What is known about the nutritional intake of women with Hyperemesis Gravidarum?: A scoping review

The IRIS clinic: A Protocol for a mixed-methods study evaluating the management of Hyperemesis Gravidarum

Background

Hyperemesis Gravidarum (HG) is a severe form of nausea and vomiting in pregnancy that affects 0.3-3% of women and has profound nutritional, physical and psychological consequences. Research is lacking regarding the most effective management of the condition. In response to patient feedback, a multidisciplinary HG day-case service (IRIS Clinic) was launched in 2020 at The National Maternity Hospital, Ireland. The clinic provides routine, day-case care in a comfortable space with pre-booked appointments. The MDT involves midwives, dietitians, perinatal mental health, obstetrics and pharmacy, and the nature of the clinic enables peer-to-peer support. As this clinic is the first of its kind in Ireland, we aim to assess its effectiveness and feasibility, and suggest recommendations for improvement.

Methods

This is a sequential, mixed-methods study that commenced in August 2021. The prospective arm of the study is ongoing and involves enrolling women (n = 50) who are attending the IRIS clinic. Data are collected on first admission (pre-intervention) and approximately 8 weeks' later (post-intervention) relating to symptoms of HG, well-being, food tolerances, quality of life and nutritional intake. Qualitative, semi-structured interviews will be conducted to evaluate women's experiences of attending the clinic. The retrospective arm of the study will be a chart review (n = 200) of women diagnosed with HG to describe assessments, treatments and pregnancy and birth outcomes.

Conclusion

The IRIS clinic has the potential to improve pregnancy outcomes and nutritional status among women with HG. If found to be effective and feasible, the model for this clinic could be replicated elsewhere.

The Nutritional Online sUrvey for pRegnancy Induced Sickness & Hyperemesis (NOURISH) study: results from the first trimester

BACKGROUND

Hyperemesis gravidarum (HG) is severe pregnancy sickness, often leading to dehydration, weight loss and electrolyte disturbances. Little is known about nutritional intake and its consequences in those affected. The aim of this study was to explore the first trimester nutritional intake and clinical characteristics in those with severe sickness.

METHOD

Recruitment was via the social media accounts of national pregnancy charities. The eligibility criteria were as follows: between 6 and 11 weeks pregnant, age ≥18 years and residing in the UK. Participants completed a self-report online questionnaire including the Pregnancy Unique Quantification of Emesis 24 (PUQE24) score and a 3-day online diet diary. Groups were compared by PUQE24 categories. Nutritional intakes were compared to dietary reference values.

RESULTS

One hundred sixty-six participants took part in the study: 36 categorised with mild, 109 with moderate and 21 with severe symptoms at a median gestation of 8.1 (interquartile range [IQR] 3) weeks. Those in the severe category had significantly higher weight loss (3.0 kg, IQR 3.5) than the mild category (0.0 kg, IQR 0.9). In those who completed the diet diary (n = 70), intakes of energy, carbohydrate, protein, fat, fibre, calcium, iron, zinc, thiamine, riboflavin, folate and vitamin C were all significantly lower in the severe category (p < 0.05). The severe group consumed only 39.5% and 41.6% of energy and protein needs, respectively, and were more likely to stop taking micronutrient supplements (p < 0.05).

CONCLUSION

Nutritional and supplement intake in those with severe pregnancy sickness was poor; however, intake across all participants was suboptimal. Future research should investigate how to improve nutritional intake across all categories of pregnancy sickness.

Watermelon and dietary advice compared to dietary advice alone following hospitalization for hyperemesis gravidarum: a randomized controlled trial

BACKGROUND

Hyperemesis gravidarum (HG) affects about 2% of pregnancies and is at the severe end of the spectrum of nausea and vomiting of pregnancy. HG causes severe maternal distress and results in adverse pregnancy outcomes long after the condition may have dissipated. Although dietary advice is a common tool in management, trial evidence to base the advice on is lacking.

