, Bottomley C. Ambulatory versus inpatient management of severe nausea and vomiting of pregnancy: a randomised control trial with patient preference arm. BMJ Open 2017; 7:e017566. [PMID: 29222135 PMCID: PMC5736029 DOI: 10.1136/bmjopen-2017-017566] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To determine whether ambulatory (outpatient (OP)) treatment of severe nausea and vomiting of pregnancy (NVP) is as effective as inpatient (IP) care. DESIGN Non-blinded randomised control trial (RCT) with patient preference arm. SETTING Two multicentre teaching hospitals in London. PARTICIPANTS Women less than 20 weeks' pregnant with severe NVP and associated ketonuria (>1+). METHODS Women who agreed to the RCT were randomised via web-based application to either ambulatory or IP treatment. Women who declined randomisation underwent the treatment of their choice in the patient preference trial (PPT) arm. Treatment protocols, data collection and follow-up were the same for all participants. MAIN OUTCOME MEASURES Primary outcome was reduction in Pregnancy Unique Quantification of Emesis (PUQE) score 48 hours after starting treatment. Secondary outcome measures were duration of treatment, improvement in symptom scores and ketonuria at 48 hours, reattendances within 7 days of discharge and comparison of symptoms at 7 days postdischarge. RESULTS 152/174 eligible women agreed to participate with 77/152 (51%) recruited to the RCT and 75/152 (49%) to the PPT.Patients were initially compared in four groups (randomised IP, randomised OP, non-randomised IP and non-randomised OP). Comprehensive cohort analysis of participants in the randomised group (RCT) and non-randomised group (PPT) did not demonstrate any differences in patient demographics or baseline clinical characteristics. Pooled analysis of IP versus OP groups showed no difference in reduction in PUQE score at 48 hours (p=0.86). There was no difference in change in eating score (p=0.69), drinking score (p=0.77), well-being rating (p=0.64) or reduction in ketonuria (p=0.47) at 48 hours, with no difference in duration of index treatment episode (p=0.83) or reattendances within 7 days (p=0.52). CONCLUSIONS Ambulatory management is an effective direct alternative to IP management of severe NVP. The trial also demonstrated that many women requiring treatment for severe NVP have strong preferences regarding treatment setting, which may need to be considered by care providers, especially given the psychological impact of severe NVP. TRIAL REGISTRATION NUMBER http://www.isrctn.com/ISRCTN24659467 (March 2014).
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Affiliation(s)
- Nicola Mitchell-Jones
- Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, London, UK
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jessica Alice Farren
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, St Mary's Hospital, Imperial College Trust, London, UK
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College Trust, London, UK
| | - Aurelio Tobias
- Institute of Metabolism and Systems Research (IMSR), University of Birmingham, Birmingham Women's NHS Foundation Trust, Birmingham, UK
| | - Tom Bourne
- Department of Surgery and Cancer, Imperial College London, London, UK
- Tommy's National Centre for Miscarriage Research, Queen Charlotte's and Chelsea Hospital, Imperial College Trust, London, UK
| | - Cecilia Bottomley
- Department of Obstetrics and Gynaecology, Chelsea and Westminster Hospital, London, UK
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20
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Seto MT, Cheung KW, Lo TK, Ng EH. Pregnancy outcomes of women randomized to receive real versus placebo acupuncture on the day of fresh or frozen-thawed embryo transfer. Eur J Obstet Gynecol Reprod Biol 2017; 218:119-122. [DOI: 10.1016/j.ejogrb.2017.09.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 09/16/2017] [Accepted: 09/22/2017] [Indexed: 11/29/2022]
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Abstract
BACKGROUND In the United States, hyperemesis gravidarum is the most common cause of hospitalization during the first half of pregnancy and is second only to preterm labor for hospitalizations in pregnancy overall. In approximately 0.3-3% of pregnancies, hyperemesis gravidarum is prevalent and this percentage varies on account of different diagnostic criteria and ethnic variation in study populations. Despite extensive research in this field, the mechanism of the disease is largely unknown. Although cases of mortality are rare, hyperemesis gravidarum has been associated with both maternal and fetal morbidity. The current mainstay of treatment relies heavily on supportive measures until improvement of symptoms as part of the natural course of hyperemesis gravidarum, which occurs with progression of gestational age. However, studies have reported that severe, refractory disease manifestations have led to serious adverse outcomes and to termination of pregnancies. SUMMARY Despite extensive research in the field, the pathogenesis of hyperemesis gravidarum remains unknown. Recent literature points to a genetic predisposition in addition to previously studied factors such as infectious, psychiatric, and hormonal contributions. Maternal morbidity is common and includes psychological effects, financial burden, clinical complications from nutritional deficiencies, gastrointestinal trauma, and in rare cases, neurological damage. The effect of hyperemesis gravidarum on neonatal health is still debated in literature with conflicting results regarding outcomes of birth weight and prematurity. Available therapy options remain largely unchanged in the past several decades and focus on parenteral antiemetic medications, electrolyte repletion, and nutritional support. Most studies of therapeutic options do not consist of randomized control studies and cross-study analysis is difficult due to considerable variation of diagnostic criteria. Key Messages: Hyperemesis gravidarum carries a significant burden on maternal health and US health care. Most published research on pathogenesis is observational and suggests multifactorial associations with hyperemesis gravidarum. Precise, strictly defined criteria for clinical diagnosis are likely to benefit meta-analyses of further research studies regarding pathogenesis as well as therapeutic options.
