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Clark SM, Zhang X, Goncharov DA. Inpatient Management of Hyperemesis Gravidarum. Obstet Gynecol 2024; 143:745-758. [PMID: 38301258 DOI: 10.1097/aog.0000000000005518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/16/2023] [Indexed: 02/03/2024]
Abstract
Hyperemesis gravidarum has a reported incidence of approximately 0.3-3% of pregnancies. Without treatment, refractory hyperemesis gravidarum can result in dehydration, electrolyte deficiencies, and severe nutritional deficiencies, resulting in significant maternal morbidity. The overall goals of inpatient management of refractory hyperemesis gravidarum are the resumption of oral intake to an adequate level to maintain hydration and nutrition, including the ability to tolerate oral pharmacotherapy. Patients initially are stabilized with rehydration and electrolyte repletion. There are numerous pharmacotherapeutics available that can be administered intravenously to control symptoms when oral intake is not an option. However, despite maximizing typical antiemetics, there will be cases refractory to these medications, and alternative pharmacotherapeutics and nutrition-support modalities must be considered. Mirtazapine, olanzapine, corticosteroids, and gabapentin are examples of alternative pharmacotherapeutics, and enteral and parenteral nutrition are alternative therapies that can be used when oral intake is not tolerated for prolonged time periods with ongoing weight loss. In refractory cases of hyperemesis gravidarum, the risks and benefits of these alternative forms of management must be considered, along with the risks of undertreated hyperemesis gravidarum and the overall effect of hyperemesis gravidarum on patients' quality of life.
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Affiliation(s)
- Shannon M Clark
- University of Texas Medical Branch at Galveston, Galveston, Texas
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Joshi A, Chadha G, Narayanan P. From Discomfort to Distress: A Critical Analysis of Hyperemesis Gravidarum in the Emergency Room. Cureus 2023; 15:e44004. [PMID: 37746494 PMCID: PMC10516742 DOI: 10.7759/cureus.44004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Hyperemesis gravidarum (HG) is a severe and debilitating condition characterized by persistent and excessive nausea and vomiting during pregnancy (NVP), often leading to significant maternal and fetal morbidity. This literature review aims to provide a scientifically comprehensive overview of HG within the context of the emergency room (ER) setting. This review aims to enhance understanding and improve the management of HG cases presented to the ER by synthesizing current knowledge and evidence-based practices. This literature review encompasses a systematic analysis of relevant scientific literature, encompassing original research studies, review articles, and clinical guidelines. An extensive search of electronic databases was conducted, covering the period from January 2003 to January 2023. Keywords related to HG, pregnancy-related complications, emergency medicine, and ER management were employed to identify pertinent publications. Through the literature review, we found the incidence of HG-related ER admission to be 0.8%. Although the etiology of HG remains to be unknown, a strong association was found between developing HG in pregnant females and a history of gastrointestinal (GI) disorders, use of cannabis, and pregnancies conceived through artificial reproductive technology (ART). Furthermore, overweight females were more likely to develop HG. Maternal smoking was found to be protective against HG. The symptoms of HG mainly include intractable nausea and vomiting occurring usually between four and nine weeks of gestational age with a significant aversion to food and loss of weight. Diagnosis is done through a strong clinical suspicion, a history of HG in previous pregnancies, and a basic metabolic panel. Treatment includes intravenous (IV) fluids, antiemetic therapy, corticoids, thiamine supplements, and laxatives. In our review, we highlight a few complications that can be seen in HG through a synopsis of unique case reports found during our literature search. In conclusion, through this review, we wish to highlight HG as an obstetrical emergency. We aim to improve understanding, enhance early recognition, and promote evidence-based management strategies for HG in the emergency room. We hope that the findings presented herein will serve as a valuable resource for healthcare professionals, researchers, and policymakers involved in the care of pregnant females experiencing HG in the ER.
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Affiliation(s)
- Arushi Joshi
- Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Garima Chadha
- Emergency Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Palaniappan Narayanan
- Obstetrics and Gynecology, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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Saz-Leal P, Zamorano-Domínguez L, Frías J, Guerra P, Saura-Valls M, Roca-Juanes R, Nebot-Troyano J, García-Aguilar E, Vilchez T, Urso K. Bioavailability of Cariban ® Capsules: A Modified-Release Fixed-Dose Combination of Doxylamine and Pyridoxine to Relieve Nausea and Vomiting During Pregnancy. Drugs R D 2023:10.1007/s40268-023-00425-7. [PMID: 37318714 DOI: 10.1007/s40268-023-00425-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Nausea and vomiting is a very prevalent condition during pregnancy. Combination of doxylamine and pyridoxine is placed as first-line pharmacological option for its treatment in most clinical guidelines. Among different release forms available, Cariban® is a fixed-dose combination of doxylamine/pyridoxine 10/10 mg, formulated as modified-release capsules. OBJECTIVES In the present study, we aimed to characterize the bioavailability performance of Cariban® in vitro and in vivo. METHODS An in vitro dissolution test was performed to evaluate the release profile of Cariban®, together with immediate- and delayed-release formulations available on the market. A single-center, single-dose, open-label bioavailability study following Cariban® administration in 12 healthy adult female patients was carried out to explore the drug behavior in vivo (protocol NBR-002-13; EUDRA-CT 2013-005422-35). These data were additionally used to perform a computational pharmacokinetic simulation of the posology approved for this drug. RESULTS Cariban® capsules demonstrate a prolonged-release performance, with an early, gradual, and progressive release of both actives until reaching a complete dissolution after 4-5 h in solution. The pharmacokinetic features of these capsules show that doxylamine and pyridoxine metabolites are early absorbed, being all detectable in plasma within 1 h following oral administration. Computational pharmacokinetic simulation predicts that different posology provides distinct profiles of metabolites in plasma, with 1-1-2 (morning-midafternoon-night) being the one that concentrates higher plasma levels but lower dose dumping for 24 h. CONCLUSION Cariban® behaves as a prolonged-release formulation, which correlates with rapid absorption and arising of the actives in the plasma, but also long-lasting and sustained bioavailability, especially when administered following the complete posology. These results would underlie its demonstrated efficacy to relieve nausea and vomiting of pregnancy (NVP) under clinical settings.
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Affiliation(s)
- Paula Saz-Leal
- Medical Department, ITF Research Pharma S.L.U., Alcobendas, Spain
| | | | - Jesús Frías
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Autonomous University of Madrid, Madrid, Spain
| | - Pedro Guerra
- Clinical Pharmacology Department, La Paz University Hospital, School of Medicine, IdiPAZ, Autonomous University of Madrid, Madrid, Spain
| | | | | | | | | | - Tatiana Vilchez
- Medical Department, ITF Research Pharma S.L.U., Alcobendas, Spain
| | - Katia Urso
- R&D Department, ITF Research Pharma S.L.U., Alcobendas, Spain.
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Fisher A, Paterson JM, Winquist B, Wu F, Reynier P, Suissa S, Dahl M, Ma Z, Lu X, Zhang J, Raymond CB, Filion KB, Platt RW, Moriello C, Dormuth CR. Patterns of antiemetic medication use during pregnancy: A multi-country retrospective cohort study. PLoS One 2022; 17:e0277623. [PMID: 36454900 PMCID: PMC9714905 DOI: 10.1371/journal.pone.0277623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 10/31/2022] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE To compare patterns in use of different antiemetics during pregnancy in Canada, the United Kingdom, and the United States, between 2002 and 2014. METHODS We constructed population-based cohorts of pregnant women using administrative healthcare data from five Canadian provinces (Alberta, British Columbia, Manitoba, Ontario, and Saskatchewan), the Clinical Practice Research Datalink from the United Kingdom, and the IBM MarketScan Research Databases from the United States. We included pregnancies ending in live births, stillbirth, spontaneous abortion, or induced abortion. We determined maternal use of antiemetics from pharmacy claims in Canada and the United States and from prescriptions in the United Kingdom. RESULTS The most common outcome of 3 848 734 included pregnancies (started 2002-2014) was live birth (66.7% of all pregnancies) followed by spontaneous abortion (20.2%). Use of antiemetics during pregnancy increased over time in all three countries. Canada had the highest prevalence of use of prescription antiemetics during pregnancy (17.7% of pregnancies overall, 13.2% of pregnancies in 2002, and 18.9% in 2014), followed by the United States (14.0% overall, 8.9% in 2007, and 18.1% in 2014), and the United Kingdom (5.0% overall, 4.2% in 2002, and 6.5% in 2014). Besides use of antiemetic drugs being considerably lower in the United Kingdom, the increase in its use over time was more modest. The most commonly used antiemetic was combination doxylamine/pyridoxine in Canada (95.2% of pregnancies treated with antiemetics), ondansetron in the United States (72.2%), and prochlorperazine in the United Kingdom (63.5%). CONCLUSIONS In this large cohort study, we observed an overall increase in antiemetic use during pregnancy, and patterns of use varied across jurisdictions. Continued monitoring of antiemetic use and further research are warranted to better understand the reasons for differences in use of these medications and to assess their benefit-risk profile in this population.
