Nausea and vomiting in pregnancy is not always nausea and vomiting of pregnancy

Incidence and risk factors of hyperemesis gravidarum: A national register-based study in Finland, 2005-2017

INTRODUCTION

Hyperemesis gravidarum is the most common reason for hospitalization in early pregnancy in pregnancies resulting in delivery. Several associative factors indicate that the etiology is likely to be multifactorial. To assess this, we used a unique procedure to compare hyperemetic pregnancies with non-hyperemetic pregnancies both in different women and in the same women's different pregnancies.

MATERIAL AND METHODS

Data about all pregnancies resulting in delivery in Finland in 2005-2017 were retrieved from healthcare registers. Women who had a diagnosis of hyperemesis gravidarum in any pregnancy in the Finnish Hospital Discharge Register were chosen as cases (n = 9315) and other women (n = 428 150) as the reference group. The incidence of hyperemesis gravidarum was calculated and associations between hyperemesis and maternal, environmental and pregnancy-related factors were analyzed in a novel setting by comparing case women's pregnancies diagnosed with hyperemesis to (1) reference group women's pregnancies and (2) case women's non-hyperemetic pregnancies.

RESULTS

Of the 437 465 women who had at least one pregnancy resulting in delivery during the study period, 9315 women had at least one hyperemetic pregnancy. The total number of pregnancies resulting in delivery was 741 387 and 9549 of those were diagnosed with hyperemesis gravidarum; thus the incidence of hyperemesis gravidarum was 1.3%. In comparison (1), case women's hyperemetic pregnancies vs reference group's pregnancies, younger maternal age, higher gravidity, underweight and overweight were associated with increased risk of hyperemesis; in contrast, in comparison (2), case women's hyperemetic pregnancies vs their non-hyperemetic pregnancies, higher age and obesity were associated with higher risk of hyperemesis, whereas the risk was lower as gravidity and parity increased. In both comparisons, smoking was associated with lower risk, whereas higher municipality population, assisted reproductive technology, multiple gestation and female sex of the fetus were associated with increased risk of hyperemesis.

CONCLUSIONS

Our novel study setting provided new insights about risk factors: hyperemetic pregnancies differ both from pregnancies of women who had never been diagnosed with hyperemesis and from hyperemetic women's non-hyperemetic pregnancies. The incidence of hyperemesis gravidarum in Finland was comparable to that in other countries.

Brucellosis in pregnancy: results of multicenter ID-IRI study

Brucellosis in pregnant women is reported to be associated with obstetric complications (OCs), and adequate data for human brucellosis during pregnancy are largely lacking. We performed this multicenter retrospective cross-sectional study to evaluate the epidemiology, clinical course, treatment responses, and outcomes of brucellosis among pregnant women. The study period comprised a 14-year period from January 2002 to December 2015. All consecutive pregnant women diagnosed with brucellosis in 23 participating hospitals were included. Epidemiological, clinical, laboratory, therapeutic, and outcome data along with the assessment data of the neonate were collected using a standardized questionnaire. Data of 242 patients were analyzed. The OC rate was 14.0% (34/242) in the cohort. Of the 242 women, 219 (90.5%) delivered at term, 3 (1.2%) had preterm delivery, 15 (6.2%) aborted, and 5 (2.1%) had intrauterine fetal demise. Seventeen (7.0%) of the newborns were considered as low birth weight. Spontaneous abortion (6.1%) was the commonest complication. There were no maternal or neonatal deaths and pertinent sequelae or complications were not detected in the newborns. Splenomegaly (p = 0.019), nausea and/or vomiting (p < 0.001), vaginal bleeding (p < 0.001), anemia (blood hemoglobin < 11 g/dL; p < 0.001), high level of serum aspartate aminotransferase (> 41 IU/L; p = 0.025), oligohydramnios on ultrasonography (p = 0.0002), history of taking medication other than Brucella treatment during pregnancy (p = 0.027), and Brucella bacteremia (p = 0.029) were the significant factors associated with OCs. We recommend that pregnant women with OC or with fever should be investigated for brucellosis if they live in or have traveled to an endemic area.

The outpatient management and special considerations of nausea and vomiting in pregnancy

With 50-90% of pregnant women experiencing nausea and vomiting of pregnancy (NVP), the burden of illness can become quite significant if symptoms are under-treated and/or under-diagnosed, thus allowing for progression of the disease. The majority of these women will necessitate at least one visit with a provider to specifically address NVP, and up to 10% or greater will require pharmacotherapy after failure of conservative measures to adequately control symptoms. As a result, initiation of prompt and effective treatment in the outpatient setting is ideal. Once NVP is diagnosed and treatment is started, it is crucial to track symptoms in order to assess for a decrease in or resolution of symptoms as well as an escalation in symptoms requiring additional therapy. Of note, co-existing gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and psychosocial factors may have a negative impact on the management of NVP. Ultimately, every woman has her own perception of disease severity and desire for treatment. It is critical that both the provider and patient be proactive in the diagnosis and management of NVP.

Review of NVP and HG and Early Pharmacotherapeutic Intervention

NVP occurs in 50–90% of pregnancies, making it a common medical condition in pregnancy. Women present differently with any combination of signs and symptoms. It is appropriate to take the pregnancy-related versus nonpregnancy-related approach when determining the cause of nausea and vomiting but other causes should be considered. The most common etiologies for NVP include the hormonal changes associated with pregnancy, the physiologic changes in the gastrointestinal tract, and a genetic predisposition. Up to 10% of women will require pharmacotherapy to treat the symptoms of NVP despite conservative measures. ACOG currently recommends that a combination of oral pyridoxine hydrochloride and doxylamine succinate be used as first-line treatment for NVP if pyridoxine monotherapy does not relieve symptoms. A review of NVP and early pharmacotherapeutic management is presented due to the fact that NVP is largely undertreated, and investigations into the safe and effective pharmacotherapies available to treat NVP are lacking.