ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy

A comprehensive review on glucocorticoids induced osteoporosis: A medication caused disease

Glucocorticoids (GCs) are steroid hormones that are extensively used in the treatment of autoimmune diseases, inflammation, and cancer. The major ill effect of administering GCs is that it has a deleterious effect on bone, which leads to GC-induced osteoporosis. GC therapy induces bone loss and is associated with the risk of nonvertebral and vertebral fractures, as it works in combination by increasing bone reabsorption and suppressing bone formation during the initial phase of therapy. It is seen and established that GC in excess or in low dose for 3 months or more can be a risk factor for fracture, and the risk increases with an increase in dose and duration of usage. The most common cause of secondary osteoporosis is the administration of GC inside the body to treat various diseases. The degree of bone loss is directly proportional to the GC dose and the exposure duration. The first step is to evaluate the patients' risk factors for the development of glucocorticoids that induce osteoporosis, which include the dose, duration of use, patient age, sex, previous fractures, and other medical conditions.

Pregnancy outcomes by hyperemesis gravidarum severity and time of diagnosis: A retrospective cohort study

OBJECTIVE

With inconsistencies regarding the possible effect of hyperemesis gravidarum on the course of pregnancy, this research aimed to study the association between hyperemesis gravidarum and pregnancy outcomes, while also addressing the trimester of diagnosis and severity.

METHODS

A retrospective cohort study was performed, including all singleton deliveries of mothers from the largest health maintenance organization in the country, in a single tertiary hospital between 1991 and 2021. The incidence of adverse pregnancy outcomes was compared between pregnancies with and without hyperemesis gravidarum diagnosis. Multivariable generalized estimation equation binary models were used to study the association between maternal hyperemesis gravidarum, trimester of diagnosis and hyperemesis gravidarum severity and the studied outcomes.

RESULTS

The study population included 232 476 pregnancies, of which 3227 (1.4%) were complicated with hyperemesis gravidarum. Women with hyperemesis gravidarum were more likely to deliver preterm (adj. OR = 1.33, 95% CI: 1.18-1.50), a newborn with low birthweight (adj. OR = 1.52, 95% CI: 1.16-1.98, only if diagnosed in the second trimester), and to have a cesarean delivery (adj. OR = 1.20, 95% CI: 1.09-1.32). They were less likely to deliver small gestational age newborn (adj. OR = 0.82, 95% CI: 0.69-0.99) and their offspring to experience perinatal mortality (adj. OR = 0.54, 95% CI: 0.31-0.93, among mild cases only). A dose-response association was observed between preterm birth and hyperemesis gravidarum (adj. OR = 1.26; 95% CI: 1.11-1.44, for mild cases and adj. OR = 2.04; 95% CI: 1.31-3.19, for severe cases).

CONCLUSIONS

Hyperemesis gravidarum is associated with an increased risk for adverse pregnancy outcomes including mainly preterm delivery in a dose-response manner and when diagnosed during the second trimester.

Primary achalasia diagnosed during pregnancy: rare cause of nausea and vomiting

Nausea and vomiting during pregnancy are very common; however, when persistent symptoms lead to severe malnutrition, other conditions should be considered. We present a patient with severe postprandial nausea and vomiting resulting in 120 lb weight loss. She was treated for presumed hyperemesis gravidarum but diagnosed with achalasia type 1 upon further work-up. The pregnancy was further complicated by fetal growth restriction, shortened cervix and preterm premature rupture of membranes, and resulted in delivery at 26 weeks of gestation. Postpartum, she underwent a peroral endoscopic myotomy procedure and has returned to normal body mass index.The differential for nausea/vomiting is broad, and major medical conditions can manifest for the first time during pregnancy. Severe malnutrition adversely affects maternal and fetal health. Further work-up should be pursued when symptoms cannot otherwise be explained.

Inpatient Management of Hyperemesis Gravidarum

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.

[Hyperemesis Gravidarum - an Interprofessional and Interdisciplinary Challenge - Evidence-Based Review]

Hyperemesis gravidarum (HG) is a multifactorial disease characterized by severe and persisting nausea and vomiting, impairment of oral intake, weight loss of at least 5%, electrolyte abnormalities, and dehydration. The prevalence of HG ranges from 0.3 to 10% worldwide. The diagnosis is made by the patient's prehistory, clinical symptoms, physical examination, and the typical laboratory abnormalities. Therapeutic cornerstones are nutrition advice, consultation of life style, psychological/psychosocial support of the mother as well as the administration of antiemetics in a stepwise approach, depending on the severity of symptoms, and finally admission to hospital in severe cases. Treatment of patients requires close interprofessional and interdisciplinary cooperation.

Hyperemesis gravidarum theories dispelled by recent research: a paradigm change for better care and outcomes

Nausea and vomiting (NVP) affect most pregnant women. At the severe end of the clinical spectrum, hyperemesis gravidarum (HG) can be life-threatening. The condition is fraught with misconceptions that have slowed progress and left women undertreated. Herein, recent scientific advances are presented that dispel common myths associated with HG related to maternal/offspring outcomes, etiology, and evolution. There is now strong evidence that (i) HG is associated with poor outcomes, (ii) a common cause of NVP and HG has been identified, and (iii) NVP is likely a protective evolutionary mechanism that occurs throughout the animal kingdom but is no longer necessary for human survival. Therefore, it is encouraging that we are finally on the cusp of testing treatments that may put an end to unnecessary suffering.

Electroencephalographic Changes in Pregnant Women with Hyperemesis Gravidarum: A Case-Control Study

OBJECTIVE

Electroencephalogram (EEG), which is frequently used in the clinical practice of neurology, has also been investigated in eating disorders and some cortical dysfunctions have been reported. Based on this, we aimed to investigate EEG changes in pregnant women with hyperemesis gravidarum (HEG).

MATERIALS AND METHODS

This case-control study was conducted on 66 pregnant women who applied to the Umraniye Training and Research Hospital, Department of Obstetrics and Gynecology. The study group consisted of 34 pregnant women diagnosed with HEG. The control group consisted of 32 healthy pregnant women who were matched with the HEG group in terms of age and gestational week. EEGs of the participants were performed with a Micromed Brain Rapid EEG device in the Neurology Department of Umraniye Training and Research Hospital. In EEGs, all channels were selected as bipolar and samples of 18 channels (Fp2-F4, F4-C4, C4-P4, P4-O2, Fp2-F8, F8-T4, T4-T6, T6-O2, Fz-Cz, Cz-Pz, Fp1-F3, F3-C3, C3-P3, P3-O1, Fp1-F7, F7-T3, T3-T5, and T5-O1) were obtained. EEG signals were sampled with a sampling frequency of 200 Hz and digitized with 12-bit resolution. EEG signals were converted to EDF (European Data Format) extension files using the MATLAB software program and analyzed using statistical features on the time and frequency axis. HEG and control groups were compared in terms of signals obtained from these 18 selected channels.

RESULTS

Both groups were similar in terms of mean age, gestational age, and parity (p>0.05). Among the 18 channels, significant changes were detected between the two groups only in the theta, beta, and gamma bands in the C4-P4 channel and the delta, beta, and gamma bands in the T4-T6 channel (p<0.05). No significant changes were detected in the channels and bands.

CONCLUSION

Theta, beta, and gamma band abnormalities in the centro-parietal area of the right hemisphere and delta, beta, and gamma band abnormalities in the temporal area of the right hemisphere were observed on HEG. However, it is unclear whether abnormalities in EEG are primary changes responsible for the development of HEG or secondary to metabolic and hormonal changes resulting from HEG itself.