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Affiliation(s)
- Anat Fisher
- Faculty of Medicine, Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada,* E-mail:
| | - J. Michael Paterson
- ICES, Toronto, Ontario, Canada,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Brandace Winquist
- College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada,Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada
| | | | - Pauline Reynier
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Quebec, Canada
| | - Samy Suissa
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada
| | - Matthew Dahl
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Zhihai Ma
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Xinya Lu
- Saskatchewan Health Quality Council, Saskatoon, Saskatchewan, Canada
| | - Jianguo Zhang
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Colette B. Raymond
- Manitoba Centre for Health Policy, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kristian B. Filion
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Quebec, Canada,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada,Department of Medicine, McGill University, Montréal, Quebec, Canada
| | - Robert W. Platt
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Quebec, Canada,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada,Department of Pediatrics, McGill University, Montréal, Quebec, Canada
| | - Carolina Moriello
- Center for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montréal, Quebec, Canada
| | - Colin R. Dormuth
- Faculty of Medicine, Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
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Deruelle P, Sentilhes L, Ghesquière L, Desbrière R, Ducarme G, Attali L, Jarnoux A, Artzner F, Tranchant A, Schmitz T, Sénat MV. [Expert consensus from the College of French Gynecologists and Obstetricians: Management of nausea and vomiting of pregnancy and hyperemesis gravidarum]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:700-711. [PMID: 36150647 DOI: 10.1016/j.gofs.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 09/14/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To determine the management of patients with 1st trimester nausea and vomiting and hyperemesis gravidarum. METHODS A panel of experts participated in a formal consensus process, including focus groups and two Delphi rounds. RESULTS Hyperemesis gravidarum is distinguished from nausea and vomiting during pregnancy by weight loss≥5 % or signs of dehydration or a PUQE score≥7. Hospitalization is proposed when there is, at least, one of the following criteria: weight loss≥10%, one or more clinical signs of dehydration, PUQE (Pregnancy Unique Quantification of Emesis and nausea) score≥13, hypokalemia<3.0mmol/L, hyponatremia<120mmol/L, elevated serum creatinine>100μmol/L or resistance to treatment. Prenatal vitamins and iron supplementation should be stopped without stopping folic acid supplementation. Diet and lifestyle should be adjusted according to symptoms. Aromatherapy is not to be used. If the PUQE score is<6, even in the absence of proof of their benefit, ginger, pyridoxine (B6 vitamin), acupuncture or electrostimulation can be used, even in the absence of proof of benefit. It is proposed that drugs or combinations of drugs associated with the least severe and least frequent side effects should always be chosen for uses in 1st, 2nd or 3rd intention, taking into account the absence of superiority of a class over another to reduce the symptoms of nausea and vomiting of pregnancy and hypermesis gravidarum. To prevent Gayet Wernicke encephalopathy, Vitamin B1 must systematically be administered for hyperemesis gravidarum needing parenteral rehydration. Patients hospitalized for hyperemesis gravidarum should not be placed in isolation (put in the dark, confiscation of the mobile phone or ban on visits, etc.). Psychological support should be offered to all patients with hyperemesis gravidarum as well as information on patient' associations involved in supporting these women and their families. When returning home after hospitalization, care will be organized around a referring doctor. CONCLUSION This work should contribute to improving the care of women with hyperemesis gravidarum. However, given the paucity in number and quality of the literature, researchers must invest in the field of nausea and vomiting in pregnancy, and HG to identify strategies to improve the quality of life of women with nausea and vomiting in pregnancy or hyperemesis gravidarum.
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Affiliation(s)
- P Deruelle
- UNISTRA, département de gynécologie-obstétrique, hôpitaux universitaires de Strasbourg, 67000 Strasbourg cedex, France.
| | - L Sentilhes
- Department of obstetrics and gynecology, Bordeaux university hospital, Bordeaux, France
| | - L Ghesquière
- ULR 2694 - METRICS - évaluation des technologies de santé et des pratiques médicales, university Lille, CHU Lille, 59000 Lille, France; Department of obstetrics, CHU Lille, 59000 Lille, France
| | | | - G Ducarme
- Service de gynécologie obstétrique, centre hospitalier départemental Vendée, 85000 La Roche-sur-Yon, France
| | - L Attali
- UNISTRA, département de gynécologie-obstétrique, hôpitaux universitaires de Strasbourg, 67000 Strasbourg cedex, France
| | | | - F Artzner
- Association 9mois avec ma bassine, France
| | - A Tranchant
- Association de lutte contre l'hyperémèse gravidique, France
| | - T Schmitz
- Université Paris Cité, 75006 Paris, France; Service de gynécologie obstétrique, hôpital Robert-Debré, Assistance publique-Hôpitaux de Paris, Paris, France
| | - M-V Sénat
- Department of obstetrics and gynecology, Bicêtre hospital, Assistance publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France
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Gastroparesis in pregnancy. Am J Obstet Gynecol 2022; 228:382-394. [PMID: 36088986 DOI: 10.1016/j.ajog.2022.09.002] [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: 04/23/2022] [Revised: 08/21/2022] [Accepted: 09/05/2022] [Indexed: 01/30/2023]
Abstract
Gastroparesis is a functional gastrointestinal disorder that more commonly affects women, with most cases being diagnosed during childbearing age. However, there is a paucity of data and guidelines to specifically highlight the epidemiology, disease course, maternal and fetal impact, and the management of existing gastroparesis during pregnancy. Apart from metoclopramide, there is no approved therapy specifically indicated for gastroparesis. More importantly, pregnant and breastfeeding women are excluded from clinical trials evaluating pharmacologic agents in the management of gastroparesis. This poses a real challenge to healthcare providers in counseling and managing patients with gastroparesis. In this systematic review, we summarize the current available literature and the knowledge gaps in the impact of pregnancy on gastroparesis and vice versa. We also highlight the efficacy and safety profiles of available pharmacologic and nonpharmacologic therapies in the management of patients with gastroparesis, with emphasis on judicious use of dietary approaches that are deemed relatively safe during pregnancy.
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Erdal H, Holst L, Heitmann K, Trovik J. Antiemetic treatment of hyperemesis gravidarum in 1,064 Norwegian women and the impact of European warning on metoclopramide: a retrospective cohort study 2002–2019. BMC Pregnancy Childbirth 2022; 22:464. [PMID: 35655181 PMCID: PMC9161510 DOI: 10.1186/s12884-022-04777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/20/2022] [Indexed: 11/10/2022] Open
Abstract
Background Women suffering from severe nausea and vomiting during pregnancy, hyperemesis gravidarum, have poor quality of life and increased risk of potentially fatal maternal and fetal complications. There is increasing and reassuring knowledge about safety of antiemetics in pregnancy. In 2013, the European Medical Agency (EMA) issued a warning on metoclopramide limiting treatment to maximum five days. Metoclopramide was the most used antiemetic in pregnancy at the time the warning was implemented in the Norwegian hyperemesis guidelines (2014). We aimed at describing changes in the treatment of hyperemesis over time, including changes associated with the EMA warning. Methods Retrospective chart review of all women hospitalized for hyperemesis gravidarum with metabolic disturbances between 01/Jan/2002 and 31/Dec/2019 at a university hospital serving nearly 10% of the pregnant population in Norway. Time-series analysis described changes over time and interrupted time series analysis quantified changes in treatment and clinical outcomes related to the EMA warning. Results In total, 1,064 women (1.2% of the birthing population) were included. The use of meclizine, prochlorperazine, and ondansetron increased during 2002–2019. This led to a yearly increase in the percentage of women using any antiemetic of 1.5% (95%CI 0.6; 2.4) pre-hospital, 0.6% (95%CI 0.2; 1.1) during hospitalization, and 2.6% (95%CI 1.3; 3.8) at discharge. Overall, only 50% of the women received antiemetics pre-hospital. Following the EMA warning, prehospital use of metoclopramide dropped by 30% (95%CI 25; 36), while use of any antiemetic pre-hospital dropped by 20% (95%CI 5.7; 34). In timely association, we observed a decrease in gestational age (-3.8 days, 98.75%CI 0.6; 7.1) at first admission, as well as indication of increased rate of termination of pregnancy with an absolute increase of 4.8% (98.75%CI 0.9; 8.7) in 2014. Conclusion During 2002–2019, the overall use of antiemetics in treatment of hyperemesis increased. The EMA-warning on metoclopramide in 2013 temporarily limited pre-hospital antiemetic provision associated with hospitalization at lower gestational length and indication of an increase in termination of pregnancy.
