Hyperemesis gravidarum and fetal outcome

An online qualitative study exploring wants and needs for a cooking programme during pregnancy in the UK and Ireland

BACKGROUND

Optimal maternal nutrition is associated with better pregnancy and infant outcomes. Culinary nutrition programmes have potential to improve diet quality during pregnancy. Therefore, this research aimed to understand the experiences of cooking and the wants and needs of pregnant women regarding a cooking and food skills programme in the United Kingdom (UK) and Republic of Ireland (ROI).

METHODS

Online focus group discussions with pregnant women and those who had experienced a pregnancy in the UK or ROI were conducted between February and April 2022. Two researchers conducted a thematic analysis. Seven focus groups with ROI participants (n = 24) and six with UK participants (n = 28) were completed.

RESULTS

Five themes were generated. These were (1) cooking during pregnancy: barriers, motivators and solutions; (2) food safety, stress and guilt; (3) need for cooking and food skills programmes and desired content; (4) programme structure; (5) barriers and facilitators to programme participation. Overall, there was support for a programme focusing on broad food skills, including planning, food storage, using leftovers and to manage pregnancy-specific physiological symptoms such as food aversions. Participants emphasised the importance of inclusivity for a diverse range of people and lifestyles for programme design and content.

CONCLUSIONS

Current findings support the use of digital technologies for culinary nutrition interventions, potentially combined with in-person sessions using a hybrid structure to enable the development of a support network.

Perinatal outcomes of infants born to mothers with hyperemesis gravidarum: A systematic review and meta-analysis

BACKGROUND

Hyperemesis gravidarum is the severe form of nausea and vomiting during pregnancy and can lead to undernutrition and low maternal weight gain. Previous epidemiologic and animal studies have shown that undernutrition and low maternal weight gain in pregnancy can increase the risk of unfavorable perinatal outcomes, like shorter gestational age, small for gestational age and lower weight at birth.

OBJECTIVE

To evaluate the effect of hyperemesis gravidarum on perinatal outcomes.

SEARCH STRATEGY

OVID Medline and Embase were searched from inception to February 9th, 2022.

STUDY ELIGIBILITY

Studies reporting on perinatal outcomes of infants born to mothers with hyperemesis gravidarum or severe nausea and vomiting in pregnancy were included. Case reports, case series, animal studies, reviews, editorials and conference abstracts were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected and extracted data. Risk of bias was assessed by the Newcastle-Ottawa Quality Assessment Scale. We conducted meta-analyses where possible.

RESULTS

Our search yielded 1387 unique papers, of which 61 studies (n = 20,532,671 participants) were included in our systematic review. Meta-analyses showed that hyperemesis gravidarum was associated with preterm birth < 34 weeks (2 studies n = 2,882: OR 2.81, 95 %CI: 1.69-4.67), birth weight < 1500 g (2 studies, n = 489,141: OR 1.43, 95 %CI: 1.02-1.99), neonatal resuscitation (2 studies, n = 4,289,344: OR 1.07, 95 %CI: 1.05-1.10), neonatal intensive care unit admission (7 studies, n = 6,509,702: OR 1.20, 95 %CI: 1.14-1.26) and placental abruption (6 studies, n = 9,368,360: OR 1.15, 95 %CI: 1.05-1.25). Hyperemesis gravidarum was associated with reductions in birthweight > 4000 g (2 studies, n = 5,503,120: OR 0.74, 95 %CI: 0.72-0.76) and stillbirth (9 studies, n = 3,973,154: OR 0.92, 95 %CI: 0.85-0.99). Meta-analyses revealed no association between hyperemesis gravidarum and Apgar scores < 7 at 1 and 5 min; fetal loss, perinatal deaths and neonatal deaths.

CONCLUSION

Hyperemesis gravidarum is associated with several adverse perinatal outcomes including low birth weight and preterm birth. We also found that pregnancies complicated by hyperemesis gravidarum less frequently were complicated by macrosomia and stillbirth. We were unable to investigate underlying mechanisms.

Influence of maternal vomiting during early pregnancy on school-age respiratory health

BACKGROUND

Hyperemesis gravidarum, a clinical entity characterized by severe nausea and excess vomiting, might lead to a suboptimal maternal nutritional status during pregnancy and subsequently to adverse respiratory health in the offspring. The role of common vomiting symptoms on offspring's respiratory health is unclear. We examined the associations of maternal daily vomiting during early pregnancy with childhood respiratory outcomes, and potential explaining factors.

