Persistent hyperemesis gravidarum and Helicobacter pylori

The association between Helicobacter pylori and gastrointestinal disorders during pregnancy: A Multicenter retrospective study

BACKGROUND

Some gastrointestinal disorders may be associated with Helicobacter pylori infection, which not only affect maternal health, but may also lead to adverse pregnancy outcomes. We aim to explore the association between H. pylori and gastrointestinal disorders in pregnant women.

MATERIALS AND METHODS

In total, 503 patients were retrospectively analyzed and divided into the H. pylori-uninfected group, the H. pylori-infected group, or the H. pylori-eradicated group. We analyzed the influence of H. pylori on gastrointestinal diseases during pregnancy among the groups, as well as the severity, symptoms, laboratory tests of the H. pylori-related diseases.

RESULTS

Pregnant women with H. pylori infection had higher risk of nausea and vomiting of pregnancy (NVP) (p < 0.001), severe NVP(p = 0.012), hyperemesis gravidarum (p = 0.027), hematemesis (p = 0.018), hyponatremia (p = 0.033), as well as functional dyspepsia symptoms including epigastric pain (p = 0.004), bloating (p = 0.024), and feeling full quickly in a meal (p = 0.031) compared with those without H. pylori infection. While the prevalence of NVP (p = 0.024), severe NVP (p = 0.009), epigastric pain (p = 0.037), and bloating (p = 0.032) were lower in H. pylori-eradicated pregnant women than in H. pylori-infected women. In addition, pregnant women with H. pylori infection had higher risk of spontaneous preterm birth than whom without H. pylori infection (p = 0.033).

CONCLUSIONS

Helicobacter pylori infection was associated with higher risks of NVP, severe NVP, hyperemesis gravidarum, functional dyspepsia, and spontaneous preterm birth in pregnant women.

Helicobacter pylori Exposure in Nausea and Vomiting of Pregnancy Increases Risk of Preterm Delivery

Background

Hyperemesis gravidarum (HG), a severe form of nausea and vomiting in pregnancy (NVP), is a leading indication for hospitalization in the first trimester. NVP and HG are associated with Helicobacter pylori (HP) infection in non-United States cohorts. How HP exposure and NVP interact to affect metabolic disturbance and pregnancy outcomes is not known.

Materials and Methods

We designed a retrospective cohort study relating HP and NVP to serum electrolyte laboratory results, preterm delivery, and infant birth weight. Single academic institution discovery and independent multi-institutional validation cohorts included pregnant subjects with an HP test result. Associations of HP, NVP, and pregnancy outcomes were assessed with odds ratio calculations, Student's t-tests, and multivariate logistic regression.

Results

Among subjects with positive HP test results, the prevalence of hyperemesis gravidarum (HG) was 0.025 (66 of 2671) and NVP was 0.27 (710 of 2671). Subjects with negative HP had prevalence of HG 0.015 (165 of 10,960) and NVP 0.22 (2392 of 10,960). History of HP exposure increased risk of NVP, including HG (odds ratio 1.3, 95% CI 1.1-1.4). Patients with HP exposure had lower serum potassium (mean difference 0.1 mEq/L) and bicarbonate (mean difference 0.3 mEq/L) during pregnancy than HP-negative patients (p < 0.01). Serum potassium was lowest in subjects with both NVP and HP exposure (mean 3.5 mEq/L [3.4-3.6], p < 0.0001). HP exposure alone carried increased risk for preterm delivery (OR 1.3 [1.1-1.4]). NVP alone increased risk of preterm delivery (OR 2.8 [2.5-3.1]) including second trimester delivery (OR 2.2 [1.7-2.8]). In multivariate analysis, HP exposure in the setting of NVP further increased risk of preterm delivery (adjusted OR 1.4 [1.0-1.9], p = 0.03).

Conclusions

H. pylori exposure and diagnosis of NVP are individually associated with metabolic disturbances and adverse pregnancy outcomes such as preterm labor and delivery, and their combination further increases risk in US populations.