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Keskin M, Çandar T, Çoban M, Ataç KG, Gürsoy AY, Çağlar GS. Evaluation of plasma cholecystokinin levels and gallbladder functions in hyperemesis gravidarum: a prospective cohort study. J OBSTET GYNAECOL 2022; 42:2463-2468. [DOI: 10.1080/01443615.2022.2054677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Müge Keskin
- Department of Obstetrics and Gynecology, Ufuk University Faculty of Medicine, Ankara, Turkey
| | - Tuba Çandar
- Department of Clinical Biochemistry, Ufuk University Faculty of Medicine, Ankara, Turkey
| | - Mehmet Çoban
- Department of Gastroenterology, Ufuk University Faculty of Medicine, Ankara, Turkey
| | - Kaan Gökçe Ataç
- Department of Radiology, Ufuk University Faculty of Medicine, Ankara, Turkey
| | - Aslı Yarci Gürsoy
- Department of Obstetrics and Gynecology, Ufuk University Faculty of Medicine, Ankara, Turkey
| | - Gamze Sinem Çağlar
- Department of Obstetrics and Gynecology, Ufuk University Faculty of Medicine, Ankara, Turkey
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Slattery J, Quinten C, Candore G, Pinheiro L, Flynn R, Kurz X, Nordeng H. Ondansetron use in nausea and vomiting during pregnancy: a descriptive analysis of prescription patterns and patient characteristics in UK general practice. Br J Clin Pharmacol 2022; 88:4526-4539. [PMID: 35483963 PMCID: PMC9545331 DOI: 10.1111/bcp.15370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/01/2022] [Accepted: 04/03/2022] [Indexed: 11/26/2022] Open
Abstract
Aims The objective of this study was to describe ondansetron drug utilization patterns during pregnancy to treat nausea and vomiting in pregnancy (NVP). Moreover, we aimed to describe the maternal factors associated with NVP and antiemetic use. Methods The data consist of pregnancies with a live birth(s) within an IMRD‐UK registered GP practice. Descriptive statistics were used to investigate patterns of ondansetron use in pregnancy and to describe maternal characteristics associated with NVP and antiemetic drug utilization. We differentiate first‐ from second‐line use during pregnancy using antiemetic prescription pathways. Results The dataset included 733 633 recorded complete pregnancies from 2005 to 2019. NVP diagnosis and ondansetron prescription prevalence increased from 2.7% and 0.1% in 2005 to 4.8% and 2.5% in 2019 respectively. Over the period 2015–2019, the most common oral daily dosages were 4 mg/d (8.5%), 8 mg/d (37.1%), 12 mg/d (37.5%) and between 16 and 24 mg/d (16.9%). Prescription of ondansetron was initiated during the first trimester of pregnancy in 40% of the cases and was moderately used as a first‐line therapy (2.8%), but preferred choice of second‐line therapy. Women with mental health disorders, asthma and/or prescribed folic acid were more likely to experience NVP and use antiemetics in pregnancy than their counterparts. Conclusion This study confirms that ondansetron is increasingly used off‐label to treat NVP during pregnancy, also in the first trimester and before other prescription antiemetics have been prescribed. Several maternal comorbidities and folic acid use were more common among women experiencing NVP and using antiemetics, including ondansetron.
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Affiliation(s)
- Jim Slattery
- Data Analytics TaskforceEuropean Medicines AgencyAmsterdamThe Netherlands
| | - Chantal Quinten
- Data Analytics TaskforceEuropean Medicines AgencyAmsterdamThe Netherlands
| | - Gianmario Candore
- Data Analytics TaskforceEuropean Medicines AgencyAmsterdamThe Netherlands
| | - Luis Pinheiro
- Data Analytics TaskforceEuropean Medicines AgencyAmsterdamThe Netherlands
| | - Robert Flynn
- Data Analytics TaskforceEuropean Medicines AgencyAmsterdamThe Netherlands
- Medicines Monitoring UnitUniversity of DundeeDundeeUK
| | - Xavier Kurz
- Data Analytics TaskforceEuropean Medicines AgencyAmsterdamThe Netherlands
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Initiative, Faculty of Mathematics and Natural SciencesUniversity of OsloOsloNorway
- Department of Child Health and DevelopmentNorwegian Institute of Public HealthOsloNorway
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Hyperemesis gravidarum in the primary care setting: cross-sectional study of GPs. BJGP Open 2021; 6:BJGPO.2021.0119. [PMID: 34620600 PMCID: PMC8958745 DOI: 10.3399/bjgpo.2021.0119] [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: 07/03/2021] [Accepted: 09/02/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Hyperemesis gravidarum (HG), if untreated, can lead to malnutrition, dehydration, and Wernicke's encephalopathy. Foetal complications include low birth weight and neurodevelopmental delay. Recent evidence supports increased rates of termination of pregnancy and suicidal ideation. Drivers included difficulty in accessing medications, which thus contributed to poor perception of care. AIM To identify factors that may influence prescribers' confidence and knowledge regarding pharmacological therapy for HG. DESIGN & SETTING Cross-sectional study of qualified GPs and GP trainees in Wales. METHOD Distribution of a 22-item online survey. Statistical analysis was carried out using SPSS. RESULTS In total, 241 responses were received, with 216 included in the analysis (59% qualified GPs, 41% GP trainees). In total, 93% of responders correctly identified cyclizine as being safe in pregnancy, but no other drug recommended in the Royal College of Obstetrics and Gynaecology guidance was considered safe by more than 58%. Those reporting higher confidence levels in managing HG were more likely to correctly report guideline-recommended drugs as safe in pregnancy (P = 0.04). Additional qualifications related to obstetrics and gynaecology (O&G) and/or prior clinical experience increased confidence levels (P = 0.0001 and P = 0.0002, respectively). Only 19% of participants routinely screened for signs of mental health complications, and prior experience or education did not increase likelihood of this happening. The majority of participants (87%) would like additional education and/or access to evidence-based resources. CONCLUSION This study demonstrates a demand for improved dissemination of evidence-based education on HG to support those working in primary care. The extent to which HG is covered in pre-existing educational programmes should also be revisited.
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Şahin B, Özçetinkaya Erdoğan S, Cura Şahin G, Karlı P, Kara OF, Hatırnaz Ş, Tinelli A. Nausea and vomiting during pregnancy: a possible correlation with obsessive compulsive disorder and alexithymia. J OBSTET GYNAECOL 2021; 42:929-934. [PMID: 34693875 DOI: 10.1080/01443615.2021.1960492] [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: 10/20/2022]
Abstract
The possible correlation between nausea and vomiting during pregnancy (NVP) with obsessive-compulsive disorder (OCD) and alexithymia were examined in this cross-sectional study. A cohort of pregnant women at the first trimester of pregnancy experiencing NVP were divided into three groups, according to severity (mild, moderate and severe) with the Pregnancy Unique Quantification of Emesis and Nausea (PUQE) test. The Maudsley Obsessive Compulsive Disorder Scale (MOCQ) and the Toronto Alexithymia Scale (TAS-20) were applied. Scores of scales were compared in all three groups, and the relationship between NVP severity and OCD and alexithymia was evaluated. On the 110 enrolled pregnant women, 42 had mild, 36 had moderate and 32 had severe NVP. Pregnant women with mild NVP had lower MOCQ scores than those with severe NVP (p = .010). Total scores of TAS-20 were higher among subjects with greater NVP severity (p < .001). PUQE scores were demonstrated significant correlations with MOCQ and total and subsection scores of the TAS-20, regardless of NVP groups. Study results showed that women with more pronounced OCD and/or alexithymia can experience somatic complaints, such as NVP, particularly intense in their first trimester of pregnancies. For this reason, psychotherapy in addition to medical treatments could be recommended to pregnant women with severe NVP.Impact statementWhat is already known on this subject? NVP is a condition experienced by most women, particularly in the first trimester of pregnancy, which can be affected by the psychosomatic condition of the pregnant woman.What do the results of this study add? The severity of nausea and vomiting according to PUQE test were significantly associated with OCD and alexithymia presence in pregnant women during their first trimester period.What are the implications of these findings for clinical practice and/or further research? These findings might demonstrate the symptoms of NVP are correlated to OCD, as well as alexithymia. Longitudinal studies are required to demonstrate the clear causal relationship between NVP and psychiatric symptoms as in OCD and in alexithymia.