METHODS

This study was embedded in a population-based prospective cohort study from early pregnancy onwards among 4232 mothers and their children. Maternal vomiting during early pregnancy was assessed by a questionnaire. At age 10 years, information on current wheezing and ever asthma was obtained by a questionnaire, and lung function was measured by spirometry at our research center. We used multiple regression analyses to assess the associations of maternal daily vomiting during early pregnancy with childhood respiratory outcomes.

RESULTS

Compared to children from mothers without daily vomiting during early pregnancy, children from mothers with daily vomiting during early pregnancy had a higher forced expiratory flow when 75% of the forced vital capacity (FVC) is exhaled (Z-score difference [95% confidence interval, CI]: 0.13 [0.03, 0.23]), and an increased risk of current wheezing and ever asthma ([odds ratio, OR] [95% CI]: 1.75 [1.10, 2.79] and 1.61 [1.13, 2.31], respectively). These associations were fully explained by sociodemographic factors, but not sex or lifestyle-, infectious-, or growth-related factors. Maternal daily vomiting during early pregnancy was not associated with forced expiratory volume in 1 s (FEV₁ ), FVC, and FEV₁ /FVC.

CONCLUSION

Only sociodemographic factors explain the associations of maternal daily vomiting during early pregnancy with childhood respiratory outcomes.

Hyperemesis gravidarum and neonatal outcomes: A systematic review of observational studies

Hyperemesis gravidarum (HG) is associated with adverse somatic and psychological effects. The impact of HG on neonatal outcomes is debatable given that disagreeing research results have appeared. The objective of this study was to systematically review, according to the PRISMA guidelines, and synthesize the available evidence from observational studies on the relationship between HG and neonatal outcomes. The PubMed, Scopus, and Science Direct databases were systematically reviewed, with the last search carried out in April 2020. The quality of the studies was estimated using the Newcastle-Ottawa Scale (NOS) for non-randomized studies. The databases search yielded 516 studies 15 of which (n = 112.372 HG cases) matched eligibility criteria while the majority of the studies were of moderate quality (n = 12). We observed heterogeneity among the studies regarding the definition of HG and characteristics of the samples. The results of this systematic review suggest that it is still uncertain whether HG has an adverse impact on neonatal outcomes, fact that requires more studies to be conducted.

Comparative Analysis of Maternal and Fetal Outcomes of Pregnancies Complicated and Not Complicated with Hyperemesis Gravidarum Necessitating Hospitalization

Objective:

To compare maternal and fetal outcomes of pregnancies complicated and not complicated with hyperemesis gravidarum (HG) necessitating hospitalization.

Method:

A total of 386 women with singleton deliveries between March 2015 and January 2018 were included in this retrospective single-center study. Of 386 women, 186 women (mean±SD age: 30.7±5.9 years) who were hospitalized with HG within the first 20 weeks of gestation comprised the hyperemetic pregnancy group, while 200 women without HG during pregnancy served as a control group.

Results:

No significant difference was noted between the HG and control groups in terms of maternal characteristics, gestational age (median 38.6 and 39.0 weeks, respectively), type of delivery (normal spontaneous delivery in 78.0% vs 80.0%), fetal gender (female: 53.2% vs 48.5%), birthweight (median 3250 g vs 3275 g) and 5-min APGAR scores (≥7 in 97.3% vs 97.5%, respectively). Adverse pregnancy outcomes were also similar between groups including preterm birth (8.1% vs 11.0%, respectively), SGA (5.9% vs 9.5%), hypertensive disorder (5.4% vs 7.5%), placental abruption (1.1% vs 0.5%,), stillbirth (0.0% vs 0.5%) and GDM (3.8%vs 2.5%). Weight loss during pregnancy was evident in 91.3% of women in the HG group, while none of women in the control group had weight loss during pregnancy (p<0.001).

Conclusions:

The findings of this study indicate that HG may not be related with adverse fetal and prenatal outcomes and this conclusion needs to be clarified with large-scale investigations.

Maternal vomiting during early pregnancy and cardiovascular risk factors at school age: the Generation R Study

Background:

Evidence suggests that low birth weight and fetal exposure to extreme maternal undernutrition is associated with cardiovascular disease in adulthood. Hyperemesis gravidarum, a clinical entity characterized by severe nausea and excess vomiting leading to a suboptimal maternal nutritional status during early pregnancy, is associated with an increased risk of adverse pregnancy outcomes. Several studies also showed that different measures related to hyperemesis gravidarum, such as maternal daily vomiting or severe weight loss, are associated with increased risks of adverse fetal pregnancy outcomes. Not much is known about long-term offspring consequences of maternal hyperemesis gravidarum and related measures during pregnancy. We examined the associations of maternal daily vomiting during early pregnancy, as a measure related to hyperemesis gravidarum, with childhood cardiovascular risk factors.

