Hyperemesis gravidarum: a holistic overview and approach to clinical assessment and management

Prevalence and determinants of hyperemesis gravidarum among pregnant women in Ethiopia: A systematic review and meta-analysis

BACKGROUND

Studies focusing on the occurrence and correlates of hyperemesis gravidarum in Ethiopia have reported varied values in different regions of the country. Additionally, there is no systematic review and meta-analysis summarizing the prevalence of hyperemesis gravidarum and its determinants in Ethiopia. Hence, this systematic review and meta-analysis aimed to estimate the overall prevalence of hyperemesis gravidarum and explore its determinants in Ethiopia.

METHODS

Cross-sectional or case-control studies conducted in Ethiopia, written in English, and reporting the prevalence or the determinant of hyperemesis gravidarum among pregnant women were included in the review. International databases (PubMed, Scopus, Cochrane Library, Google Scholar, Science Direct, African Journal Online, Directory of Open Access Journal, and African Index Medicus) and Ethiopian university repositories (Jimma, Addis Ababa, Haramaya, Hawassa, and Gondar Universities) were searched from September 4-15, 2023, to identify articles published on the topic. The pooled prevalence of hyperemesis gravidarum with a 95% confidence interval was presented using the forest plots. The heterogeneity of the studies was checked by I2 with its corresponding p-values and the Galbraith plot. Subgroup analysis and meta-regression were performed to identify sources of heterogeneity. Funnel plot, Egger, and Begg's tests were used to assess publication bias.

RESULTS

A total of 11 articles with a 3510-sample size were included in this systematic review and meta-analysis. The pooled prevalence of hyperemesis gravidarum among pregnant women in Ethiopia was 7.12% with a 95% CI (4.09-10.15) and a high level of heterogeneity (I2 = 86.5%, p<0.001). Subgroup analyses revealed the overall prevalence of hyperemesis gravidarum was highest in the Amhara region with 11.30%, 95% CI (8.20-14.40), and lowest in Oromia with 3.40%, 95% CI (1.94-4.85). Having a previous history of hyperemesis gravidarum (POR = 3.828, 95% CI: 1.673-5.983), being in the first trimester of pregnancy (POR = 8.476, 95% CI: 5.047-11.905), and Helicobacter pylori infection (POR = 3.924, 95% CI: 2.027-5.821) were found to be significantly associated with hyperemesis gravidarum in Ethiopia.

CONCLUSION

The prevalence of hyperemesis gravidarum among pregnant women in Ethiopia is high. Targeting pregnant women in the first trimester, with a previous history of hyperemesis gravidarum, and those with Helicobacter pylori infection during prenatal counseling on how to manage and reduce hyperemesis gravidarum is very helpful to avert related complications.

REGISTRATION

The review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number "CRD42023461808", on September 19, 2023.

Determinants of hyperemesis gravidarum among pregnant women in public hospitals of Guji, West Guji, and Borana zones, Oromia, Ethiopia, 2022

Objectives

Hyperemesis gravidarum is a severe form of nausea and vomiting during pregnancy sufficiently enough to produce weight loss greater than 5%, dehydration, ketosis, alkalosis, and hypokalemia. Several studies have investigated risk factors for hyperemesis gravidarum in Ethiopia, but the studies have reported conflicting results attributed to study design, lack of proper sample size, and the selection of variables. This study aimed to assess the determinants of hyperemesis gravidarum among pregnant women in public hospitals of Guji, West Guji, and Borana zones, Southern Ethiopia, 2022.

Methods

An institutional-based case-control study design was conducted from April 15 to June 15, 2022 with a ratio of 1:2 (103 cases and 206 controls). Cases were all pregnant women admitted with a diagnosis of hyperemesis gravidarum by a clinician while controls were pregnant women who were visiting antenatal care services at the same time. Cases were selected consecutively until the required sample size is attained, while controls were selected by a simple random sampling technique. Data were collected using structured questionnaires with face-to-face interviews. The collected data were cleaned, coded, and entered into EpiData version 3.1, and then exported to SPSS version 25 for analysis. Frequency distribution for categorical variables, median, and interquartile range for continuous variables was computed. Backward stepwise logistic regression analyses were done. A significant association was declared with a 95% confidence interval at a p value less than 0.05.

Results

Those mothers who had antenatal follow-up (adjusted odds ratio = 0.082, 95% confidence interval: 0.037-0.180), pregnancy with multiple gestations (adjusted odds ratio = 3.557, 95% confidence interval: 1.387-9.126), previous history of hyperemesis gravidarum (adjusted odds ratio = 6.66, 95% confidence interval: 2.57-17.26), family history of hyperemesis gravidarum (adjusted odds ratio = 2.067, 95% confidence interval: 1.067-4.015), and those women had exercised before pregnancy (adjusted odds ratio = 0.352, 95% confidence interval: 0.194-0.639) were determinants of hyperemesis gravidarum.

Conclusion

Antenatal follow-up, number of the fetus, previous and family history of hyperemesis gravidarum, and exercise before pregnancy were significantly associated with outcome. Lifestyle modification, early treatment, and early ultrasound scans for pregnant women are crucial to reducing the burden of hyperemesis gravidarum.