Use of Thiamine Supplementation in Pregnant Women Diagnosed With Hyperemesis Gravidarum and Wernicke Encephalopathy

Hyperemesis gravidarum is the most common condition requiring hospital care for women during the first 20 weeks of pregnancy and may lead to malnutrition, dehydration, and vitamin deficiencies. Depletion of vitamins such as thiamine may result in the development of Wernicke encephalopathy, a severe neurological disorder that can increase the risk for mortality and morbidity for the mother and fetus. A lack of awareness regarding the relationship of hyperemesis gravidarum and Wernicke encephalopathy may result in delayed treatment and disease management. Glucose administration in the presence of thiamine deficiency may induce Wernicke encephalopathy; protocols are needed to ensure dextrose is used for women with hyperemesis gravidarum in times of prolonged vomiting and poor oral intake only after first administering thiamine. This article includes a discussion of best practices for thiamine supplementation with hyperemesis gravidarum and Wernicke encephalopathy.

Evaluation of controlling nutritional status (CONUT) score in the prognosis of hyperemesis gravidarum

OBJECTIVE

To investigate the predictive value of the Controlling Nutritional Status (CONUT) score on hyperemesis gravidarum (HG) severity, hospitalization, and length of stay.

MATERIALS AND METHODS

This retrospective cross-sectional study, conducted between December 2022 and June 2023, involved two groups. Group 1 comprised 52 pregnant women diagnosed with HG in the first trimester, receiving hospitalization and treatment. Group 2 included 105 pregnant women diagnosed with HG in the first trimester, managed and treated as outpatients. The CONUT score was calculated with the formula: Serum albumin score + total lymphocyte score + total cholesterol score. This score is calculated with a number of points between 0 and 12. The interpretation of the score involves four categories: normal (0-1), light (2-4), moderate (5-8), and severe (9-12).

RESULTS

The CONUT score differed significantly between the hospitalized (4, IQR: 2.25-5) and outpatient groups (2, IQR: 2-3) (p < 0.001). A CONUT score >3 was associated with the need for hospitalization, demonstrating a sensitivity of 60%, a specificity of 84% (p < 0.001). The CONUT score was the parameter with the highest odds ratio (OR) value among the parameters related to the need for hospitalization, and each unit increase in the CONUT score increased the need for hospitalization by 1.683 times [OR = 1.683 (95% CI: 1.042-2.718), p = 0.033]. A positive correlation was found between the CONUT score and the duration of hospital stay (r = 0.316, p = 0.023).

CONCLUSIONS

This study suggests CONUT score as a valuable tool for predicting HG severity, hospitalization need, and duration of hospital stay.

Association of the Verbal Rating Scale-Measured Dysmenorrhea with Nausea and Vomiting in Pregnancy: A Retrospective Cohort Study

OBJECTIVES

Nausea and vomiting in pregnancy (NVP) is a common condition that reduces the quality of life by negatively affecting work and family life, physical and mental health, and economic well-being. However, its risk factors remain unclear. This study aimed to explore the association between NVP and verbal rating scale (VRS)-measured dysmenorrhea and to explore potential protective factors.

METHODS

This retrospective cohort study was conducted from June 2018 to December 2020 at Tongji Hospital in Wuhan. Information on baseline characteristics, pregnancy-related history, periconceptional micronutrient supplementation, and obstetric outcomes were collected. The severity of dysmenorrhea was assessed using VRS.

RESULTS

A total of 443 pregnant women were recruited and divided into the NVP group (n = 76) and the control group (n = 367). A significant association was observed between NVP and VRS-measured dysmenorrhea (c2=10.038, P = 0.007). After adjusting for covariates, the association between moderate/severe dysmenorrhea and NVP remained significant (OR 2.384; 95% CI 1.104-5.148, P = 0.004). First-trimester docosahexaenoic acid supplement (OR 0.443; 95% CI 0.205-0.960, P = 0.039) may be beneficial in reducing the risk of NVP.

CONCLUSIONS

Women with moderate to severe dysmenorrhea have a higher risk of experiencing NVP during the first trimester. Periconceptional docosahexaenoic acid supplementation may play a protective role.

The timing, duration, and severity of nausea and vomiting of pregnancy and adverse birth outcomes among controls without birth defects in the National Birth Defects Prevention Study

BACKGROUND

Nausea and vomiting of pregnancy (NVP) occurs in approximately 70% of pregnant people, with varying severity and duration. Treatments include pharmacologic and herbal/natural medications. The associations between NVP and birth outcomes, including preterm birth, small for gestational age (SGA), and low birth weight are inconclusive.

OBJECTIVE

To determine whether NVP and reported medications are associated with adverse birth outcomes.

METHODS

We used data from the population-based, multisite National Birth Defects Prevention Study (1997-2011) to evaluate whether self-reported NVP according to timing, duration, and severity or its specific treatments were associated with preterm birth, SGA, and low birth weight among controls without birth defects. Odds ratios (aOR) and 95% confidence intervals (CI) were adjusted for sociodemographic, reproductive, and medical factors. For any NVP, duration, treatment use, and severity score analyses, the comparison group was participants with no reported NVP. For timing analyses, the comparison group was women with no reported NVP in the same trimester of pregnancy.

RESULTS

Among 6018 participants, 4339 (72.1%) reported any NVP. Among those with NVP, moderate or severe symptoms were more common than mild symptoms. Any versus no NVP was not associated with any of the outcomes of interest. NVP in months 4-6 (aOR 1.21, 95% CI: 1.00, 1.47) and 7-9 (aOR 1.57, 95% CI: 1.22, 2.01) of pregnancy were associated with an increase in the risk of preterm birth. NVP lasting one trimester in duration was associated with decrease in risk of SGA (aOR: 0.74, 95% CI: 0.58, 0.95), and NVP present in every trimester of pregnancy had a 50% increase in risk of preterm birth (aOR: 1.50, 95% CI: 1.11, 2.05). For NVP in months 7-9 and preterm birth, ORs were elevated for moderate (aOR: 1.82, 95% CI: 1.26, 2.63), and severe (aOR: 1.53, 95% CI: 1.06, 2.19) symptoms. NVP was not significantly associated with low birth weight. Our analyses of medications were limited by small numbers, but none suggested increased risk of adverse outcomes associated with use of the medication.

CONCLUSION

Mild NVP and NVP limited to early pregnancy appear to have no effect or a small protective effect on birth outcomes. Long-lasting NVP, severe NVP, and NVP later in pregnancy may increase risk of preterm birth and SGA.

The Effects of Emotional Freedom Techniques Implemented During Early Pregnancy on Nausea-Vomiting Severity and Anxiety: A Randomized Controlled Trial

Objective: This randomized controlled trial investigated the effect of emotional freedom techniques (EFT) on the severity of nausea-vomiting and anxiety in early pregnancy. Design: The sample consisted of 131 pregnant women in the experimental and control groups between 6 and 16 weeks of pregnancy attending an antenatal clinic. Participants were randomly assigned to receive training on EFT or a control group. Data were collected using a personal information form, subjective experiences, the Pregnancy-Related Anxiety Questionnaire, and the Pregnancy-Unique Quantification of Emesis. Both groups attended two visits, a week apart. The participants in the EFT group received a session of EFT at each visit and completed two EFT sessions as home assignments, 2 and 4 days after the first visit. The participants in the control group attended two visits a week apart and completed assessments but did not receive EFT. Results: There were 55 women in each group who completed the study, and the groups were similar in terms of baseline measures, including socioeconomic status, smoking status, previous pregnancy, severity of nausea-vomiting, and total pregnancy-related anxiety. EFT significantly reduced anxiety levels from the baseline to the second session (fear of delivery, worries about bearing a handicapped child, concern about one's own appearance) and total pregnancy-related anxiety (total pretest 29.85 ± 9.87, post-test 20.67 ± 8.38; p < 0.001), while the control group showed no reduction in pregnancy-related anxiety (total pretest 26.1 ± 7.79, post-test 25.98 ± 8.49; p = 0.933). Although nausea-vomiting was reduced in both groups over the two-session period, at the end of treatment, the EFT group had significantly lower nausea intensity (EFT group 4.4 ± 1.81, control group 5.36 ± 2.48; p = 0.02). Conclusions: EFT is a nonpharmacologic intervention that can be effective in reducing nausea, vomiting, and anxiety in early pregnancy. Clinical Trials Registration Number: NCT05337852.