Methods:

In a population-based prospective cohort study from early pregnancy onwards among 4,769 mothers and their children in Rotterdam, the Netherlands, we measured childhood body mass index, total fat mass percentage, android/gynoid fat mass ratio, preperitoneal fat mass area, blood pressure, lipids, and insulin levels. We used multiple regression analyses to assess the associations of maternal vomiting during early pregnancy with childhood cardiovascular outcomes.

Results:

Compared with the children of mothers without daily vomiting during early pregnancy, the children of mothers with daily vomiting during early pregnancy had a higher childhood total body fat mass (difference 0.12 standard deviation score [SDS]; 95% confidence interval [CI] 0.03–0.20), android/gynoid fat mass ratio (difference 0.13 SDS; 95% CI 0.04–0.23), and preperitoneal fat mass area (difference 0.10 SDS; 95% CI 0–0.20). These associations were not explained by birth characteristics but partly explained by higher infant growth. Maternal daily vomiting during early pregnancy was not associated with childhood blood pressure, lipids, and insulin levels.

Conclusions:

Maternal daily vomiting during early pregnancy is associated with higher childhood total body fat mass and abdominal fat mass levels, but not with other cardiovascular risk factors. Further studies are needed to replicate these findings, to explore the underlying mechanisms and to assess the long-term consequences.

Association between vomiting in the first trimester and preterm birth: a retrospective birth cohort study in Wuhan, China

OBJECTIVE

Although vomiting in the first trimester has been reported to be associated with preterm birth (PTB), findings supporting this association remain inconsistent. Our aim was to assess the association between vomiting and PTB, as well as evaluate if the association is modified by pre-pregnancy body mass index (BMI).

DESIGN

A retrospective cohort study.

SETTING

Wuhan, a central city of China.

PARTICIPANTS

A total of 317 463 pregnant women who had a live, singleton newborn from 1 January 2010 to 23 May 2016 were enrolled in our study.

MAIN OUTCOME MEASURE

PTB was defined as gestational age <37 gestational weeks. Gestational age was calculated using reports from mothers based on the first day of their last menstrual period. An ultrasound was routinely used to determine gestational age before 12 gestational weeks.

RESULTS

Of the 317 463 pregnant women, 29.88% (94 857) experienced vomiting in the first trimester and 5.00% (15 889) experienced a PTB. Vomiting in the first trimester increased the risk for PTB and the multivariable adjusted OR was 1.05 (95% CI 1.02 to 1.09). In the stratified analyses, the association of vomiting in the first trimester was significant among underweight women (adjusted OR=1.08, 95% CI 1.04 to 1.17) and normal pre-pregnancy BMI women (adjusted OR=1.06, 95% CI 1.02 to 1.11), but not in overweight women (adjusted OR=1.01, 95% CI 0.90 to 1.14) and obese women (adjusted OR=0.93, 95% CI 0.73 to 1.19).

CONCLUSIONS

Our study indicates that vomiting in the first trimester was associated with PTB. Additionally, women with underweight and normal pre-pregnancy BMI who experienced vomiting are more likely to have a PTB.

Hyperemesis gravidarum and placental dysfunction disorders

Background

Evidence about the consequence of hyperemesis gravidarum (HG) on pregnancy outcomes is still inconclusive. In this study, we evaluated if occurrence of hyperemesis gravidarum is associated with placental dysfunction disorders and neonatal outcomes.

Methods

A prospective cohort study was conducted in a maternal and child health primary care referral center, Budi Kemuliaan Hospital and its branch, in Jakarta, Indonesia. 2252 pregnant women visiting the hospital for regular antenatal care visits from July 2012 until October 2014 were included at their first clinic visit. For women without, with mild and with severe hyperemesis, placental dysfunction disorders (gestational hypertension, preeclampsia (PE), stillbirth, miscarriage), neonatal outcomes (birth weight, small for gestational age (SGA), low birth weight (LBW), Apgar score at 5 min, gestational age at delivery) and placental outcomes (placental weight and placental-weight-to-birth-weight ratio (PW/BW ratio)) were studied.

Results

Compared to newborns of women without hyperemesis, newborns of women with severe hyperemesis had a 172 g lower birth weight in adjusted analysis (95%CI -333.26; -10.18; p = 0.04). There were no statistically significant effects on placental dysfunction disorders or other neonatal outcome measures.

Conclusions

The results of our study suggest that hyperemesis gravidarum does not seem to induce placental dysfunction disorders, but does, if severe lead to lower birth weight.