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Affiliation(s)
- Banuhan Şahin
- Gynecology and Obstetrics Department, Amasya University Sabuncuoglu Serefeddin Training and Research Hospital, Amasya, Turkey
| | - Serap Özçetinkaya Erdoğan
- Psychiatry Department, Amasya University Sabuncuoglu Serefeddin Training and Research Hospital, Amasya, Turkey
| | | | - Pervin Karlı
- Gynecology and Obstetrics Department, Amasya University Sabuncuoglu Serefeddin Training and Research Hospital, Amasya, Turkey
| | - Osman Fadıl Kara
- Gynecology and Obstetrics Department, Amasya University Sabuncuoglu Serefeddin Training and Research Hospital, Amasya, Turkey
| | - Şafak Hatırnaz
- Gynecology and Obstetrics Department, IVF Unit, Medicana International Hospital, Samsun, Turkey
| | - Andrea Tinelli
- Obstetrics and Gynecology Department, Veris delli Ponti Hospital, Scorrano, Lecce, Italy.,Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Vito Fazzi Hospital, Lecce, Italy.,Faculty of Biological and Medical Physics, Phystech BioMed School, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russia
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12
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Bruun MR, Ernst A, Arendt LH, Ramlau-Hansen CH, Brix N. Nausea During Pregnancy and Timing of Pubertal Development in Sons and Daughters: A Population-Based Cohort Study. Clin Epidemiol 2021; 13:895-905. [PMID: 34621134 PMCID: PMC8491783 DOI: 10.2147/clep.s324805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/31/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The objective of this study was to explore whether maternal nausea in pregnancy, a potential surrogate marker of endogenous estrogen levels, was associated with age at attaining pubertal milestones in sons and daughters. MATERIALS AND METHODS The study included a total of 14,612 boys and girls born in 2000-2003, from the Danish National Birth Cohort. Information on nausea was reported by mothers during pregnancy in telephone interviews scheduled around gestational week 12 and 30. Their children were invited every six months from 11 years of age until 18 years of full maturation to provide information on current pubertal status. Pubertal milestones included pubic hair, axillary hair and acne for both sexes, besides genital development, voice break and first ejaculation for boys, and breast development and menarche for girls. Mean monthly differences in age at attaining several pubertal milestones for boys and girls were estimated according to duration of nausea in the first trimester (0, 1-6, 7-11, 12 weeks). Further, we explored whether duration of nausea in the first two trimesters (0, 1-8, 9-15 or 16-28 weeks) and severity (measured by co-existence of vomiting and weight loss) were associated with pubertal timing. RESULTS Neither maternal nausea in the first trimester nor duration or severity of nausea in the first two trimesters were associated with pubertal timing. CONCLUSION Our study does not support the hypothesis that nausea in pregnancy - as a surrogate marker of endogenous estrogen levels - is associated with age at attaining pubertal milestones in children.
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Affiliation(s)
- Mette Rahbek Bruun
- Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
| | - Andreas Ernst
- Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Urology, Aarhus University Hospital, Aarhus, Denmark
| | - Linn Håkonsen Arendt
- Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Obstetrics and Gynecology, Regional Hospital Horsens, Horsens, Denmark
| | | | - Nis Brix
- Department of Public Health, Research Unit for Epidemiology, Aarhus University, Aarhus, Denmark
- Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
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13
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Effectiveness of Acupuncture in the Treatment of Hyperemesis Gravidarum: A Systematic Review and Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:2731446. [PMID: 34367299 PMCID: PMC8337134 DOI: 10.1155/2021/2731446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/15/2021] [Indexed: 11/18/2022]
Abstract
Background Hyperemesis gravidarum (HG) is a common gastrointestinal disease afflicting gravidas. It usually results in hospital admission in early pregnancy. Objective Through a meta-analysis, this study intended to explore acupuncture's clinical efficacy in treating HG. Materials and Methods A comprehensive search of PubMed, the Cochrane Library, EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biological Medical (CBM), Wanfang Database, and China Science and Technology Journal (VIP) for published clinical randomized controlled trials (RCTs) of acupuncture for treating HG was conducted from the date of database creation to 20th January 2021. We also searched grey literature in four databases: Chinese Cochrane Center, Chinese Clinical Trial Registry, GreyNet International, and Open Grey from their inception to 20th January 2021. Two authors independently screened the literature, extracted data, and evaluated the quality of the literature with Cochrane Handbook 5.1.0 and Review Manager 5.2 software. Review Manager 5.2 and STATA 12.0 software were applied to analyze data. Heterogeneity analysis was performed by the Cochran Chi-square test and I 2 statistic. Egger's tests together with funnel plots were used to identify publication bias. Results A total of 16 trials covering 1043 gravidas were included. Compared with the conventional treatment, acupuncture had a significantly higher effective rate (OR: 8.11, 95% CI: 5.29∼12.43; P < 0.00001), a higher conversion rate of urine ketone (RR: 1.36, 95% CI: 1.15∼1.60; P=0.0003), an improvement rate of nausea and vomiting (OR: 26.44, 95% CI: 3.54∼197.31; P=0.001), and a relatively higher improvement rate of food intake (RR: 1.17, 95% CI: 1.01∼1.36; P=0.04). Acupuncture also shortened hospitalization time and manifested with a lower pregnancy termination rate and fewer adverse events. Nevertheless, no statistical variation in the improvement of nausea intensity, vomiting episodes, and lassitude symptom, recurrence rate, and serum potassium was observed. Conclusion Our study suggested that acupuncture was effective in treating HG. However, as the potential inferior quality and underlying publication bias were found in the included studies, there is a need for more superior-quality RCTs to examine their effectiveness and safety. PROSPERO registration number: CRD42021232187.
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14
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MIZRAK ŞAHİN B. Investigation of factors associated with nausea and vomiting in pregnant women. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.924353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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15
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Karakayalı Ay Ç, Aksoy Derya Y. The relationship between birth fear and psychosocial health level of nausea-vomiting severity in pregnancy: An example from Turkey. CURRENT PSYCHOLOGY 2021. [DOI: 10.1007/s12144-021-01907-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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16
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Hsiao HF, Thomas A, Kay-Smith C, Grzeskowiak LE. Pregnant women report being denied medications to treat severe nausea and vomiting of pregnancy or hyperemesis gravidarum - findings from an Australian online survey. THE AUSTRALIAN & NEW ZEALAND JOURNAL OF OBSTETRICS & GYNAECOLOGY 2021; 61:616-620. [PMID: 33984156 DOI: 10.1111/ajo.13359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 02/28/2021] [Accepted: 03/17/2021] [Indexed: 11/29/2022]
Abstract
We conducted an online survey of 249 Australian women who currently or previously experienced severe nausea and vomiting of pregnancy (NVP) or hyperemesis gravidarum (HG) and examined their experiences in being denied medications during pregnancy. One in four women reported being denied medications for NVP/HG, which most commonly involved doxylamine and encounters with community pharmacists. Women's experiences reflected that lack of awareness of guidelines and unfavourable risk-benefit assessments appeared to be key barriers to facilitating medication access. Approaches towards identifying and effectively addressing barriers to the provision of effective treatments for severe NVP and HG are urgently needed.