News in pharmacology for the main medical pathologies of gestation

Obstetric diseases represent a highly complex medical challenge, especially regarding its clinical approach. The use of pharmacological agents during pregnancy is one of the main therapeutic alternatives in this group of patients; however, there is a general lack of knowledge about its use, efficacy, and possible adverse effects that may occur in routine clinical practice, even among medical professionals themselves. The high percentage of pregnant women who undergo drugs at some point during pregnancy, together with the developments that have occurred in recent years in the field of pharmacology, show the need for a detailed analysis that shows the existing current knowledge and helps in the clinical decision making. In this sense, the aim of this work is to conduct a review of the available scientific literature on the novelties in pharmacology for the main medical pathologies of pregnancy. Thus, the role of this field in analgesia, antibiotic therapy, digestive, respiratory, urological, psychiatric and neurological pathologies will be detailed, evaluating the indications, precautions and considerations that must be taken into account for its use.

Effect of acupressure in nausea and vomiting treatment during pregnancy: A meta-analysis

BACKGROUND AND OBJECTIVE

Many women experience nausea and vomiting in early pregnancy. Regardless of the disease severity, it affects the work and life of pregnant women. However, drug treatment may potentially impact the foetus; thus, alternative safe and effective measures are essential. We aimed to evaluate the effect of acupressure, a non-drug treatment for nausea and vomiting, during pregnancy.

METHODS

PubMed, EMBASE, Cochrane, Web of Science, CNKI, CBM, VIP, and Wanfang databases were searched using 'pregnancy', 'nausea', 'vomiting', and 'acupressure' as keywords. The search period was from database inception to 30 November 2022. Two researchers independently screened articles, extracted data, and used RevMan 5.4 software for statistical analysis.

RESULTS

We included 33 trials and 3 390 patients in this meta-analysis. Acupressure was effective for women with nausea and vomiting during pregnancy (odds ratio (OR)= 4.81, 95% confidence interval (CI) [3.47, 6.68]; p<0.0001); it significantly reduced the nausea score of the Rhodes index (mean square deviation (MD): -3.21, 95% CI [-4.85, -1.57], Z = 3.83, p = 0.0001), modified Pregnancy Unique Quantification of Emesis and Nausea score (MD: -2.18, 95% CI [-3.21, -1.15], Z = 4.15, p<0.0001), and hospital stay (OR=-3.27, 95% CI [-6.18, -0.36]; p = 0.03) and improved quality of life (MD: -14.06,95% CI [- 17.31, -10.18], Z = 8.48, p<0.00001). However, no significant difference was observed in nursing satisfaction and anxiety scores (OR=4.13, 95% CI [0.89, 19.15]; p = 0.07) (MD: -13.26,95% CI [-32.04,5.53], Z = 1.38, p = 0.17).

CONCLUSIONS

This meta-analysis provides evidence of a non-drug intervention for women with nausea and vomiting during pregnancy; acupressure effectively reduces nausea and vomiting during pregnancy.

Bias analyses to investigate the impact of differential participation: Application to a birth defects case-control study

BACKGROUND

Certain associations observed in the National Birth Defects Prevention Study (NBDPS) contrasted with other research or were from areas with mixed findings, including no decrease in odds of spina bifida with periconceptional folic acid supplementation, moderately increased cleft palate odds with ondansetron use and reduced hypospadias odds with maternal smoking.

OBJECTIVES

To investigate the plausibility and extent of differential participation to produce effect estimates observed in NBDPS.

METHODS

We searched the literature for factors related to these exposures and participation and conducted deterministic quantitative bias analyses. We estimated case-control participation and expected exposure prevalence based on internal and external reports, respectively. For the folic acid-spina bifida and ondansetron-cleft palate analyses, we hypothesized the true odds ratio (OR) based on prior studies and quantified the degree of exposure over- (or under-) representation to produce the crude OR (cOR) in NBDPS. For the smoking-hypospadias analysis, we estimated the extent of selection bias needed to nullify the association as well as the maximum potential harmful OR.

RESULTS

Under our assumptions (participation, exposure prevalence, true OR), there was overrepresentation of folic acid use and underrepresentation of ondansetron use and smoking among participants. Folic acid-exposed spina bifida cases would need to have been ≥1.2× more likely to participate than exposed controls to yield the observed null cOR. Ondansetron-exposed cleft palate cases would need to have been 1.6× more likely to participate than exposed controls if the true OR is null. Smoking-exposed hypospadias cases would need to have been ≥1.2 times less likely to participate than exposed controls for the association to falsely appear protective (upper bound of selection bias adjusted smoking-hypospadias OR = 2.02).

CONCLUSIONS

Differential participation could partly explain certain associations observed in NBDPS, but questions remain about why. Potential impacts of other systematic errors (e.g. exposure misclassification) could be informed by additional research.

Evaluation of nausea and vomiting in the first trimester on the risk of adverse birth outcomes and the contribution of genetic polymorphisms: a pilot prospective study

PURPOSE

To evaluate the impact of Nausea and Vomiting in Pregnancy (NVP) on the risk of Preterm Birth (PTB) and Low Birth Weight (LBW), and explore the effect of genetic polymorphisms on the severity of NVP.

METHODS

A prospective study was conducted. Participants' experience of NVP prior to 12 gestational weeks were evaluated by a Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) scale. 11 Single Nucleotide Polymorphisms (SNPs) loci located in growth differentiation factor 15 (GDF15) and leucine-rich repeat containing 25 (LRRC25) gene of chr19p13.11 and intergenic region of chr4q12 were genotyped, which were implicated as genetic risk factors for NVP. Logistic regression models were applied to determine the effect of NVP in the first trimester on the risk of PTB and LBW, and genetic polymorphisms on the risk of NVP.

RESULTS

Among 413 pregnant women, the incidence of nausea and vomiting was 85.5% (n = 353) in the first trimester, including 38.7% (n = 160) mild vomiting, 42.6% (n = 176) moderate vomiting and 4.1% (n = 17) severe vomiting. 33 were PTB, 20 were LBW. Compared with pregnant women without NVP, women with mild, moderate or severe NVP in the first trimester were not associated with the risk of PTB and LBW. Besides, the polymorphisms of 11 SNPs loci were not associated with the risk of NVP.

CONCLUSIONS

Our study indicated that symptoms of nausea and vomiting in the first trimester were not significantly associated with PTB and LBW, and there were also no associations between GDF15 and LRRC25 polymorphisms and NVP.

Prevalence and burden of nausea and vomiting in pregnant women: Interim analysis of the PURITY survey

OBJECTIVES

Nausea and vomiting in pregnancy is a common and invalidating condition in early pregnancy. However, no data are available on its prevalence in Italy. This survey aims to evaluate the prevalence and impact of nausea and vomiting during pregnancy on the quality of life of Italian women.