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Affiliation(s)
- Viktoriya London
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, State University of New York (SUNY), Downstate Medical Center, Brooklyn, NY, USA
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22
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Abramowitz A, Miller ES, Wisner KL. Treatment options for hyperemesis gravidarum. Arch Womens Ment Health 2017; 20:363-372. [PMID: 28070660 PMCID: PMC7037589 DOI: 10.1007/s00737-016-0707-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/19/2016] [Indexed: 12/27/2022]
Abstract
Hyperemesis gravidarum (HG) is a severe and prolonged form of nausea and/or vomiting during pregnancy. HG affects 0.3-2% of pregnancies and is defined by dehydration, ketonuria, and more than 5% body weight loss. Initial pharmacologic treatment for HG includes a combination of doxylamine and pyridoxine. Additional interventions include ondansetron or dopamine antagonists such as metoclopramide or promethazine. The options are limited for women who are not adequately treated with these medications. We suggest that mirtazapine is a useful drug in this context and its efficacy has been described in case studies. Mirtazapine acts on noradrenergic, serotonergic, histaminergic, and muscarinic receptors to produce antidepressant, anxiolytic, antiemetic, sedative, and appetite-stimulating effects. Mirtazapine is not associated with an independent increased risk of birth defects. Further investigation of mirtazapine as a treatment for HG holds promise to expand treatment options for women suffering from HG.
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Affiliation(s)
- Amy Abramowitz
- UIC Department of Psychiatry, University of Illinois at Chicago, 912 S. Wood Street, Chicago, IL, 60612, USA.
| | - Emily S Miller
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Katherine L Wisner
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, 303 E. Chicago Ave, Chicago, IL, 60611, USA
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Horn CC, Yates BJ. Biology and control of nausea and vomiting 2015: Perspectives and overview of the conference. Auton Neurosci 2016; 202:3-4. [PMID: 27773432 DOI: 10.1016/j.autneu.2016.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Charles C Horn
- Biobehavioral Oncology Program, University of Pittsburgh Cancer Institute, University of Pittsburgh, Pittsburgh, PA 15213, USA; Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA; Department of Anesthesiology, University of Pittsburgh, Pittsburgh, PA 15213, USA; Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Bill J Yates
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, USA; Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Grooten IJ, Roseboom TJ, Painter RC. Barriers and Challenges in Hyperemesis Gravidarum Research. Nutr Metab Insights 2016; 8:33-9. [PMID: 26917969 PMCID: PMC4755698 DOI: 10.4137/nmi.s29523] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/30/2015] [Accepted: 12/03/2015] [Indexed: 12/27/2022] Open
Abstract
Nausea and occasional vomiting in early pregnancy (NVP) are common. When vomiting is severe or protracted, it is referred to as hyperemesis gravidarum (HG). HG affects up to 3% of pregnancies and is characterized by weight loss, dehydration, electrolyte imbalance, and the need for hospital admission. HG has significant consequences for maternal well-being, is associated with adverse birth outcomes, and leads to major health care costs. Treatment options are symptomatic, hampered by the lack of evidence-based options including studies on nutritional interventions. One of the reasons for this lack of evidence is the use of a broad range of definitions and outcome measures. An internationally accepted definition and the formulation of core outcomes would facilitate meta-analysis of trial results and implementation of evidence in guidelines to ultimately improve patient care.