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Affiliation(s)
- Han-Fang Hsiao
- SA Pharmacy, Flinders Medical Centre, SA Health, Adelaide, South Australia, Australia
| | - Alicia Thomas
- SA Pharmacy, Flinders Medical Centre, SA Health, Adelaide, South Australia, Australia
| | | | - Luke E Grzeskowiak
- SA Pharmacy, Flinders Medical Centre, SA Health, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia.,Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide, South Australia, Australia.,South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
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17
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van Gelder MMHJ, Nordeng H. Antiemetic Prescription Fills in Pregnancy: A Drug Utilization Study Among 762,437 Pregnancies in Norway. Clin Epidemiol 2021; 13:161-174. [PMID: 33664595 PMCID: PMC7924249 DOI: 10.2147/clep.s287892] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/20/2021] [Indexed: 12/28/2022] Open
Abstract
Objective To determine antiemetic prescription fill patterns during pregnancy in Norway, with special focus on the use of ondansetron and recurrent use in subsequent pregnancies. Methods We conducted a population-based registry study based on data from the Medical Birth Registry of Norway linked to the Norwegian Prescription Database for 762,437 pregnancies >12 gestational weeks ending in live or non-live births between 2005 and 2017. Prescription fills of medications used for nausea and vomiting of pregnancy were summarized in treatment pathways to determine drug utilization patterns. Logistic regression analyses were used to estimate associations between maternal and pregnancy characteristics and antiemetic prescription fills. Results The prescription fill rate for antiemetic medication during pregnancy was 7.6%. However, prescription fill rates were 35.5% in the second pregnancy after filling an antiemetic prescription in the first pregnancy and 53.5% for women who filled antiemetic prescriptions in the previous 2 pregnancies. Among pregnancies with antiemetic prescription fills, 62.2% were dispensed metoclopramide, 28.2% meclizine, and 17.2% promethazine. First-line treatment started with monotherapy in 97.4% of these pregnancies, which was the only treatment received in 78.7%. Prescriptions for ondansetron were filled in 0.3% of pregnancies, with 76.9% being initially filled in the first trimester. Ondansetron as first-line prescription medication and/or use in the first trimester was associated with proxies for more severe nausea and vomiting of pregnancy, including a diagnosis of hyperemesis gravidarum, multiple gestations, a higher obstetric comorbidity index, and concomitant use of medication for gastroesophageal reflux disease and nervous system medications. Women who filled an antiemetic prescription in their first pregnancy were less likely to have subsequent pregnancies than women who did not fill an antiemetic prescription in their first pregnancy (OR 0.93, 95% CI 0.90–0.96). Conclusion Complex patterns of antiemetic prescription fills in pregnancy may mirror the challenge of optimal management of nausea and vomiting of pregnancy in clinical practice, especially for women with severe symptoms.
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Affiliation(s)
- Marleen M H J van Gelder
- Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.,Radboud REshape Innovation Center, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, and PharmaTox Strategic Research Initiative, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway.,Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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18
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Yan R, Zhan J, Liu G, Li C, Cai P, Chen Y, Cao H. A comparison of the efficacy and safety of traditional Chinese medicine external treatment for the hyperemesis gravidarum: A protocol for systematic review and network meta-analysis. Medicine (Baltimore) 2020; 99:e23019. [PMID: 33157951 PMCID: PMC7647590 DOI: 10.1097/md.0000000000023019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The symptoms of frequent nausea and vomiting, inability to eat, and fluid imbalance caused by hyperemesis gravidarum (HG) seriously impact the quality of life of pregnant women. In some serious cases, it is even necessary to terminate the pregnancy, and threatens the life of the pregnant woman. A great many of studies have proved that HG can be effectively treated by traditional Chinese medicine (TCM) external treatment. Nevertheless, its relative effectiveness and safety haven't yet been confirmed because of the variety of TCM external treatment. Therefore, we will use the method of network meta-analysis to verify the effectiveness and safety of different types of TCM external treatment for the HG. METHODS In this study, English and Chinese literatures that meet the requirements will be searched in EMBASE, PubMed, Cochrane Library, Web of Science, CnKI, VIP, Wanfang, and CBM. Regardless of whether blinding is used or not, all randomized controlled trials (RCTs) using TCM external treatment for the HG will be included. Then, Stata 16.0 will be used to conduct a series of pairwise meta-analysis. WinBUGS 1.4.3 and Stata 16.0 will be used to conduct Bayesian network meta-analysis to evaluate the relative results of different TCM external treatments for the HG. The quality included in the study will be evaluated through the classification of Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS This study will evaluate the effectiveness and safety of TCM external treatment for the HG according to the primary and secondary outcomes, and we rank different kinds of TCM external treatments in accordance with effectiveness. The primary outcomes are the intensity of nausea and vomiting. Secondary outcomes include quality of life, adverse outcome of pregnant women, adverse outcome of fetal, duration of hospitalization and so on. CONCLUSION This study will provide more convincing and detailed information of TCM external treatment for the HG, and the reference value for clinical treatment. INPLASY REGISTRATION NUMBER INPLASY 202090089.
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Affiliation(s)
- Rugen Yan
- The First Clinical College, Shandong University of Traditional Chinese Medicine
| | - Junyi Zhan
- The First Clinical College, Shandong University of Traditional Chinese Medicine
| | - Gongxue Liu
- The First Clinical College, Shandong University of Traditional Chinese Medicine
| | - Changzhong Li
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province
| | - Pingping Cai
- Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong Province
| | - Yin Chen
- Xuyi County Hospital of Chinese Medicine, Xuyi, Jiangsu Province, China
| | - Huanze Cao
- The First Clinical College, Shandong University of Traditional Chinese Medicine
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19
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Pecriaux C. [Interest of vitamin b6 for treatment of nausea and/or vomiting during pregnancy]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2020; 48:840-843. [PMID: 32961339 DOI: 10.1016/j.gofs.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Indexed: 06/11/2023]
Abstract
In France there is no official recommendation for the drug management of nausea and vomiting during pregnancy. In the USA, Canada and Australia, vitamin B6 is officially recommended in the treatment of mild to moderate pregnancy sickness and vomiting. Indeed, some studies have shown some effectiveness of oral vitamin B6, most often in combination with doxylamine, in comparison with a placebo. In addition, the harmlessness of oral vitamin B6 during pregnancy has been established for doses up to 40-60mg/day, mainly in combination with doxylamine (40mg/40mg). Thus, in France, as in other countries, vitamin B6 could be integrated into the therapeutic arsenal of mild to moderate nausea and vomiting during pregnancy according to the following dosage schedule: oral intake of 10mg four times a day of a compounded preparation of vitamin B6, alone or in combination with doxylamine.
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Affiliation(s)
- C Pecriaux
- Centre de référence sur les agents tératogènes (CRAT), DMU ESPRIT (Épidémiologie et biostatistique, santé publique, pharmacie, pharmacologie, recherche, information médicale, thérapeutique et médicaments), GHU AP-HP Sorbonne université, Site Trousseau 26 avenue Dr Netter, 75571 Paris cedex 12, France.
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20
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Cochrane KM, Mayer C, Devlin AM, Elango R, Hutcheon JA, Karakochuk CD. Is natural (6S)-5-methyltetrahydrofolic acid as effective as synthetic folic acid in increasing serum and red blood cell folate concentrations during pregnancy? A proof-of-concept pilot study. Trials 2020; 21:380. [PMID: 32370802 PMCID: PMC7201521 DOI: 10.1186/s13063-020-04320-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/10/2020] [Indexed: 01/21/2023] Open
Abstract
Background North American health authorities recommend 0.4 mg/day folic acid before conception and throughout pregnancy to reduce the risk of neural tube defects. Folic acid is a synthetic form of folate that must be reduced by dihydrofolate reductase and then further metabolized. Recent evidence suggests that the maximal capacity for this process is limited and unmetabolized folic acid has been detected in the circulation. The biological effects of unmetabolized folic acid are unknown. A natural form of folate, (6S)-5-methyltetrahydrofolic acid (Metafolin®), may be a superior alternative because it does not need to be reduced in the small intestine. Metafolin® is currently used in some prenatal multivitamins; however, it has yet to be evaluated during pregnancy. Methods/design This double-blind, randomized trial will recruit 60 pregnant women aged 19–42 years. The women will receive either 0.6 mg/day folic acid or an equimolar dose (0.625 mg/day) of (6S)-5-methyltetrahydrofolic acid for 16 weeks. The trial will be initiated at 8–21 weeks’ gestation (after neural tube closure) to reduce the risk of harm should (6S)-5-methyltetrahydrofolic acid prove less effective. All women will also receive a prenatal multivitamin (not containing folate) to ensure adequacy of other nutrients. Baseline and endline blood samples will be collected to assess primary outcome measures, including serum folate, red blood cell folate and unmetabolized folic acid. The extent to which the change in primary outcomes from baseline to endline differs between treatment groups, controlling for baseline level, will be estimated using linear regression. Participants will have the option to continue supplementing until 1 week postpartum to provide a breastmilk and blood sample. Exploratory analyses will be completed to evaluate breastmilk and postpartum blood folate concentrations. Discussion This proof-of-concept trial is needed to obtain estimates of the effect of (6S)-5-methyltetrahydrofolic acid compared to folic acid on circulating biomarkers of folate status during pregnancy. These estimates will inform the design of a definitive trial which will be powered to assess whether (6S)-5-methyltetrahydrofolic acid is as effective as folic acid in raising blood folate concentrations during pregnancy. Ultimately, these findings will inform folate supplementation policies for pregnant women. Trial registration ClinicalTrials.gov, ID: NCT04022135. Registered on 14 July 2019.