METHODS

A randomized trial was conducted in a university hospital from May 2019 to December 2020. 128 women at their discharge following hospitalization for HG were randomized: 64 to watermelon and 64 to control arm. Women were randomized to consume watermelon and to heed the advice leaflet or to heed the dietary advice leaflet alone. A personal weighing scale and a weighing protocol were provided to all participants to take home. Primary outcomes were bodyweight change at the end of week 1 and week 2 compared to hospital discharge.

RESULTS

Weight change (kg) at end of week 1, median[interquartile range] -0.05[-0.775 to + 0.50] vs. -0.5[-1.4 to + 0.1] P = 0.014 and to the end of week 2, + 0.25[-0.65 to + 0.975] vs. -0.5[-1.3 to + 0.2] P = 0.001 for watermelon and control arms respectively. After two weeks, HG symptoms assessed by PUQE-24 (Pregnancy-Unique Quantification of Emesis and Nausea over 24 h), appetite assessed by SNAQ (Simplified Nutritional Appetite Questionnaire), wellbeing and satisfaction with allocated intervention NRS (0-10 numerical rating scale) scores, and recommendation of allocated intervention to a friend rate were all significantly better in the watermelon arm. However, rehospitalization for HG and antiemetic usage were not significantly different.

CONCLUSION

Adding watermelon to the diet after hospital discharge for HG improves bodyweight, HG symptoms, appetite, wellbeing and satisfaction.

TRIAL REGISTRATION

This study was registered with the center's Medical Ethics Committee (on 21/05/2019; reference number 2019327-7262) and the ISRCTN on 24/05/2019 with trial identification number: ISRCTN96125404 . First participant was recruited on 31/05/ 2019.

Diet Quality and Nutritional Risk Based on the FIGO Nutrition Checklist among Greek Pregnant Women: A Cross-Sectional Routine Antenatal Care Study

The International Federation of Gynecology and Obstetrics (FIGO) nutrition checklist is a tool for everyday antenatal clinical practice, easy to use by most healthcare professionals, aiming to initiate a conversation regarding gestational weight gain (GWG) and nutrition and identify women who might require further assessment. The present cross-sectional study aimed to apply the FIGO nutrition checklist to pregnant women attending routine antenatal care and identify nutritional risk factors. Pregnant women (n = 200) were recruited from the outpatient pregnancy clinics of two hospitals in Thessaloniki and completed the checklist. The FIGO-diet quality score and the FIGO-nutritional risk score (NRS) were calculated. The results revealed that 99% of the women exhibited at least one nutritional risk factor based on the checklist. The median FIGO diet quality score of the sample was 4.0 (3.0-5.0), with 95% of the participants responding negatively to at least one question, indicating the need for improving diet quality. Improved diet quality was noted in cases of hyperemesis gravidarum and among those receiving vitamin D supplements. A large percentage of the participants (36%) exhibited five or more nutritional risk factors, as indicated by a total FIGO-NRS below 5. Women with low middle-upper arm circumference, indicative of protein-energy malnutrition (20.6% of the sample), exhibited more nutritional risk factors compared with the rest. On the other hand, being in the third trimester of pregnancy was associated with lower nutritional risk and, subsequently, better diet quality.

Nausea and Vomiting during Early Pregnancy among Chinese Women and Its Association with Nutritional Intakes