Helicobacter pylori infection: a predictor of vomiting severity in pregnancy and adverse birth outcome

BACKGROUND

Nausea and occasional vomiting in early pregnancy is common. Why some women experience severe nausea and occasional vomiting in early pregnancy is unknown. Causes are multifactorial and only symptomatic treatment options are available, although adverse birth outcomes have been described. Helicobacter pylori infection has been implicated in the cause of nausea and occasional vomiting in early pregnancy.

OBJECTIVE

The purpose of this study was to investigate the association of H pylori with vomiting severity in pregnancy and its effect on birth outcome.

STUDY DESIGN

We assembled a population-based prospective cohort of pregnant women in The Netherlands. Enrolment took place between 2002 and 2006. H pylori serology was determined in mid gestation. Women reported whether they experienced vomiting in early, mid, and late gestation. Maternal weight was measured in the same time periods. Birth outcomes were obtained from medical records. Main outcome measures were vomiting frequency (no, occasional, daily) and duration (early, mid, late gestation), maternal weight gain, birthweight, small for gestational age, and prematurity. Data were analyzed with the use of multivariate regression.

RESULTS

We included 5549 Women, of whom 1932 (34.8%) reported occasional vomiting and 601 (10.8%) reported daily vomiting. Women who were H pylori-positive (n=2363) were more likely to report daily vomiting (adjusted odds ratio, 1.44; 95% confidence interval, 1.16-1.78). H pylori-positivity was associated with a reduction of total weight gain in women with daily vomiting (adjusted difference, -2.1 kg; 95% confidence interval, -2.7 to -1.5); infants born to women with H pylori and daily vomiting had slightly reduced birthweight (addjusted difference -60g; 95% confidence interval, -109 - -12) and an increased risk of being small for gestational age (adjusted odds ratio, 1.49; 95% confidence interval, 1.04-2.14). H pylori and daily vomiting did not significantly affect prematurity rate.

CONCLUSION

This study suggests that H pylori is an independent risk factor for vomiting in pregnancy. In women with daily vomiting, H pylori is also associated with low maternal weight gain, reduced birth weight, and small for gestational age. Because effective treatments for severe nausea and occasional vomiting in early pregnancy are currently lacking, the effect of H pylori eradication therapy on nausea and occasional vomiting in early pregnancy symptom severity should be the target of future studies.

Barriers and Challenges in Hyperemesis Gravidarum Research

Nausea and occasional vomiting in early pregnancy (NVP) are common. When vomiting is severe or protracted, it is referred to as hyperemesis gravidarum (HG). HG affects up to 3% of pregnancies and is characterized by weight loss, dehydration, electrolyte imbalance, and the need for hospital admission. HG has significant consequences for maternal well-being, is associated with adverse birth outcomes, and leads to major health care costs. Treatment options are symptomatic, hampered by the lack of evidence-based options including studies on nutritional interventions. One of the reasons for this lack of evidence is the use of a broad range of definitions and outcome measures. An internationally accepted definition and the formulation of core outcomes would facilitate meta-analysis of trial results and implementation of evidence in guidelines to ultimately improve patient care.

Helicobacter pylori Infection Is Associated with an Increased Risk of Hyperemesis Gravidarum: A Meta-Analysis

Background. Several studies have shown a possible involvement of Helicobacter pylori (H. pylori) infection in individuals with hyperemesis gravidarum (HG), but the relationship remains controversial. This meta-analysis was performed to validate and strengthen the association between HG and H. pylori infection. Methods. PubMed, Embase, and Web of Science databases up to March 20, 2014, were searched to select studies on the prevalence of H. pylori infection between pregnant women with HG and the normal pregnant control subjects. Results. Of the HG cases, 1289 (69.6%) were H. pylori-positive; however, 1045 (46.2%) were H. pylori-positive in control group. Compared to the non-HG normal pregnant controls, infection rate of H. pylori was significantly higher in pregnant women with HG (OR = 3.34, 95% CI: 2.32–4.81, P < 0.001). Subgroup analysis indicated that H. pylori infection was a risk factor of HG in Asia, Africa, and Oceania, especially in Africa (OR = 12.38, 95% CI: 7.12–21.54, P < 0.001). Conclusions. H. pylori should be considered one of the risk factors of HG, especially in the developing countries. H. pylori eradication could be considered to relieve the symptoms of HG in some intractable cases.