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Affiliation(s)
- Kelsey M Cochrane
- Food, Nutrition and Health, Faculty of Land and Food Systems, The University of British Columbia, 2205 East Mall, Vancouver, BC, V6T 1Z4, Canada.,BC Children's Hospital Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada
| | - Chantal Mayer
- Department of Obstetrics and Gynaecology, University of British Columbia, 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Angela M Devlin
- BC Children's Hospital Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.,Department of Paediatrics, Faculty of Medicine, The University of British Columbia, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada
| | - Rajavel Elango
- BC Children's Hospital Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.,Department of Paediatrics, Faculty of Medicine, The University of British Columbia, 4480 Oak Street, Vancouver, BC, V6H 3V4, Canada.,School of Population and Public Health, Faculty of Medicine, The University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Jennifer A Hutcheon
- BC Children's Hospital Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.,Department of Obstetrics and Gynaecology, University of British Columbia, 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada
| | - Crystal D Karakochuk
- Food, Nutrition and Health, Faculty of Land and Food Systems, The University of British Columbia, 2205 East Mall, Vancouver, BC, V6T 1Z4, Canada. .,BC Children's Hospital Research Institute, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.
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21
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The Management of Nausea and Vomiting of Pregnancy: Synthesis of National Guidelines. Obstet Gynecol Surv 2020; 74:161-169. [PMID: 31634919 DOI: 10.1097/ogx.0000000000000654] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Nausea and vomiting of pregnancy (NVP) affects a high proportion of the pregnant population. Objective The aim of this study was to compare and synthesize recommendations from national guidelines regarding the management of NVP. Evidence Acquisition A descriptive review of 3 recently published national guidelines on NVP was conducted: Royal College of Obstetricians and Gynaecologists on "The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum," American College of Obstetricians and Gynecologists on "Nausea and Vomiting of Pregnancy," and Society of Obstetricians and Gynaecologists of Canada on "The Management of Nausea and Vomiting of Pregnancy." These guidelines were summarized and compared in terms of the recommended management of pregnant women. The quality of evidence was also reviewed based on the method of reporting. Results Several differences were identified on the different guidelines regarding the management of NVP. Frequent small meals and avoidance of iron supplements are recommended for prevention. The consumption of ginger, acustimulations, antihistamines, phenothiazines, dopamine, and serotonin 5-hydroxytryptamine type 3 receptor antagonists is routinely recommended for use in the community as treatment. Conclusions Evidence-based medicine may lead to the adoption of an international guideline for the management of NVP, which may lead to a more effective management of that entity.
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Nahrisah P, Somrongthong R, Viriyautsahakul N, Viwattanakulvanid P, Plianbangchang S. Effect of Integrated Pictorial Handbook Education and Counseling on Improving Anemia Status, Knowledge, Food Intake, and Iron Tablet Compliance Among Anemic Pregnant Women in Indonesia: A Quasi-Experimental Study. J Multidiscip Healthc 2020; 13:43-52. [PMID: 32021233 PMCID: PMC6970256 DOI: 10.2147/jmdh.s213550] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 12/13/2019] [Indexed: 12/19/2022] Open
Abstract
Purpose To determine the effect of individual education through a pictorial handbook on anemia in conjunction with counseling on improving hemoglobin and hematocrit level, birth weight, knowledge, iron-rich food and iron-folic acid (IFA) intake. Patients and Methods The study developed a pictorial handbook that was conceptualized based on the Health Belief Model and adjusted to some cultural and local contexts. A quasi-experimental pre-test–post-test control group design was used, purposefully conducted between two homogenous municipalities, each having a rate of anemic pregnancy that was 40% or greater. The sample consists of 140 anemic pregnant women randomly allocated via lottery into two groups; the intervention group (n=70), which received two home visits—one for education and another for a counseling session, and control group (n=70), which received routine antenatal care. A chi-square test and a Mann–Whitney U-test were conducted to compare the baseline socio-demographics. An analysis of covariance (ANCOVA), controlling some possible confounders, was performed to analyze the effect of intervention. Results The post-test means of hemoglobin F (1, 132) = 122, p-value <0.001, and hematocrit levels F (1, 132) = 373, p-value <0.001, were significantly different and higher in the intervention group compared to the control group. Similar results were found in knowledge, food frequency score, number of IFA intake (with p-value <0.001), birth weight and daily iron intake from food (with p-value <0.05). The intervention had a particularly large effect on food frequency score and number of IFA intake, and medium effect on hemoglobin and hematocrit levels. Conclusion Individual education through a pictorial handbook on anemia in conjunction with the counseling intervention program had a positive impact on hemoglobin and hematocrit levels for anemic pregnant women in their third trimester of pregnancy.
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Affiliation(s)
- Putri Nahrisah
- College of Public Health Sciences, Chulalongkorn University, Pathumwan, Bangkok 10330, Thailand.,Health Office of Kota Langsa Municipality, Kota Langsa, Province of Aceh, Indonesia
| | - Ratana Somrongthong
- College of Public Health Sciences, Chulalongkorn University, Pathumwan, Bangkok 10330, Thailand
| | | | | | - Samlee Plianbangchang
- College of Public Health Sciences, Chulalongkorn University, Pathumwan, Bangkok 10330, Thailand
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Bérard A, Sheehy O, Gorgui J, Zhao JP, Soares de Moura C, Bernatsky S. New evidence for concern over the risk of birth defects from medications for nausea and vomitting of pregnancy. J Clin Epidemiol 2019; 116:39-48. [PMID: 31352006 DOI: 10.1016/j.jclinepi.2019.07.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 06/11/2019] [Accepted: 07/20/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The aim of the study was to quantify the risk of major congenital malformations (MCM) associated with first-trimester exposure to antiemetics. STUDY DESIGN AND SETTING Using the Quebec Pregnancy Cohort (1998-2015), first-trimester doxylamine-pyridoxine, metoclopramide, and ondansetron exposures were assessed for their association with MCM. Generalized estimating equations were used to estimate odds ratios (OR), adjusting for potential confounders (aOR). RESULTS Within 17 years of follow-up, the prevalence of antiemetic use during pregnancy increased by 76%. Within our cohort, 45,623 pregnancies were exposed to doxylamine-pyridoxine, 958 to metoclopramide, and 31 to ondansetron. Doxylamine-pyridoxine and metoclopramide use were associated with an increased risk of overall MCM (aOR 1.07, 95% confidence interval [CI]: 1.03-1.11; 3,945 exposed cases) and (aOR 1.27, 95% CI: 1.03-1.57; 105 exposed cases), respectively. Doxylamine-pyridoxine exposure was associated with increased risks of spina bifida (aOR 1.87, 95% CI: 1.11-3.14; 23 exposed cases), nervous system (aOR 1.25, 95% CI: 1.06-1.47; 225 exposed cases), and musculoskeletal system defects (aOR 1.08, 95% CI: 1.02-1.14; 1,735 exposed cases). Metoclopramide exposure was associated with an increased risk of genital organ defects (aOR 2.26, 95% CI: 1.14-4.48; 10 exposed cases). No statistically significant association was found between ondansetron exposure and the risk of overall MCM. CONCLUSION First-trimester doxylamine-pyridoxine and metoclopramide exposure was associated with a significantly increased risk of overall and specific MCM.