STUDY DESIGN

The survey was performed in three Italian public University Hospitals in two distinct periods: a first interview took place between the 18th and 22nd week of pregnancy, using the Questionnaire for Pregnancy Period (14 questions regarding demographic data and 30 questions about nausea and vomiting in pregnancy, including Pregnancy-Unique Quantification of Emesis questionnaire), and a follow-up interview, by telephone call, took place immediately after giving birth and in any case within 14 days of delivery, using the Questionnaire for Post-Pregnancy (9 questions). Included women were Caucasian, in physiological pregnancy and between the 18th and 22nd week (time of morphological ultrasound), able to communicate adequately with the interviewer, understand the questionnaires and able to provide valid informed consent. Twin pregnancies and women who recurred to medically assisted procreation were excluded. This is an interim report on data collected from 232 of the planned 600 women.

RESULTS

Mean age of the recruited subjects was 32.6 ± 4.6 years, with approximately 60% primiparous. The prevalence of nausea and vomiting in pregnancy in the sample examined was 65.5% overall (152 out of 232 subjects). Of these 152 women, 63 (41.4%) experienced only nausea, 6 (3.9%) only vomiting, and 83 (54.6%) reported both. Symptoms were reported to begin at 7.2 ± 2.7 weeks, lasted 10.2 ± 5.6 weeks, and persisted at the time of the interview in 32.2% of cases. Overall, over 50% of the women interviewed experienced a negative impact of nausea and vomiting in pregnancy on social relationships and work activity.

CONCLUSIONS

A high prevalence of nausea and vomiting in pregnancy, 65.5% overall, was found in this interim analysis. These symptoms appeared capable of negatively influencing women quality of life. Screening procedures should be offered during pregnancy and measures that address nausea and vomiting in pregnancy impact warranted.

The effects of pyridoxine (vitamin B6) supplementation in nausea and vomiting during pregnancy: a systematic review and meta-analysis

PURPOSE

Nausea and vomiting during pregnancy (NVP) are common symptoms in pregnancy. Although no definitive treatment option for NVP, pyridoxine (Vitamin B6) supplementation has been used widely. The present study aims to systematically evaluate the current evidence regarding pyridoxine for the treatment of NVP.

METHODS

Data were obtained using a stepwise search process using keywords in the following online medical databases; PubMed®, Web of Science®, and Scopus® for studies published before 1st May 2021. Studies reporting intervention with pyridoxine supplementation alone and/or with other active substances were included. A meta-analysis was performed on the PUQE score and Rhode's score for nausea and vomiting.

FINDINGS

Initial database searching indicated 548 potentially eligible articles, of which 18 studies satisfying the inclusion criteria were selected. Eight studies showed beneficial effects with pyridoxine alone as the supplementation, while six others found that the supplementation of pyridoxine in combination with another active substance had favourable effects. Supplementation of pyridoxine alone as well as combined treatment of pyridoxine with an active ingredient as the intervention significantly improved the symptoms of nausea according to Rhode's score [0.78 [95% CI: 0.26, 1.31; p = 0.003; I2 = 57%, p = 0.10)] and PUQE score [0.75 (95% CI: 0.28, 1.22; p = 0.002; I2 = 0%, p = 0.51)], respectively.

CONCLUSION

Supplementation of pyridoxine alone as well as with an active ingredient demonstrated beneficial effects for women suffering from NVP.

Better safe than sorry: Exploring the collective sensemaking process in pregnancy virtual communities through thematic analysis

Physical symptoms induced by pregnancy are often perceived as a normal part of the physiological process and therefore not commonly discussed in clinical settings during prenatal care. This study aimed to explore how pregnant individuals adapt to physical symptoms related to their pregnancy, using the perspective of collective sensemaking. A retrospective study design with an inductive thematic analysis approach of qualitative data extracted from web-based forum posts was conducted. Among 574 initial posts and 2801 comments, three themes were identified: (i) awareness of changing pregnancy body, (ii) uncertainty about physical symptoms, and (iii) coping with discomforts associated with pregnancy. A shared identity as a group of individuals dealing with similar challenges enables pregnant individuals to develop a better comprehension of their experiences. Healthcare professionals should recognize the importance of individual and collective sensemaking in pregnancy forums and strive to provide a supportive and empathetic environment for pregnant individuals to share their experiences and seek guidance.

Choosing the appropriate pharmacotherapy for breast cancer during pregnancy: what needs to be considered?

INTRODUCTION

Breast cancer is the most commonly diagnosed malignancy during pregnancy. Breast cancer during pregnancy is a challenging clinical condition requiring proper and timely multidisciplinary management.

AREAS COVERED

This review focuses on the management of breast cancer during pregnancy with a focus about the current state-of-the-art on the feasibility and safety of pharmacotherapy approaches in this setting.

EXPERT OPINION

Multidisciplinary care is key for a proper diagnostic-therapeutic management of breast cancer during pregnancy. Engaging patients and their caregivers in the decision-making process is essential and psychological support should be provided. The treatment of patients with breast cancer during pregnancy should follow the same recommendations as those for breast cancer in young women outside pregnancy but taking into account the gestational age at the time of treatment.Anthracycline-, cyclophosphamide-, and taxane-based regimens can be safely administered during the second and third trimesters with standard protocols, preferring weekly regimens whenever possible. Endocrine therapy, immune checkpoint inhibitors, and targeted agents are contraindicated throughout pregnancy, also due to the very limited data available to guide their administration in this setting. During treatment, careful fetal growth monitoring is mandatory, and even after delivery proper health monitoring for the children exposed in utero to chemotherapy should be continued.

Association between Dietary Patterns and the Risk of Hyperemesis Gravidarum

(1) Background: Although studies have suggested that dietary interventions may have potential benefits over conventional medical treatments, research on the association between dietary patterns and hyperemesis gravidarum (HG) in pregnant women is scarce. (2) Methods: To explore the relationship between dietary patterns and the risk of HG, a cross-sectional study was conducted in Xi'an, China from April 2021 to September 2022. Dietary intake was assessed by a semi-quantitative food-frequency questionnaire, and then factor analysis was used to derive dietary patterns. HG was defined as persistent and severe nausea and vomiting with weight loss ≥ 5%, pregnancy-unique quantification of emesis (PUQE) score ≥ 13, or hospitalization due to vomiting. Logistic regression models were used to estimate ORs and 95% CIs for HG according to dietary pattern scores. Stratified analyses and tests for interaction were performed by potential confounders. (3) Results: Of the 3122 pregnant women enrolled, 2515 individuals (mean age: 31.2 ± 3.4 years) were included in the final analysis. In total, 226 (8.9%) pregnant women were identified as having HG. Five dietary patterns were identified. After adjusting for covariates, the highest quartile of the "fish, shrimp and meat" and "egg, milk and water drinking" patterns was associated with a 37% and 58% lower risk of HG compared with the lowest quartile, respectively (p-trend < 0.05). Conversely, the highest quartile of the "beverage" pattern was associated with a 64% higher risk of HG compared with the lowest quartile (p-trend = 0.02). Furthermore, significant interactions were observed between the "egg, milk and water drinking" pattern and parity, employment status and nutritional supplement use (p-interaction < 0.05). (4) Conclusions: A diet rich in eggs, milk, seafood and unprocessed poultry and animal meat may be a protective factor against HG, while a diet high in beverages may be detrimental to HG. These associations may vary by parity, employment status and nutritional supplement use.

Waterpipe Tobacco (Hookah) Use in Pregnancy: Associations with Nausea and Vomiting of Pregnancy

OBJECTIVE

Waterpipe tobacco (WPT) use is common among reproductive age patients and is often perceived as safer than cigarette use. Prior studies have shown a decrease in nausea and vomiting symptoms among pregnant women who use cigarettes, but no studies to date have examined these symptoms in pregnant women who use WPT. This study was aimed to investigate the extent of symptoms of nausea/vomiting of pregnancy among participants who self-reported WPT use during pregnancy.