Pre-Pregnancy Risk Factors for Severe Hyperemesis Gravidarum: Korean Population Based Cohort Study

Hyperemesis gravidarum is known to be associated with poor perinatal outcomes. This study aimed to identify pre-pregnancy risk factors for hospital admission in women with hyperemesis gravidarum. We enrolled women who had delivered between 1 January 2013 and 31 December 2015, and had undergone a national health screening examination through the National Health Insurance Corporation 1-2 years before their first delivery. Multiple logistic regression analysis was performed to estimate the risk factors for hospital admission due to hyperemesis gravidarum. Of the 216,373 study participants with hyperemesis gravidarum, 2210 (1.02%) pregnant women were hospitalized. These women had lower waist circumference and were underweight based on body mass index compared to pregnant women who did not require hospitalization due to hyperemesis gravidarum. On multivariate analysis, primiparity, multiple pregnancies, female fetus, alcohol consumption, and pre-pregnancy underweight status were associated with an increased risk of hospitalization due to the condition. In this population-based cohort study, we found that hospitalization due to hyperemesis gravidarum was associated with pre-pregnancy lifestyle characteristics. Early recognition and management of these pre-pregnancy factors may help control the need for hospitalization in women with the condition in subsequent pregnancies.

Predictive factors of Hyperemesis Gravidarum: A systematic review

PURPOSE

Hyperemesis gravidarum (HG) is the main cause of hospitalization during the first trimester of pregnancy. Although it has been associated with serious complications, little is known about its predictive factors. The aim of this systematic review was to search for and critically appraise the studies that investigate the predictive factors for HG.

METHODS

Search strategy included PubMed, CENTRAL and EMBASE databases (till December 2017). All studies examining risk factors for HG were included. Screening of available studies was carried out by two reviewers, as well as the quality assessment of the included studies, based on the Newcastle-Ottawa Scale for observational studies.

RESULTS

The search located 308 articles, of which 14 observational studies (four low-, eight medium- and two high-quality), involving 1400 women who met the eligibility criteria. In four studies, there was no association between Helicobacter (H.) Pylori infection and HG, in contrast to two studies which demonstrated such an association. Pre-pregnancy body mass index (BMI), adipose tissue, maternal age, leptin, ghrelin, beta-chorionic gonadotropin (β-hCG), total (T₄) and free thyroxine (fT₄) correlated with HG in various studies, and could be considered as predictive markers. Regarding the high-quality evidence, a cohort study associated leptin and nephatin-1 with HG, whereas a cross-sectional study found no association between H. pylori infection and HG.

CONCLUSIONS

More studies of high quality and adequate sample size have to be carried out to identify the predictive factors for HG.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Interventions for treating hyperemesis gravidarum: a network meta-analysis of randomized clinical trials

Background: Several interventions were explored in clinical trials for treating hyperemesis gravidarum (HG). The present study is a network meta-analysis of such interventions.Methods: Electronic databases were searched for appropriate randomized clinical trials comparing interventions for treatment of patients with HG. Control of HG symptoms was the primary outcome and emetic episodes, hospital stay, nausea scores, patients requiring rescue antiemetics, hospital readmission, adverse events, and adverse pregnancy outcomes were the secondary outcome measures. Random-effects model was used and odds ratio (OR) [95% confidence interval (CI)] was the effect estimate for categorical outcomes and weighted mean difference (WMD) [95% confidence interval] for numerical outcomes.Results: Twenty studies were included in the systematic review and 18 in the meta-analysis. Acupuncture (OR: 18.9; 95% CI: 2.1, 168), acupressure (OR: 26.7; 95% CI: 2.5, 283.1) and methylprednisolone (OR: 6.7; 95% CI: 1.1, 38.8) were associated with better control of HG symptoms than standard of care. Acupressure decreases the requirement of rescue antiemetics (OR: 0.06; 95% CI: 0.01, 0.44); ondansetron with reduced hospital stay (WMD: -0.2; 95% CI: -0.31, -0.01) and diazepam with reduced risk of hospital admission (OR: 0.11; 95% CI: 0.01, 0.95). The quality of evidence is very low.Conclusion: Acupuncture, acupressure, and methylprednisolone were observed with better therapeutic benefits than other interventions for treating HG. However, the pooled estimates may change with the advent of results from future head-to-head clinical trials.

Gastrointestinal Diseases in Pregnancy: Nausea, Vomiting, Hyperemesis Gravidarum, Gastroesophageal Reflux Disease, Constipation, and Diarrhea

Many disorders of the gastrointestinal tract are common in pregnancy. Elevated levels of progesterone may lead to alterations in gastrointestinal motility which could contribute to nausea, vomiting, and/or GERD. Pregnancy-induced diarrhea may be due to elevated levels prostaglandins. This article reviews the normal physiologic and structural changes associated with pregnancy that could contribute to many of the common gastrointestinal complaints in pregnant patients. Additionally, the appropriate clinical and laboratory evaluations, other pathologic conditions that should be included in the differential, as well as the nonpharmacologic and pharmacologic therapies for each of these conditions is discussed.