Nausea and vomiting in pregnancy (NVP) is one of the most common uncomfortable symptoms of women in early pregnancy. A total of 303 Chinese pregnant women from 10 urban cities in their first trimester were recruited in this study to collect their sociodemographic characteristics and their NVP occurrence. Their dietary nutrient and food intakes were also collected by a 24 h dietary recall and a semi-quantitative food frequency questionnaire (SFFQ). Using the univariate analysis and multiple linear regression analysis to estimate the correlation between NVP and dietary intake, we found that 255 (84.1%) pregnant women experienced NVP during their first trimester. The intake of energy, protein, fat, vitamin A, thiamin, riboflavin, vitamin E, phosphorus, potassium, iron and zinc was lower in women with NVP than in those with no NVP. Additionally, women with NVP were more likely to have insufficient intake of protein, riboflavin, calcium, phosphorus and selenium. In terms of specific food groups, the average daily intake of mushrooms, algae, nuts and seeds, meat, eggs and dairy products in the NVP group was lower. Women in the severe NVP group even had insufficient gestational weight gain. We should pay more attention to women who experience nausea and vomiting during pregnancy and provide them with targeted nutritional support.

Hyperemesis gravidarum severity, enteral tube feeding and cardiometabolic markers in offspring cord blood

This study aimed to investigate the association between hyperemesis gravidarum (HG) severity and early enteral tube feeding on cardiometabolic markers in offspring cord blood. We included women admitted for HG, who participated in the MOTHER randomised controlled trial (RCT) and observational cohort. The MOTHER RCT showed that early enteral tube feeding in addition to standard care did not affect symptoms/birth outcomes. Among RCT and cohort participants, we assessed how HG severity affected lipid, c-peptide, glucose and free thyroxine cord blood levels. HG severity measures were severity of vomiting at inclusion and 3 weeks after inclusion, pregnancy weight gain and 24-h energy intake at inclusion, readmissions and duration of hospital admissions. Cord blood measures were also compared between RCT participants allocated to enteral tube feeding and those receiving standard care. Between 2013-2016, 215 women were included: 115 RCT and 100 cohort participants. Eighty-one cord blood samples were available. Univariable not multivariable regression analysis showed that lower maternal weight gain was associated with higher cord blood glucose levels (β: -0·08, 95% CI -0·16, -0·00). Lower maternal weight gain was associated with higher Apo-B cord blood levels in multivariable regression analysis (β: -0·01, 95% CI -0·02, -0·01). No associations were found between other HG severity measures or allocation to enteral tube feeding and cord blood cardiometabolic markers. In conclusion, while lower maternal weight gain was associated with higher Apo-B cord blood levels, no other HG severity measures were linked with cord blood cardiometabolic markers, nor were these markers affected by enteral tube feeding.

Zinc Deficiency-Associated Dysgeusia Preventing the Improvement of Severe Hyperemesis Gravidarum

A 23-year-old primigravida visited the hospital frequently since the early phase of her pregnancy because of severe hyperemesis gravidarum. She was hospitalized for the same at 14 weeks and 1 day of pregnancy. After admission, peripheral intravenous nutrition was started; however, her symptoms did not improve. At 17 weeks and 1 day of gestation, a blood sample was collected to determine the presence of trace element deficiencies, and a zinc deficiency was revealed. We examined the patient's symptoms and found that she had developed dysgeusia. After receiving a zinc preparation, her taste disorder gradually improved, and her oral intake increased. Her hyperemesis gravidarum resolved, and she was discharged from the hospital at 18 weeks and 2 days of gestation. The findings from this case suggest that prolonged peripheral intravenous nutrition in patients with severe hyperemesis gravidarum can lead to zinc deficiency and impede the successful treatment of hyperemesis gravidarum.

Systematic evidence map of evidence addressing the top 10 priority research questions for hyperemesis gravidarum

OBJECTIVE

Knowledge gaps regarding hyperemesis gravidarum (HG) are substantial. We aimed to systematically identify and map recent evidence addressing the top 10 priority questions for HG, as published in 2021 in a James Lind Alliance Priority Setting Partnership.

DESIGN

Systematic evidence map.

METHODS

We searched MEDLINE and EMBASE on 12 January 2021 and CINAHL on 22 February 2021 with search terms hyperemesis gravidarum, pernicious vomiting in pregnancy and their synonyms. Results were limited to 2009 onwards. Two reviewers independently screened titles and abstracts to assess whether the studies addressed a top 10 priority questions for HG. Differences were discussed until consensus was reached. Publications were allocated to one or more top 10 research questions. Study design was noted, as was patient or public involvement. Two reviewers extracted data synchronously and both cross-checked 10%. Extracted data were imported into EPPI-Reviewer software to create an evidence map.