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Affiliation(s)
- Anick Bérard
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montréal, Québec H3T 1C5, Canada; Faculty of Pharmacy, University of Montreal, Pavillon Jean-Coutu, 2940, chemin de Polytechnique, Montréal, Québec H3T 1J4, Canada.
| | - Odile Sheehy
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montréal, Québec H3T 1C5, Canada
| | - Jessica Gorgui
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montréal, Québec H3T 1C5, Canada; Faculty of Pharmacy, University of Montreal, Pavillon Jean-Coutu, 2940, chemin de Polytechnique, Montréal, Québec H3T 1J4, Canada
| | - Jin-Ping Zhao
- Research Center, CHU Sainte-Justine, 3175, Chemin de la Côte-Sainte-Catherine, Montréal, Québec H3T 1C5, Canada
| | - Cristiano Soares de Moura
- Faculty of Medicine, Department of Clinical Epidemiology, McGill University, Purvis Hall 1020 Pine Ave. West, Montréal, Québec H3A 1A2, Canada
| | - Sasha Bernatsky
- Faculty of Medicine, Department of Clinical Epidemiology, McGill University, Purvis Hall 1020 Pine Ave. West, Montréal, Québec H3A 1A2, Canada
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Havnen GC, Truong MBT, Do MLH, Heitmann K, Holst L, Nordeng H. Women's perspectives on the management and consequences of hyperemesis gravidarum - a descriptive interview study. Scand J Prim Health Care 2019; 37:30-40. [PMID: 30822254 PMCID: PMC6454401 DOI: 10.1080/02813432.2019.1569424] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Hyperemesis gravidarum (HG) affects 0.3-3% of pregnant women and is a leading cause of hospitalization in early pregnancy. The aim of the study was to investigate women's treatment and management of HG, as well as the consequences of HG on women's daily life. DESIGN AND SETTING A cross-sectional study based on a structured telephone interview and an online questionnaire. Participants were recruited by social media and by the Norwegian patient's organization for HG. SUBJECTS Norwegian women that experienced HG. MAIN OUTCOME MEASURE Women's perspectives on management and consequences of HG. RESULTS The study included 107 women. Maternal morbidity was profound; about 3/4 of participants were hospitalized due to HG, and the majority showed clinical signs of dehydration (79%), ketonuria (75%), and >5% weight loss (84%). Antiemetics were used by >90% and frequently prescribed "as needed". Metoclopramide (71%) and meclozine (51%) were most commonly used. Participants described HG as having severe psychosocial consequences and profound impact on daily activities. Almost two out of five reported thoughts of elective abortion, and 8 women had at least one elective pregnancy termination due to HG. Overall, 20 women (19%) changed GPs due to dissatisfaction with HG management. CONCLUSION Despite the high psychosocial burden and major impact on daily activities, many women with HG reported a lack of support from healthcare professionals and suboptimal management. Greater awareness and knowledge among healthcare professionals is needed to improve care for women with HG. Key Points There is a paucity of studies on management and the consequences of HG on women's daily lives and psychosocial burden. We found that: • Many women described HG as one of their worst life experiences with profound morbidity. • Many women reported suboptimal management of HG and lack of support from healthcare professionals. • Greater understanding of patient perspectives among healthcare professionals is important to improve care and management for HG patients.
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Affiliation(s)
- Gro C. Havnen
- Regional Medicines Information and Pharmacovigilance Centre (RELIS), Oslo University Hospital, Oslo, Norway;
- CONTACT Gro C. Havnen Regional Medicines Information and Pharmacovigilance Centre (RELIS), Oslo University Hospital HF Rikshopitalet, Pb 4950 Nydalen, 0424Oslo, Norway
| | - Maria Bich-Thuy Truong
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway;
| | - Mai-Linh H. Do
- Regional Medicines Information and Pharmacovigilance Centre (RELIS), Oslo University Hospital, Oslo, Norway;
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway;
| | - Kristine Heitmann
- Regional Medicines Information and Pharmacovigilance Centre (RELIS), Haukeland University Hospital, Bergen, Norway;
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway;
| | - Lone Holst
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway;
| | - Hedvig Nordeng
- PharmacoEpidemiology and Drug Safety Research Group, Department of Pharmacy, University of Oslo, Oslo, Norway;
- Department of Child Health and Development, Norwegian Institute of Public Health, Oslo, Norway
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Lavecchia M, Chari R, Ross S. Gaining Insight Into Ondansetron Safety in Early Pregnancy. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:419-420. [PMID: 30685231 DOI: 10.1016/j.jogc.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Melissa Lavecchia
- Department of Obstetrics and Gynecology, University of Alberta, Lois Hole Hospital for Women, Edmonton, AB
| | - Radha Chari
- Department of Obstetrics and Gynecology, University of Alberta, Lois Hole Hospital for Women, Edmonton, AB
| | - Sue Ross
- Department of Obstetrics and Gynecology, University of Alberta, Lois Hole Hospital for Women, Edmonton, AB; Women and Children's Health Research Institute, Department of Obstetrics and Gynecology, University of Alberta, Edmonton, AB
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Sridharan K, Sivaramakrishnan G. Interventions for treating nausea and vomiting in pregnancy: a network meta-analysis and trial sequential analysis of randomized clinical trials. Expert Rev Clin Pharmacol 2018; 11:1143-1150. [PMID: 30261764 DOI: 10.1080/17512433.2018.1530108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/26/2018] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Several drugs were explored for their utility in treating nausea and vomiting in pregnancy (NVP). The present study is a network meta-analysis of such drugs. METHODS Electronic databases were searched for randomized clinical trials that have compared active interventions (with placebo or other active interventions) for treating NVP. Nausea scores were the primary outcome and changes in nausea scores, emetic episodes, adverse events, and vomiting control were the key secondary outcomes. Weighted mean difference was the effect estimate for continuous variable and odds ratio for the numerical variable. Random-effects model was used and the strength of the evidence was graded. RESULTS Fifty studies were included in the systematic review and 42 in the meta-analysis. Acupuncture, chamomile, dimenhydrinate, doxylamine/vitamin B6, ginger, quince, metoclopramide, and vitamin B6 were associated with reduced nausea scores compared to placebo. Of these interventions, ginger and vitamin B6 were also associated with better vomiting control and less incidence of adverse events. Adequate evidence supporting the use exists only for ginger and the quality of evidence for this comparison is moderate. Strength of evidence for all other comparisons is very low. CONCLUSION Present evidence is conclusive on the therapeutic benefits of ginger in treating NVP. Although favorable results were obtained for several other interventions, the strength of evidence is very low. The results of this network meta-analysis should be interpreted with extreme caution as it might change with the advent of data from future head-to-head clinical trials.
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Affiliation(s)
- Kannan Sridharan
- a Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences , Arabian Gulf University , Manama , Bahrain
| | - Gowri Sivaramakrishnan
- b School of Oral Health, College of Medicine, Nursing and Health Sciences , Fiji National University , Suva , Fiji
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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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Affiliation(s)
- Kerstin Austin
- Department of Gastroenterology and Hepatology; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin USA
| | - Kelley Wilson
- Clinical Nutrition Services; University of Wisconsin Hospital and Clinics; Madison Wisconsin USA
| | - Sumona Saha
- Department of Gastroenterology and Hepatology; University of Wisconsin School of Medicine and Public Health; Madison Wisconsin USA
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Skalley G, Denny J, Allen E, Rao S. Optimisation of hyperemesis gravidarum management through an emergency department setting. BMJ Open Qual 2018; 7:e000330. [PMID: 30234172 PMCID: PMC6135454 DOI: 10.1136/bmjoq-2018-000330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 07/05/2018] [Accepted: 07/10/2018] [Indexed: 11/04/2022] Open
Abstract
Hyperemesis gravidarum is a common condition characterised by severe nausea and vomiting. The referral process from the emergency department (ED) to obstetrics and gynaecology (O&G) can lead to treatment delays before the gynaecology team review the patient, resulting in unnecessary prolonged inpatient stays in O&G. This quality improvement project created a clinical pathway which optimised care of patients presenting with hyperemesis gravidarum in the ED at the Princess Royal University Hospital using a treatment protocol. Two audits were carried out to assess improvements in patient care and reduction in admissions to O&G. Overall, admissions to O&G were reduced by 68.7% (cycle 1) and 70.5% (cycle 2) compared with admission rates before the proforma, saving the trust an estimated £265 700 and 235 bed days over a year.
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Affiliation(s)
- Graham Skalley
- Emergency Department, Princess Royal University Hospital, Orpington, Kent, UK
| | - John Denny
- Department of General Medicine, Princess Royal University Hospital, Orpington, Kent, UK
| | - Eve Allen
- Obstetrics and Gynaecology Department, Princess Royal University Hospital, Orpington, Kent, UK
| | - Shwetha Rao
- Emergency Department, Princess Royal University Hospital, Orpington, Kent, UK
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Stanisiere J, Mousset PY, Lafay S. How Safe Is Ginger Rhizome for Decreasing Nausea and Vomiting in Women during Early Pregnancy? Foods 2018; 7:foods7040050. [PMID: 29614764 PMCID: PMC5920415 DOI: 10.3390/foods7040050] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/19/2018] [Accepted: 03/19/2018] [Indexed: 01/23/2023] Open
Abstract
Ginger, Zingiber officinale Roscoe, is increasingly consumed as a food or in food supplements. It is also recognized as a popular nonpharmacological treatment for nausea and vomiting of pregnancy (NVP). However, its consumption is not recommended by all countries for pregnant women. Study results are heterogeneous and conclusions are not persuasive enough to permit heath care professionals to recommend ginger safely. Some drugs are also contraindicated, leaving pregnant women with NVP with few solutions. We conducted a review to assess effectiveness and safety of ginger consumption during early pregnancy. Systematic literature searches were conducted on Medline (via Pubmed) until the end of December 2017. For the evaluation of efficacy, only double-blind, randomized, controlled trials were included. For the evaluation of the safety, controlled, uncontrolled, and pre-clinical studies were included in the review. Concerning toxicity, none can be extrapolated to humans from in vitro results. In vivo studies do not identify any major toxicities. Concerning efficacy and safety, a total of 15 studies and 3 prospective clinical studies have been studied. For 1 g of fresh ginger root per day for four days, results show a significant decrease in nausea and vomiting and no risk for the mother or her future baby. The available evidence suggests that ginger is a safe and effective treatment for NVP. However, beyond the ginger quantity needed to be effective, ginger quality is important from the perspective of safety.