STUDY DESIGN

Secondary analysis of a prospective cohort study examining WPT use during pregnancy. Participants completed the Pregnancy-Unique Quantification of Emesis (PUQE) during first and third trimesters. Medical conditions were determined by medical record review. Participants were evaluated by sole WPT use versus dual/polysubstance WPT use and frequency of WPT use.

RESULTS

Ninety-nine (100%) participants completed the PUQE questionnaire during first trimester and 82 (82.8%) completed the PUQE during third trimester. Almost all (91.9%) participants reported moderate nausea/vomiting symptoms at both assessments. There was no difference in frequency of WPT use in pregnancy or rates of dual/polysubstance WPT use in participants with all levels of the PUQE questionnaire. There was also no difference in rates of WPT use or PUQE scores between sole WPT users and dual/polysubstance users. When comparing low and high WPT use, those who were in the higher frequency use group had higher waterpipe dependence scale scores (7.2 vs. 5.3, p < 0.02). With regard to maternal medical comorbidities, the only difference between groups was that sole WPT users were more likely to have a diagnosis of asthma than dual/polysubstance users (36.8 vs. 14.9%, p < 0.02).

CONCLUSION

There were no differences in symptoms of nausea and vomiting of pregnancy or medical conditions in pregnant women who use WPT with any frequency during pregnancy. However, sole WPT users had higher rates of asthma than dual/polysubstance WPT users.

KEY POINTS

· Waterpipe tobacco use is one of the most common forms of tobacco use among reproductive age patients.. · Waterpipe tobacco use was not associated with any changes in nausea/vomiting of pregnancy symptoms.. · Future research on the use of waterpipe tobacco in pregnancy can aid in public health responses..

Acupuncture and Doxylamine-Pyridoxine for Nausea and Vomiting in Pregnancy : A Randomized, Controlled, 2 2 Factorial Trial

BACKGROUND

An effective and safe treatment for nausea and vomiting of pregnancy (NVP) is lacking.

OBJECTIVE

To assess the efficacy and safety of acupuncture, doxylamine-pyridoxine, and a combination of both in women with moderate to severe NVP.

DESIGN

Multicenter, randomized, double-blind, placebo-controlled, 2 × 2 factorial trial. (ClinicalTrials.gov: NCT04401384).

SETTING

13 tertiary hospitals in mainland China from 21 June 2020 to 2 February 2022.

PARTICIPANTS

352 women in early pregnancy with moderate to severe NVP.

INTERVENTION

Participants received daily active or sham acupuncture for 30 minutes and doxylamine-pyridoxine or placebo for 14 days.

MEASUREMENTS

The primary outcome was the reduction in Pregnancy-Unique Quantification of Emesis (PUQE) score at the end of the intervention at day 15 relative to baseline. Secondary outcomes included quality of life, adverse events, and maternal and perinatal complications.

RESULTS

No significant interaction was detected between the interventions (P = 0.69). Participants receiving acupuncture (mean difference [MD], -0.7 [95% CI, -1.3 to -0.1]), doxylamine-pyridoxine (MD, -1.0 [CI, -1.6 to -0.4]), and the combination of both (MD, -1.6 [CI, -2.2 to -0.9]) had a larger reduction in PUQE score over the treatment course than their respective control groups (sham acupuncture, placebo, and sham acupuncture plus placebo). Compared with placebo, a higher risk for births with children who were small for gestational age was observed with doxylamine-pyridoxine (odds ratio, 3.8 [CI, 1.0 to 14.1]).

LIMITATION

The placebo effects of the interventions and natural regression of the disease were not evaluated.

CONCLUSION

Both acupuncture and doxylamine-pyridoxine alone are efficacious for moderate and severe NVP. However, the clinical importance of this effect is uncertain because of its modest magnitude. The combination of acupuncture and doxylamine-pyridoxine may yield a potentially larger benefit than each treatment alone.

PRIMARY FUNDING SOURCE

The National Key R&D Program of China and the Project of Heilongjiang Province "TouYan" Innovation Team.

Bioavailability of Cariban® Capsules: A Modified-Release Fixed-Dose Combination of Doxylamine and Pyridoxine to Relieve Nausea and Vomiting During Pregnancy

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.

First-Trimester Pregnancy: Considerations for Wilderness and Remote Travel

Women increasingly participate in outdoor activities in wilderness and remote environments. We performed a literature review to address diagnostic and therapeutic considerations during first-trimester pregnancy for remote multiday travel. Pretrip planning for pregnant patients traveling outside access to advanced medical care should include performing a transvaginal ultrasound to confirm pregnancy location and checking D rhesus status. We discuss the risk of potential travel-related infections and recommended vaccinations prior to departure based on destination. Immediate evacuation to definitive medical care is required for patients with a pregnancy of unknown location and vaginal bleeding. We propose algorithms for determining the need for evacuation and present therapeutic options for nausea and vomiting, urinary tract infections, and candidiasis in the field.

Unveiling the Unprecedented: An Astonishing Rarity of Metoclopramide Hydrochloride-Triggered Nystagmus in a Pregnant Woman

Metoclopramide hydrochloride is a widely used medication for the treatment of gastrointestinal disorders such as nausea, vomiting, and gastroparesis. However, it has been associated with extrapyramidal side effects (EPS) such as tardive dyskinesia, nystagmus, and other locomotive disorders on rare occasions. These reactions are commonly seen in children and females, particularly in young people. In this article, we report a rare case of a 15-week pregnant woman who was prescribed metoclopramide hydrochloride in view of nausea and vomiting, which was later diagnosed as vomiting in pregnancy not relieved with first-line medications, and has later developed drug-induced nystagmus, highlighting its unpredictable nature and shortcomings of management in the pregnant woman. This article will draw the attention of obstetricians and gynecologists to wisely prescribe metoclopramide hydrochloride for treating nausea and vomiting in pregnant women.

Impact of a primary care pharmacist consultations on pregnant women's medication use: the SafeStart intervention study linked to a national prescription database

BACKGROUND

Prior studies show that pharmacist consultations are highly appreciated by pregnant women and feasible in community pharmacies. However, it is unknown whether such counseling has an impact on medication use during pregnancy.

AIM

This study aimed to assess whether a pharmacist consultation in early pregnancy was associated with pregnant women's medication use, with a focus on antiemetic medications.

METHOD

The SafeStart study recruited Norwegian pregnant women in the first trimester between February 2018 and February 2019. Women in the intervention group received a pharmacist consultation in a community pharmacy or by phone. A follow-up questionnaire was completed 13 weeks after enrollment. Data from the SafeStart study were linked to the Norwegian Prescription Database. Logistic regression was used to assess the association between the pharmacist intervention and medication use in the second trimester.

RESULTS

The study included 103 women in the intervention group and 126 in the control group. Overall prescription fills in the first and second trimesters were 55% and 45% (intervention group) and 49% and 52% (control group), respectively. In total, 16-20% of women in the first trimester and 21-27% of women in the second trimester had a prescription for antiemetics. The pharmacist intervention was not associated with women's medication use in the second trimester.

CONCLUSION

This study did not detect an impact of a pharmacist consultation on pregnant women's use of medications. In the future, pharmacist consultations should focus on other outcome factors, such as risk perception, knowledge level, and the use of other health care services. Trial registration The SafeStart study is registered with ClinicalTrials.gov (identifier: NCT04182750, registration date: December 2, 2019).