Helicobacter pylori and pregnancy-related disorders

Helicobacter pylori (H. pylori) infection is investigated in gastric diseases even during pregnancy. In particular, this Gram-negative bacterium seems to be associated with hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy. During the last decade, the relationship among H. pylori and several extra-gastric diseases strongly emerged in literature. The correlation among H. pylori infection and pregnancy-related disorders was mainly focused on iron deficiency anemia, thrombocytopenia, fetal malformations, miscarriage, pre-eclampsia and fetal growth restriction. H. pylori infection may have a role in the pathogenesis of various pregnancy-related disorders through different mechanisms: depletion of micronutrients (iron and vitamin B₁₂) in maternal anemia and fetal neural tube defects; local or systemic induction of pro-inflammatory cytokines release and oxidative stress in gastrointestinal disorders and pre-eclampsia; cross-reaction between specific anti-H. pylori antibodies and antigens localized in placental tissue and endothelial cells (pre-eclampsia, fetal growth restriction, miscarriage). Since H. pylori infection is most likely acquired before pregnancy, it is widely believed that hormonal and immunological changes occurring during pregnancy could activate latent H. pylori with a negative impact not only on maternal health (nutritional deficiency, organ injury, death), but also on the fetus (insufficient growth, malformation, death) and sometime consequences can be observed later in life. Another important issue addressed by investigators was to determine whether it is possible to transmit H. pylori infection from mother to child and whether maternal anti-H. pylori antibodies could prevent infant’s infection. Studies on novel diagnostic and therapeutic methods for H. pylori are no less important, since these are particularly sensitive topics in pregnancy conditions. It could be interesting to study the possible correlation between H. pylori infection and other pregnancy-related diseases of unknown etiology, such as gestational diabetes mellitus, obstetric cholestasis and spontaneous preterm delivery. Since H. pylori infection is treatable, the demonstration of its causative role in pregnancy-related disorders will have important social-economic implications.

Hyperemesis gravidarum and Helicobacter pylori infection: a systematic review

OBJECTIVE

To systematically review studies examining the relationship between hyperemesis gravidarum and Helicobacter pylori (H pylori) infection.

DATA SOURCES

A 1966 to January 2007 search using MEDLINE/PubMed, EMBASE, and Web of Science included MeSH terms: "Helicobacter pylori," "Helicobacter infections," "hyperemesis gravidarum," and the text words "nausea," "vomit," "pregnancy," and "Helicobacter." References of selected papers were examined for additional relevant studies.

METHODS OF STUDY SELECTION

We evaluated studies investigating a relationship between hyperemesis gravidarum and H pylori infection. Studies were included in which the diagnosis of hyperemesis gravidarum was made at or before entry into the study, and H pylori diagnosis was made by serum antibody sample, gastric biopsy, saliva test, or stool sample. The search produced 169 titles; 22 were reviewed in further detail.

TABULATION, INTEGRATION, AND RESULTS

Fourteen case-control studies met established criteria, involving 1,732 participants and controls tested for H pylori infection. Studies were evaluated according to patient demographics and study methodology (case definition, exclusion criteria, H pylori testing). An estimate of the odds ratios with 95% confidence intervals was calculated by using a random effects model for dichotomous variables with review article software. Ten studies showed a significant association between hyperemesis gravidarum and H pylori infection. Odds ratios varied from 0.55 to 109.33; three results were less than 1.0. Tests for heterogeneity applied to several subgroups were considerable with values above 75% for all groups.

CONCLUSION

An association between hyperemesis gravidarum and H pylori infection is suggested by this systematic review. However, the considerable heterogeneity among studies highlights study limitations.