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Affiliation(s)
- Iris J Grooten
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.; Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Tessa J Roseboom
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands.; Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
| | - Rebecca C Painter
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands
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Matthews A, Haas DM, O'Mathúna DP, Dowswell T. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev 2015; 2015:CD007575. [PMID: 26348534 PMCID: PMC7196889 DOI: 10.1002/14651858.cd007575.pub4] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Nausea, retching and vomiting are very commonly experienced by women in early pregnancy. There are considerable physical, social and psychological effects on women who experience these symptoms. This is an update of a review of interventions for nausea and vomiting in early pregnancy last published in 2014. OBJECTIVES To assess the effectiveness and safety of all interventions for nausea, vomiting and retching in early pregnancy, up to 20 weeks' gestation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, the Cochrane Complementary Medicine Field's Trials Register (19 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA All randomised controlled trials of any intervention for nausea, vomiting and retching in early pregnancy. We excluded trials of interventions for hyperemesis gravidarum, which are covered by another Cochrane review. We also excluded quasi-randomised trials and trials using a cross-over design. DATA COLLECTION AND ANALYSIS Four review authors, in pairs, reviewed the eligibility of trials and independently evaluated the risk of bias and extracted the data for included trials. MAIN RESULTS Forty-one trials involving 5449 women, met the inclusion criteria. These trials covered many interventions, including acupressure, acustimulation, acupuncture, ginger, chamomile, lemon oil, mint oil, vitamin B6 and several antiemetic drugs. There were no included studies of dietary and other lifestyle interventions. Evidence regarding the effectiveness of P6 acupressure, auricular (ear) acupressure and acustimulation of the P6 point was limited. Acupuncture (P6 or traditional) showed no significant benefit to women in pregnancy. The use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent, though three recent studies support ginger over placebo. There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, Doxylamine-pyridoxoine and other anti-emetic drugs to relieve mild or moderate nausea and vomiting. There was little information on maternal and fetal adverse outcomes and on psychological, social or economic outcomes.We were unable to pool findings from studies for most outcomes due to heterogeneity in study participants, interventions, comparison groups, and outcomes measured or reported. The methodological quality of the included studies was mixed. Risk of bias was low related to performance bias, detection bias and attrition bias for most studies. Selection bias risk was unclear for many studies and almost half of the studies did not fully or clearly report all pre-specified outcomes. AUTHORS' CONCLUSIONS Given the high prevalence of nausea and vomiting in early pregnancy, women and health professionals need clear guidance about effective and safe interventions, based on systematically reviewed evidence. There is a lack of high-quality evidence to support any particular intervention. This is not the same as saying that the interventions studied are ineffective, but that there is insufficient strong evidence for any one intervention. The difficulties in interpreting and pooling the results of the studies included in this review highlight the need for specific, consistent and clearly justified outcomes and approaches to measurement in research studies.
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Affiliation(s)
- Anne Matthews
- Dublin City UniversitySchool of Nursing and Human SciencesCollins AvenueDublinIreland9
| | - David M Haas
- Indiana University School of MedicineDepartment of Obstetrics and Gynecology1001 West 10th Street, F‐5IndianapolisIndianaUSA46202
| | - Dónal P O'Mathúna
- Dublin City UniversitySchool of Nursing and Human SciencesCollins AvenueDublinIreland9
| | - Therese Dowswell
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Matthews A, Haas DM, O'Mathúna DP, Dowswell T. Interventions for nausea and vomiting in early pregnancy. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2015. [PMID: 26348534 DOI: 10.1002/14651858.cd007575] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nausea, retching and vomiting are very commonly experienced by women in early pregnancy. There are considerable physical, social and psychological effects on women who experience these symptoms. This is an update of a review of interventions for nausea and vomiting in early pregnancy last published in 2014. OBJECTIVES To assess the effectiveness and safety of all interventions for nausea, vomiting and retching in early pregnancy, up to 20 weeks' gestation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, the Cochrane Complementary Medicine Field's Trials Register (19 January 2015) and reference lists of retrieved studies. SELECTION CRITERIA All randomised controlled trials of any intervention for nausea, vomiting and retching in early pregnancy. We excluded trials of interventions for hyperemesis gravidarum, which are covered by another Cochrane review. We also excluded quasi-randomised trials and trials using a cross-over design. DATA COLLECTION AND ANALYSIS Four review authors, in pairs, reviewed the eligibility of trials and independently evaluated the risk of bias and extracted the data for included trials. MAIN RESULTS Forty-one trials involving 5449 women, met the inclusion criteria. These trials covered many interventions, including acupressure, acustimulation, acupuncture, ginger, chamomile, lemon oil, mint oil, vitamin B6 and several antiemetic drugs. There were no included studies of dietary and other lifestyle interventions. Evidence regarding the effectiveness of P6 acupressure, auricular (ear) acupressure and acustimulation of the P6 point was limited. Acupuncture (P6 or traditional) showed no significant benefit to women in pregnancy. The use of ginger products may be helpful to women, but the evidence of effectiveness was limited and not consistent, though three recent studies support ginger over placebo. There was only limited evidence from trials to support the use of pharmacological agents including vitamin B6, Doxylamine-pyridoxoine and other anti-emetic drugs to relieve mild or moderate nausea and vomiting. There was little information on maternal and fetal adverse outcomes and on psychological, social or economic outcomes.We were unable to pool findings from studies for most outcomes due to heterogeneity in study participants, interventions, comparison groups, and outcomes measured or reported. The methodological quality of the included studies was mixed. Risk of bias was low related to performance bias, detection bias and attrition bias for most studies. Selection bias risk was unclear for many studies and almost half of the studies did not fully or clearly report all pre-specified outcomes. AUTHORS' CONCLUSIONS Given the high prevalence of nausea and vomiting in early pregnancy, women and health professionals need clear guidance about effective and safe interventions, based on systematically reviewed evidence. There is a lack of high-quality evidence to support any particular intervention. This is not the same as saying that the interventions studied are ineffective, but that there is insufficient strong evidence for any one intervention. The difficulties in interpreting and pooling the results of the studies included in this review highlight the need for specific, consistent and clearly justified outcomes and approaches to measurement in research studies.
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Affiliation(s)
- Anne Matthews
- School of Nursing and Human Sciences, Dublin City University, Collins Avenue, Dublin, Ireland, 9
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