Review article: Functional dyspepsia and pregnancy-Effects and management in a special population

BACKGROUND

Around 10% of Americans meet the Rome IV criteria for functional dyspepsia (FD), with a significantly higher rate in women. FD also has a higher prevalence in women below the age of 50, suggesting that women who are affected are likely to be of reproductive age. Unfortunately, there is a lack of research or evidence-based guidelines on managing FD in pregnancy.

AIMS AND METHODS

To address this issue, we aimed to perform a systematic review of the interactions between FD and pregnancy and managing pre-existing FD in the peripartum and post-partum phases using current lifestyle, pharmacological, non-pharmacological and alternative medicine interventions.

RESULTS

Due to the lack of Rome IV FD-specific data in pregnancy, we instead performed a narrative review on how existing FD interventions could be extrapolated to the pregnant population. Where possible we use the highest level of available evidence or official guidelines to answer these questions, which often involves synthesising treatment and safety evidence of these interventions in other diseases during pregnancy. Finally, we highlight current substantial knowledge gaps requiring further research for the safe management of a pregnant patient with pre-existing FD.

CONCLUSIONS

Overall, despite the paucity of knowledge of treating FD during pregnancy, providers can mitigate this uncertainty by planning ahead with the patient. Patients should ideally minimise treatment until after breastfeeding. However, interdisciplinary resources are available to ensure that minimal-risk interventions are maximised, while interventions with more risks, if necessary, are justifiable by both the patient and the care team. Future investigations should continue to elicit the mechanistic relationship between FD and pregnancy while cautiously expanding prospective research on promising and safe therapies in pregnant patients with pre-existing FD.

Patient-Centered Care in the Management of Cancer During Pregnancy

The management of cancer during pregnancy requires a patient-centered, multidisciplinary approach to balance maternal and fetal well-being given the rarity of this clinical scenario and lack of substantial data. Involvement of oncology and nononcology medical specialists and ethical, legal, and psychosocial supports, as needed, is instrumental in navigating the complexities of care for this patient population. Critical periods of fetal development and physiological changes in pregnancy must be considered when planning diagnostic and therapeutic approaches during pregnancy. The complexity of symptom recognition and interventional approaches contributes to diagnostic delays of cancers during pregnancy. Ultrasound and whole-body diffusion-weighted magnetic resonance imaging are safe throughout pregnancy. Surgery can be safely performed throughout pregnancy, with the early second trimester preferred for intra-abdominal surgery. Chemotherapy can be safely administered after 12-14 weeks of gestation until 1-3 weeks before the anticipated delivery. Most targeted and immunotherapeutic agents are contraindicated during pregnancy because of limited data. Pelvic radiation during pregnancy is absolutely contraindicated, while if radiation to the upper body is needed, administration should only be considered early in pregnancy. To ensure that the total cumulative fetal exposure to ionizing radiation does not exceed 100 mGy, early inclusion of the radiology team in the care plan is required. Closer prenatal monitoring is recommended for maternal and fetal treatment-related toxicities. Delivery before 37 weeks of gestation should be avoided if possible, and vaginal delivery is preferred unless obstetrically indicated or specific clinical scenarios. Postpartum, breastfeeding should be discussed, and the neonate should receive blood work to assess for acute toxicities with follow-up arranged for long-term monitoring.

Hyperemesis Gravidarum: Risk of Recurrence in Subsequent Pregnancies

This study aimed to examine whether the recurrence risk of hyperemesis gravidarum (HG) is modified by the timing of diagnosis, the severity of illness, and interpregnancy interval. The Kaiser Permanente Southern California 1998-2020 longitudinally linked medical records were used to examine the recurrence risk of HG in the first two (n = 93,444) and first three (n = 17,492) successive pregnancies. The timing of diagnosis- and the severity of illness-specific recurrence risks were examined by estimating the adjusted relative risks (aRR). The risks of HG in the second pregnancy among patients with and without previous HG were 23.8% and 3.4%, respectively (aRR: 8.20; 95% confidence interval [CI]: 7.52, 8.94). The recurrence risk persisted regardless of the trimester at diagnosis and the gestational age of delivery in the first pregnancy. The recurrence risk was greater for patients with metabolic disturbances requiring in-hospital treatment (30.0%) than those managed on an outpatient basis (18.6%) in the first pregnancy (aRR: 10.84 95% CI: 9.66, 12.16). Although Asian/Pacific Islander (RR = 12.9) and White (RR = 8.9) patients had higher HG recurrence risk regardless of the gestational age at delivery in the first pregnancy, all patients had significant recurrence risk only if their first pregnancy was delivered after 32 weeks of gestation. African American patients had the highest recurrence rate (34.4%). HG recurrence risk was unaffected by interpregnancy interval and correlated with the number of previous pregnancies complicated by HG. There is an increased recurrence risk of HG in subsequent pregnancies that is influenced by race/ethnicity and gestational age at delivery. The number of pregnancies complicated by HG synergistically adds to the recurrence risk.

Antiretroviral Options and Treatment Decisions During Pregnancy

The majority of pediatric human immunodeficiency virus (HIV) infections are the result of vertical transmissions that occur during pregnancy, childbirth, and breastfeeding. The treatment of all pregnant persons living with HIV remains a global health initiative. Early and consistent use of antiretroviral therapy throughout pregnancy and childbirth drastically reduces the risk of perinatal transmission of HIV, resulting in fewer children living with the disease worldwide. Given that the maternal HIV viral load is the strongest predictor of perinatal transmission, suppressive antiretroviral treatment during pregnancy is the principal means to eliminate transmission of HIV from mother to child. With the use of combined antiretroviral therapy, typically with dual-nucleoside reverse transcriptase inhibitors plus an integrase strand transfer inhibitor or a ritonavir-boosted protease inhibitor, HIV-infected mothers can now achieve virologic suppression to undetectable levels and yield a perinatal transmission rate of less than 2%. Important considerations of HIV treatment in pregnancy include the safety and efficacy of antiretroviral drugs, altered pregnancy-related pharmacokinetics, potential for birth defects or adverse neonatal outcomes, and individualized delivery planning based on maternal viral load. This practical review article summarizes the options, considerations, and recommendations for antiretroviral treatment in pregnancy to reduce perinatal HIV transmission and optimize health outcomes for mothers and infants worldwide.

The association of nausea and vomiting of pregnancy, its treatments, and select birth defects: Findings from the National Birth Defect Prevention Study

BACKGROUND

Nausea and vomiting of pregnancy (NVP) occurs in approximately 70% of pregnant people. Treatments include pharmacologic and herbal/natural products. Research on the associations between NVP and its treatments and birth defects is limited.

METHODS

We used data from the case-control National Birth Defects Prevention Study (1997-2011) to examine whether first-trimester NVP or its specific treatments were associated with 37 major birth defects. Odds ratios (aOR) and 95% confidence intervals (CIs) were adjusted for sociodemographic and reproductive factors.

RESULTS

Mothers of 66.6% of 28,628 cases and 69.9% of 11,083 controls reported first-trimester NVP. Compared to no NVP, mothers with NVP had ≥10% reduction in risk of cardiac and noncardiac defects overall, and of 18 specific defects. Over-the-counter antiemetic use, compared to untreated NVP, was associated with ≥10% increase in risk for nine defect groups (heterotaxy, hypoplastic left heart syndrome [HLHS], aortic stenosis, cataracts, anophthalmos/microphthalmos, biliary atresia, transverse limb deficiency, omphalocele, and gastroschisis), whereas use of prescription antiemetics increased risk ≥10% for seven defect groups (tetralogy of Fallot, HLHS, spina bifida, anopthlamos/microphthalmos, cleft palate, craniosynostosis, and diaphragmatic hernia). We observed increased risks for promethazine and tetralogy of Fallot (aOR: 1.49, 95% CI: 1.05-2.10), promethazine and craniosynostosis (1.44, 1.08-1.92), ondansetron and cleft palate (1.66, 1.18-2.31), pyridoxine and heterotaxy (3.91, 1.49-10.27), and pyridoxine and cataracts (2.57, 1.12-5.88).