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Boelig RC, Barton SJ, Saccone G, Kelly AJ, Edwards SJ, Berghella V. Interventions for treating hyperemesis gravidarum: a Cochrane systematic review and meta-analysis. J Matern Fetal Neonatal Med 2017; 31:2492-2505. [PMID: 28614956 DOI: 10.1080/14767058.2017.1342805] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION While nausea and vomiting in early pregnancy are very common, affecting approximately 80% of the pregnancies, hyperemesis gravidarum is a severe form affecting 0.3-1.0% of the pregnancies. Although hyperemesis gravidarum is rarely a source of mortality, it is a significant source of morbidity. It is one of the most common indications for hospitalization in pregnancy. Beyond the maternal and fetal consequences of malnutrition, the severity of hyperemesis symptoms causes a major psychosocial burden leading to depression, anxiety, and even pregnancy termination. The aim of this meta-analysis was to examine all randomized controlled trials of interventions specifically for hyperemesis gravidarum and evaluate them based on both subjective and objective measures of efficacy, maternal and fetal/neonatal safety, and economic costs. MATERIAL AND METHODS Randomized controlled trials were identified by searching electronic databases. We included all randomized controlled trials for the treatment of hyperemesis gravidarum. The primary outcome was intervention efficacy as defined by severity, reduction, or cessation in nausea/vomiting; number of episodes of emesis; and days of hospital admission. Secondary outcomes included other measures of intervention efficacy, adverse maternal/fetal/neonatal outcomes, quality of life measures, and economic costs. RESULTS Twenty-five trials (2052 women) met the inclusion criteria but the majority of 18 different comparisons described in the review include data from single studies with small numbers of participants. Selected comparisons reported below: No primary outcome data were available when acupuncture was compared with placebo. There was insufficient evidence to identify clear differences between acupuncture and metoclopramide in a study with 81 participants regarding reduction/cessation in nausea or vomiting (risk ratio (RR) 1.40, 95% CI 0.79-2.49 and RR 1.51, 95% CI 0.92-2.48, respectively). Midwife-led outpatient care was associated with fewer hours of hospital admission than routine inpatient admission (mean difference (MD) - 33.20, 95% CI -46.91 to -19.49) with no difference in pregnancy-unique quantification of emesis and nausea (PUQE) score, decision to terminate the pregnancy, miscarriage, small-for-gestational age infants, or time off work when compared with routine care. Women taking vitamin B6 had a slightly longer hospital stay compared with placebo (MD 0.80 days, 95% CI 0.08-1.52). There was insufficient evidence to demonstrate a difference in other outcomes including mean number of episodes of emesis (MD 0.50, 95% CI -0.40-1.40) or side effects. A comparison between metoclopramide and ondansetron identified no clear difference in the severity of nausea or vomiting (MD 1.70, 95% CI -0.15-3.55, and MD -0.10, 95% CI -1.63-1.43; one study, 83 women, respectively). However, more women taking metoclopramide complained of drowsiness and dry mouth (RR 2.40, 95% CI 1.23-4.69, and RR 2.38, 95% CI 1.10-5.11, respectively). There were no clear differences between groups for other side effects. In a single study with 146 participants comparing metoclopramide with promethazine, more women taking promethazine reported drowsiness, dizziness, and dystonia (risk ratio (RR) 0.70, 95% CI 0.56-0.87, RR 0.48, 95% CI 0.34-0.69, and RR 0.31, 95% CI 0.11-0.90, respectively). There were no clear differences between groups for other important outcomes including quality of life and other side effects. In a single trial with 30 women, those receiving ondansetron had no difference in duration of hospital admission compared to those receiving promethazine (mean difference (MD) 0.00, 95% CI -1.39-1.39), although there was increased sedation with promethazine (RR 0.06, 95% CI 0.00-0.94). Regarding corticosteroids, in a study with 110 participants there was no difference in days of hospital admission compared to placebo (MD -0.30, 95% CI -0.70-0.10), but there was a decreased readmission rate (RR 0.69, 95% CI 0.50-0.94; 4 studies, 269 women). For hydrocortisone compared with metoclopramide, no data were available for primary outcomes and there was no difference in the readmission rate (RR 0.08, 95% CI 0.00-1.28; one study, 40 women). In a study with 80 women, compared to promethazine, those receiving prednisolone had increased nausea at 48 h (RR 2.00, 95% CI 1.08-3.72), but not at 17 days (RR 0.81, 95% CI 0.58-1.15). There was no clear difference in the number of episodes of emesis or subjective improvement in nausea/vomiting. CONCLUSIONS While there were a wide range of interventions studied, both pharmaceutical and otherwise, there were a limited number of placebo controlled trials. In comparing the efficacy of the commonly used antiemetics, metoclopramide, ondansetron, and promethazine, the results of this review do not support the clear superiority of one over the other in symptomatic relief. Other factors such as side effect profile medication safety and healthcare costs should also be considered when selecting an intervention.
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Affiliation(s)
- Rupsa C Boelig
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Thomas Jefferson University , Philadelphia , PA , USA
| | | | - Gabriele Saccone
- c Department of Neuroscience, Reproductive Science and Dentistry, School of Medicine , University of Naples "Federico II" , Naples , Italy
| | - Anthony J Kelly
- d Department of Obstetrics and Gynecology , Brighton and Sussex University Hospitals NHS Trust , Brighton , UK
| | | | - Vincenzo Berghella
- a Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine , Thomas Jefferson University , Philadelphia , PA , USA
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Dochez V, Dimet J, David-Gruselle A, Le Thuaut A, Ducarme G. French family physician experience concerning the outpatient care for women suffering from nausea and vomiting in pregnancy. J Gynecol Obstet Hum Reprod 2017. [PMID: 28643666 DOI: 10.1016/j.jogoh.2017.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To explore thoughts and attitudes among French family physicians on the outpatient care for women suffering from nausea and vomiting in pregnancy (NVP). DESIGN AND SETTING A retrospective study was conducted among family physicians who had taken care of pregnant women who gave birth in our hospital in 1 year. PATIENTS AND METHODS Fifty-nine French family physicians responded to a questionnaire assessing their experience about outpatient care for women suffering from NVP. Analysis were done according to the physicians' age, as the annual demographics data analysis from the French Medical Council. RESULTS More than 89% of family physicians asked systematically the question concerning NVP (53/59), which were estimated as a frequent symptom (n=44, 74.6%). The intensity of NVP was assessed as mild in 28.8% (n=17), moderate in 62.7% (n=37), severe in 6.8% (n=4) and unbearable in 1.7% (n=1). Physicians younger than 40 years questionned less frequently about NVP compared to those older than 40 or older than 60 years (66.7% vs. 90.5% vs. 95.5%, respectively; P=0.04). Severe and unbearable NVP were significantly estimated more frequent among younger physicians (33.3% vs. 6.8%; P=0.03). Treatments (sick leave, diet, drugs, homeopathy, acupuncture or psychotherapy) did not differ between groups. DISCUSSION AND CONCLUSION Outpatient care for women suffering from NVP may vary according to the physician. French family physicians played a key role in NVP. Younger family physician considered NVP as a frequent symptom which needed active management in severe forms.
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Affiliation(s)
- V Dochez
- Department of obstetrics and gynecology, centre hospitalier departemental, Les Oudairies, 85000 La-Roche-sur-Yon, France; Department of obstetrics and gynecology, centre hospitalier universitaire, 44000 Nantes, France
| | - J Dimet
- Clinical research center, centre hospitalier departemental, Les Oudairies, La-Roche-sur-Yon, France
| | | | - A Le Thuaut
- Clinical research center, centre hospitalier departemental, Les Oudairies, La-Roche-sur-Yon, France
| | - G Ducarme
- Department of obstetrics and gynecology, centre hospitalier departemental, Les Oudairies, 85000 La-Roche-sur-Yon, France.
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