OUTCOME MEASURES

The number and design of studies in the search yield, displayed per the published 10 priority questions.

RESULTS

Searches returned 4338 results for screening; 406 publications were included in the evidence map. 136 publications addressed multiple questions. Numerous studies address the immediate and long-term outcomes or possible markers for HG (question 8 and 9, respectively 164 and 82 studies). Very few studies seek a possible cure for HG (question 1, 8 studies), preventative treatment (question 4, 2 studies) or how to achieve nutritional requirements of pregnancy (question 10, 17 studies). Case reports/series were most numerous with 125 (30.7%) included. Few qualitative studies (9, 2.2%) were identified. 25 (6.1%) systematic reviews addressed eight questions, or aspects of them. 31 (7.6%) studies included patient involvement.

CONCLUSIONS

There are significant gaps and overlap in the current HG literature addressing priority questions. Researchers and funders should direct their efforts at addressing the gaps in the top 10 questions.

Long-term health outcomes of children born to mothers with hyperemesis gravidarum: a systematic review and meta-analysis

OBJECTIVE

Hyperemesis gravidarum is characterized by severe nausea and vomiting in pregnancy, frequently resulting in severe maternal nutritional deficiency. Maternal undernutrition is associated with adverse offspring health outcomes. Whether hyperemesis gravidarum permanently affects offspring health remains unclear. This review aimed to evaluate the effects of maternal hyperemesis gravidarum on offspring health.

DATA SOURCES

MEDLINE and Embase were searched from inception to September 6, 2021.

STUDY ELIGIBILITY CRITERIA

Studies reporting on health at any age beyond the perinatal period of children born to mothers with hyperemesis gravidarum were included.

METHODS

Two reviewers independently selected studies and extracted data. The Newcastle-Ottawa Quality Assessment Scale was used to assess risk of bias. We conducted a narrative synthesis and meta-analysis where possible. In meta-analyses with high heterogeneity (I²>75%), we did not provide a pooled odds ratio.

RESULTS

Nineteen studies were included in this systematic review (n=1,814,785 offspring). Meta-analysis (n=619, 2 studies: 1 among adolescents and 1 among adults) showed that hyperemesis gravidarum was associated with anxiety disorder (odds ratio, 1.74; 95% confidence interval, 1.04-2.91; I², 0%) and sleep problems in offspring (odds ratio, 2.94; 95% confidence interval, 1.25-6.93; I², 0%). Hyperemesis gravidarum was associated with testicular cancer in male offspring aged up to 40 years on meta-analysis (5 studies, n=20,930 offspring), although heterogeneity was observed on the basis of a wide 95% prediction interval (odds ratio, 1.60; 95% confidence interval, 1.07-2.39; I², 0%; 95% prediction interval, 0.83-3.08). All 6 studies reporting on attention deficit (hyperactivity) disorder and autism spectrum disorder reported an increase among children of mothers with hyperemesis gravidarum in comparison with children of unaffected mothers. Meta-analysis showed high heterogeneity, precluding us from reporting a pooled odds ratio. Most studies reporting on cognitive and motor problems found an increase among hyperemesis gravidarum-exposed children. One study investigated brain structure and found smaller cortical volumes and areas among children from hyperemesis gravidarum-affected pregnancies than among those from unaffected pregnancies. Studies evaluating anthropometry and cardiometabolic disease risk of hyperemesis gravidarum-exposed children had inconsistent findings.

CONCLUSION

Our systematic review showed that maternal hyperemesis gravidarum is associated with small increases in adverse health outcomes among children, including neurodevelopmental disorders, mental health disorders, and possibly testicular cancer, although evidence is based on few studies of low quality.