CONCLUSIONS

NVP does not increase risks of birth defects. Our findings that some treatments for NVP increase risk of specific birth defects should be investigated further before clinical recommendations are made.

Obstetrical and neonatal outcomes of cardio-facio-cutaneous syndrome: Prenatal consequences of Ras/MAPK dysregulation

We systematically delineated the prenatal phenotype, and obstetrical and neonatal outcomes of the RASopathy cardio-facio-cutaneous (CFC) syndrome. A comprehensive, retrospective medical history survey was distributed to parents of children with confirmed CFC in collaboration with CFC International, Inc. Data were collected on CFC gene variant, maternal characteristics, pregnancy course, delivery, and neonatal outcomes with the support of medical records. We identified 43 individuals with pathogenic variants in BRAF (81%), MEK1 (14%), or MEK2 (5%) genes. The median age was 8.5 years. Hyperemesis gravidarum, gestational diabetes, gestational hypertension, and preeclampsia occurred in 5/43 (12%), 4/43 (9%), 3/43 (7%), and 3/43 (7%) of pregnancies, respectively. Second and third trimester ultrasound abnormalities included polyhydramnios, macrocephaly, macrosomia, and renal and cardiac abnormalities. Delivery occurred via spontaneous vaginal, operative vaginal, or cesarean delivery in 15/42 (36%), 7/42 (16%), and 20/42 (48%), respectively. Median gestational age at delivery was 37 weeks and median birth weight was 3501 grams. Germline pathogenic vaiants had mutiple congenital consequences including polyhydramnios, renal and cardiac abnormalities, macrosomia, and macrocephaly on second and third trimester ultrasound. Elevated rates of operative delivery and neonatal complications were also noted. Understanding and defining a prenatal phenotype may improve prenatal prognostic counseling and outcomes.

Thiamine deficiency in pregnancy and lactation: implications and present perspectives

During pregnancy, many physiologic changes occur in order to accommodate fetal growth. These changes require an increase in many of the nutritional needs to prevent long-term consequences for both mother and the offspring. One of the main vitamins that are needed throughout the pregnancy is thiamine (vitamin B1) which is a water-soluble vitamin that plays an important role in many metabolic and physiologic processes in the human body. Thiamine deficiency during pregnancy can cause can have many cardiac, neurologic, and psychological effects on the mother. It can also dispose the fetus to gastrointestinal, pulmonological, cardiac, and neurologic conditions. This paper reviews the recently published literature about thiamine and its physiologic roles, thiamine deficiency in pregnancy, its prevalence, its impact on infants and subsequent consequences in them. This review also highlights the knowledge gaps within these topics.

Patterns of antiemetic medication use during pregnancy: A multi-country retrospective cohort study

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.

Serotonin Syndrome After Treatment of Nausea and Vomiting in Pregnancy

BACKGROUND

Nausea and vomiting in pregnancy often require pharmacotherapy for symptom management. Serotonin syndrome is a rare clinical entity that can be precipitated by the medications used to treat nausea and vomiting in pregnancy.

CASE

A 35-year-old pregnant individual with a history of hyperemesis gravidarum in an earlier pregnancy requiring prolonged hospitalization presented with nausea and vomiting at 7 weeks of gestation. She was incidentally found to have severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection when she was universally screened at the time of admission. She required pharmacotherapy, including prochlorperazine and ondansetron for treatment of nausea as well as sumatriptan for migraine. She developed acute spasticity, autonomic dysfunction, and temperature rise, precipitated by antiemetic therapy, consistent with serotonin syndrome. The syndrome resolved with supportive care and benzodiazepines.

CONCLUSION

Serotonin syndrome is a serious clinical entity that can be provoked by the pharmacotherapy given to treat nausea and vomiting in pregnancy. This medical emergency requires early recognition and prompt management.

Cerebral venous thrombosis as a rare cause of nausea and vomiting in early pregnancy: Case series in a single referral center and literature review

Objectives

Cerebral venous thrombosis (CVT) in early pregnancy is extremely rare and evidence limited to only a few published reports. This study aims to present our experience and summarize the available literature to further elucidate the clinical manifestations, treatment, and outcomes of CVT in early pregnancy.

Methods

A retrospective case series of seven patients diagnosed with CVT in early pregnancy (&lt;12 weeks of gestations) in a tertiary referral center (2018–2021), along with a review of published literature.

Results

All the patients presented with nausea, vomiting, headaches, and neurological symptoms including aphasia (n = 5, 71.4%), limb weakness (n = 4, 57.1%), seizures (n = 2, 28.6%), altered mental status (n = 3, 42.9%), and blurred vision (n = 2, 28.6%). All the patients were diagnosed with CVT by neuroimaging, which revealed various extents of sinus involvement, with the transverse sinus being the most common site (n = 7, 100%) followed by the sigmoid sinus (n = 5, 71.4%). All the patients received subcutaneous low-molecular-weight heparin once the diagnosis was confirmed. Two patients with rapid deterioration underwent venous thrombectomy, and one patient subsequently underwent decompressive craniotomy but died despite the above interventions. All the other patients proceeded with induced abortion after stabilization and were discharged on oral anticoagulation for 1 year. On the 12-month follow-up, the MRI/magnetic resonance venography (MRV) revealed recanalization of sinuses and resolution of thrombi.

Conclusions

Cerebral venous thrombosis (CVT) in early pregnancy represents a diagnostic challenge given its rarity and nonspecific overlapping clinical features with nausea and vomiting of pregnancy/hyperemesis gravidarum (NVP/HG), which could lead to delay in diagnosis and result in rapid deterioration. Persistent or aggravating headaches combined with other focalizing neurological symptoms in NVP/HG patients could be an initial sign of CVT. Urgent MRI/MRV remains the cornerstone for diagnosis, and immediate anticoagulation is the key for disease prognosis. Glasgow coma scale (GCS) evaluation on admission is probably correlated with the prognosis. Early pregnancy combined with CVT is not a contraindication of continued pregnancy.

Gastroparesis in pregnancy

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.

Assessment of management approaches for hyperemesis gravidarum and nausea and vomiting of pregnancy: a retrospective questionnaire analysis

Background

Hyperemesis gravidarum is the most severe form of nausea and vomiting of pregnancy, or morning sickness. 2% of pregnancies in the United States are affected by hyperemesis gravidarum. The condition is characterized by severe vomiting in pregnant people, especially during the first trimester, often leading to hypovolemia and weight loss. The standard of care for hyperemesis and nausea and vomiting of pregnancy is commonly ineffective. We hypothesize that based on patient experience; the current treatment guidelines for hyperemesis are not clinically effective. Our objective was to identify the efficacy of the various management approaches that are currently in place for hyperemesis and nausea and vomiting of pregnancy.

Methods

A questionnaire was designed based on diagnostic criteria, standard demographic identifiers, and common medications for the treatment of hyperemesis gravidarum. This questionnaire was distributed online to through hyperemesis and nausea and vomiting of pregnancy support groups, personal social media, and institutional email.

Results

In our study, most participants diagnosed with hyperemesis gravidarum trialed at least three medications, most of which were ineffective and/or had severe side effects. The most used medication for treatment of hyperemesis gravidarum is ondansetron, a standard antiemetic, with fatigue and constipation being the most reported side effects. All data in the dataset was coded as categorical and analyzed using contingency tables using Mantel-Haenszel Chi square tests.

Conclusions

The data presented in this research provides insight into the suffering that patients with these diagnoses face day-to-day due to the lack of efficacious, well-tolerated treatment options. Establishing this gap in treatment can facilitate the development of effective treatments that will provide relief for thousands of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04922-6.

Analytical Eco-Scale for Evaluating the Uniqueness of Voltammetric Method used for Determination of Antiemetic Binary Mixture Containing Doxylamine Succinate in Presence of its Toxic Metabolite

Green analytical procedures are gaining popularity in the pharmaceutical research area as a way to reduce environmental impact and improve analyst health safety. The current work presents a green and sensitive electrochemical carbon paste electrode that has been chemically modified with zirconium dioxide and multi-walled carbon nanotubes for estimation of pyridoxine HCl (PYR) and doxylamine succinate (DOX) using the square wave voltammetric technique. Under optimum conditions, the linearity ranges were 20.00–2000.00 ng mL−1 and 2.00–20.00 µg mL−1 for both drugs in the 1st linear segment and 2nd linear segment, respectively. Stability testing assesses how the quality of a drug substance changes over time, depending on environmental and laboratory factors. DOX was found to undergo oxidative degradation when refluxed for 7 h using 30% H2O2 and the degraded product (DOX DEG) (toxic metabolite) was successfully characterized utilizing LC–MS. The developed electrode showed selectivity for the determination of binary mixture in pure form, pharmaceutical form, and in the presence of DOX DEG and common interfering molecules with good recovery. The proposed method was found to be eco-friendlier than the reported method in terms of the use of hazardous chemicals and solvents, energy consumption, and waste generation.

Graphical Abstract

Impact of a Mobile Application for Tracking Nausea and Vomiting During Pregnancy (NVP) on NVP Symptoms, Quality of Life, and Decisional Conflict Regarding NVP Treatments: MinSafeStart Randomized Controlled Trial

Background

Pregnant women are active users of mobile apps for health purposes. These apps may improve self-management of health-related conditions. Up to 70% of pregnant women experience nausea and vomiting (NVP). Even mild NVP can significantly reduce quality of life (QoL), and it can become an economic burden for both the woman and society. NVP often occurs before the first maternal care visit; therefore, apps can potentially play an important role in empowering pregnant women to recognize, manage, and seek appropriate treatment for NVP, when required.

Objective

This study investigated whether the MinSafeStart (MSS) mobile app could impact NVP-related symptoms, QoL, and decisional conflict regarding NVP treatment.

Methods

This randomized controlled trial enrolled 268 pregnant women with NVP in Norway from 2019 to 2020. The intervention group had access to the MSS app, which could be used to track NVP symptoms and access tailored advice. NVP severity was rated with the Pregnancy Unique Quantification of Emesis (PUQE) score. The control group followed standard maternal care. We collected data on maternal baseline characteristics, NVP severity, QoL, and decisional conflict using 2 sets of online questionnaires. One set of questionnaires was completed at enrollment, and the other was completed after 2 weeks. We performed linear regression analyses to explore whether the use of the MSS app was associated with NVP severity, QoL, or decisional conflict.

Results

Among the 268 women enrolled in the study, 192 (86.5%) completed the baseline questionnaires and were randomized to either the intervention (n=89) or control group (n=103). In the intervention group, 88 women downloaded the app, and 468 logs were recorded. In both groups, women were enrolled at a median of 8 gestational weeks. At baseline, the average PUQE scores were 4.9 and 4.7; the average QoL scores were 146 and 149; and the average DCS scores were 40 and 43 in the intervention and control groups, respectively. The app had no impact on NVP severity (aβ 0.6, 95% Cl −0.1 to 1.2), QoL (aβ −5.3, 95% Cl −12.5 to 1.9), or decisional conflict regarding NVP treatment (aβ −1.1, 95% Cl −6.2 to 4.2), compared with standard care.

Conclusions

Tracking NVP symptoms with the MSS app was not associated with improvements in NVP symptoms, QoL, or decisional conflict after 2 weeks, compared with standard care. Future studies should include a process evaluation to improve our understanding of how pregnant women use the app and how to optimize its utility within maternity care. Specifically, studies should focus on how digital tools might facilitate counseling and communication between pregnant women and health care providers regarding NVP management during pregnancy.

Trial Registration

ClinicalTrails.gov (NCT04719286): https://www.clinicaltrials.gov/ct2/show/NCT04719286

Pregnancy-Associated Liver Diseases

The liver disorders unique to pregnancy include hyperemesis gravidarum, intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and preeclampsia-associated hepatic impairment, specifically hemolysis, elevated liver enzymes, and low platelet count syndrome (HELLP). Their importance lies in the significant maternal and fetal/neonatal morbidity and mortality. Expeditious diagnosis and clinical evaluation is critical to ensure timely, appropriate care and minimize risks to the pregnant woman and her fetus/baby. A multidisciplinary approach is essential, including midwives, maternal-fetal-medicine specialists, anesthetists, neonatologists, and hepatologists.

Antiemetic treatment of hyperemesis gravidarum in 1,064 Norwegian women and the impact of European warning on metoclopramide: a retrospective cohort study 2002–2019

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.

Usability of Pregnancy-Unique Quantification of Emesis questionnaire in women hospitalised for hyperemesis gravidarum: a prospective cohort study

OBJECTIVES

Pregnancy-Unique Quantification of Emesis (PUQE) questionnaire is mainly used in outpatient care to assess the severity of nausea and vomiting of pregnancy (NVP). Our aim was to evaluate the usability of the Finnish-translated PUQE in hospitalised women with hyperemesis gravidarum (HG).

DESIGN

Prospective cohort study.

SETTING

University hospital in Finland.

PARTICIPANTS

Ninety-five women admitted due to HG for at least overnight.

PRIMARY AND SECONDARY OUTCOME MEASURES

Categorised and continuous PUQE scores, physical and mental quality of life (QoL) and urine ketones at admission and at discharge, analysing the first admission and readmissions separately.

RESULTS

The most common PUQE categories at admission were 'moderate' and 'severe', whereas at discharge they were 'mild' and 'moderate'. Likewise, continuous PUQE scores improved between admission and discharge (p<0.0001). At admission, women rating worse physical QoL (first admission adjusted OR (AOR) 1.09; 95% CI 1.03 to 1.16; readmissions AOR 1.13; 95% CI 1.02 to 1.25) and women with ketonuria of +++ (first admission AOR 16.00; 95% CI 1.44 to 177.82) fell into higher PUQE score category. On discharge day, women with better physical QoL had lower PUQE score category (first admission AOR 0.94; 95% CI 0.91 to 0.98; readmissions AOR 0.93; 95% CI 0.90 to 0.97). The results between physical QoL and continuous PUQE scores were similar. Concerning readmissions, better mental QoL was associated with lower PUQE score category at discharge (AOR 0.93; 95% CI 0.89 to 0.97). As for continuous PUQE score, worse mental QoL was associated with higher score at admission (readmissions, p=0.007) and better mental QoL with lower score at discharge (readmissions, p=0.007).

CONCLUSIONS

PUQE scores reflected alleviation of NVP severity in women hospitalised due to HG. Further, the decrease in PUQE score was associated with improved physical QoL and partly also with improved mental QoL. We therefore suggest PUQE as a complementary instrument for inpatient setting.

Ondansetron use in nausea and vomiting during pregnancy: a descriptive analysis of prescription patterns and patient characteristics in UK general practice

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.