Lack of catch-up in weight gain may intermediate between pregnancies with hyperemesis gravidarum and reduced fetal growth: the Japan Environment and Children’s Study

Background

Women with nausea and vomiting of pregnancy (NVP) have higher birth weight infants, while those with hyperemesis gravidarum, a severe manifestation of NVP, have lower birth weight infants. We aimed to investigate the associations between maternal weight loss (a consequence of hyperemesis gravidarum), NVP, and infant birth weight.

Methods

This study was a secondary analysis of a nationwide birth cohort in Japan. Singleton pregnancies delivered at 28–41 weeks of gestation were included in the analysis. Women were categorized based on their weight change in the 1^st trimester (as a proportion to their pre-pregnancy weight: >  + 3%, > 0 to + 3%, > -3 to 0%, > -5 to -3%, ≤ -5%) and severity of NVP (no nausea, only nausea, vomiting but able to eat, vomiting and unable to eat). The effects of weight change and severity of NVP on infant birth weight and small for gestational age (SGA) were assessed using regression models. We further examined how these effects could be modified by maternal weight gain up to the 2^nd trimester.

Results

Among 91,313 women, 5,196 (5.7%) lost ≥ 5% of their pre-pregnancy weight and 9,983 (10.9%) experienced vomiting and were unable to eat in the 1^st trimester. Women with weight loss ≥ 5% in the 1^st trimester had infants 66 (95% CI: 53, 78) g lighter and higher odds of SGA (aOR: 1.29; 95% CI: 1.14, 1.47) than women who gained > 3% during the same period. However, when adjusting for weight gain up to the 2^nd trimester, women with weight loss ≥ 5% in the 1^st trimester had infants 150 (95% CI: 135, 165) g heavier and lower odds of SGA (aOR: 0.39; 95% CI: 0.33, 0.46) than those who gained > 3% during the same period. In contrast, women with more severe NVP tended to have infants with larger birth weight and lower odds of SGA compared to women without NVP. These trends were strengthened when adjusting for weight gain up to the 2^nd trimester.

Conclusions

Our study suggests the possibility that reduced fetal growth in pregnancies with hyperemesis gravidarum may be caused by the lack of catch-up in gestational weight gain up to the 2^nd trimester.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04542-0.

Weight loss among pregnant women hospitalized because of hyperemesis gravidarum: Is there a lack of nutrition intervention?

BACKGROUND

Nutrition therapy is a key component in the management of hyperemesis gravidarum (HG). The aim of this study was to describe sociodemographic, anthropometric, and nutrition aspects of pregnant women hospitalized because of HG and raise a discussion about the nutrition care provided.

MATERIALS AND METHODS

This is a retrospective descriptive study that includes 26 pregnant women with confirmed diagnosis of HG who were hospitalized because of this condition in a tertiary hospital. Data of interest were collected from official medical records and analyzed to obtain measures of central tendency and dispersion, as well as frequencies.

RESULTS

The studied individuals had a mean age of 25.7 years and a low level of education, and 65% of them were single mothers. They registered a low weight gain (2.8 kg) during pregnancy and in the course of their hospitalization, during which they lost an average of 1.7 kg, showing a decline in nutrition status during this period. Although the average intake of oral diet (OD) was 55% during hospital stay and only 5% of the studied population met caloric needs through OD, the prescription of complementary medical nutrition therapy (oral supplements, enteral or parenteral nutrition) was scarcely observed in this sample.

CONCLUSION

Despite the negative impact that HG can impose on the mother's nutrition status and the known benefits that complementary nutrition therapies can provide, few nutrition interventions have been carried out to improve this situation. That indicates an urgent need for implementation or reviewing of nutrition assistance protocols for HG patients.

Nutritional consequences and management of hyperemesis gravidarum: a narrative review

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.

The Contribution of Registered Dietitians in the Management of Hyperemesis Gravidarum in the United Kingdom

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.