Hyperemesis gravidarum in northern Israel: a retrospective epidemiological study

Background

Hyperemesis gravidarum (HG) is characterized by severe intractable nausea and vomiting in pregnancy leading to electrolyte imbalance, ketonuria, and weight loss. The cause is unknown. This study sought to investigate the prevalence and characteristics of HG in the Western Galilee in two ethnic populations and to estimate its economic burden.

Methods

Data on ethnicity, age, gestational age, number of pregnancies, and length of hospitalization were collected from the medical files of all women with HG admitted to the Galilee Medical Center in 2010–2013. Findings were compared between Arabs and Jews. Prevalence was assessed relative to total number of births. Economic burden was assessed by cost of hospitalization and work days lost.

Results

The cohort included 184 women, 124 Arabic (67.4 %) and 60 Jewish (32.6 %). There were 13,630 births at the medical center during the study period, for a calculated prevalence of HG of 1.2 %. There was no difference in the relative proportions of Arabs and Jews between the cohort and the total women giving birth at our center. Mean patient age was 27.2 years, gestational age 9.3 weeks, parity 2.35. Mean age was significantly higher in the Jewish group. There were no significant between-group differences in the other clinical parameters. Mean number of hospitalization days was 2.24 days, and of additional rest days prescribed, 4.62. The calculated annual cost of HG was 452,943.42 NIS (120,144.14 USD), crudely extrapolated to a nationwide cost of 15–20 million NIS (5,300,000 USD).

Conclusion

The prevalence and characteristics of HG are similar in the Arabic and Jewish populations of northern Israel. Mean gestational age at admission for HG was lower in our study than earlier ones, probably owing to the universal health care provided by law in Israel. HG prevalence was twice that reported previously in southern Israel but still within the range observed in other world regions. The socioeconomic differences between Arabs and Jews in the Galilee are smaller than elsewhere in Israel, suggesting a multifactorial etiology of HG. HG poses a major economic burden which should be considered when planning health policies. Further studies of this issue are warranted.

Weight loss in pregnancy and cardiometabolic profile in childhood: findings from a longitudinal birth cohort

OBJECTIVE

To investigate the consequences of weight loss in pregnancy on pregnancy outcomes and cardiometabolic profile in childhood.

DESIGN

Prospective birth cohort (ABCD study).

SETTING

Between 2003 and 2004, all pregnant women in Amsterdam were approached for study participation.

POPULATION

7818 pregnant women were included, of which 3165 consented to having their children examined at 5-6 years of age. In 1956 children fasting capillary blood samples were also taken.

METHODS

At antenatal booking, women answered questions about their pregnancy and whether they suffered from severe weight loss (SWL; >5 kg). Pregnancy details and outcomes were available through the obstetric caregiver.

MAIN OUTCOME MEASURES

At birth main outcome measures were prematurity (<37 weeks) and birthweight. At follow-up, body mass index (BMI), blood pressure, glucose and lipids were assessed.

RESULTS

SWL occurred in 6.8% of cases. Women with SWL had similar preterm birth rates compared with women without these complaints (adjusted OR 1.1, 95%CI 0.7, 1.7). Birthweight (adjusted difference - 31 g, 95%CI -76, 15) and BMI at 5-6 years of age (adjusted difference 0.2 kg/m(2) , 95%CI 0.0, 0.5) were similar in children born to mothers with SWL and without SWL, but blood pressure was increased. For diastolic blood pressure this association was independent of confounders (adjusted difference 1.4 mmHg, 95%CI 0.4, 2.4). Lipid and glucose levels were not significantly different between these groups.

CONCLUSION

Early pregnancy weight loss, usually occurring as a manifestation of hyperemesis gravidarum, could have long-term consequences for offspring health.

Hyperemesis gravidarum: current perspectives

Hyperemesis gravidarum is a complex condition with a multifactorial etiology characterized by severe intractable nausea and vomiting. Despite a high prevalence, studies exploring underlying etiology and treatments are limited. We performed a literature review, focusing on articles published over the last 10 years, to examine current perspectives and recent developments in hyperemesis gravidarum.

Pregnancy outcomes in severe hyperemesis gravidarum in a multi-ethnic population

We evaluated pregnancy outcomes among women with hyperemesis gravidarum (HG) in a North London multi-ethnic population. A retrospective case-control study was performed on records of obstetric admissions during a 4-year period, at North Middlesex University Hospital in North London. A total of 208 women with HG were identified according to Fairweather's criteria occurring in the first 20 weeks of pregnancy, which is severe enough to require admission to hospital. The control study group consisted of 208 women without HG, matched for age, ethnicity and parity. Maternal characteristics as well as pregnancy outcomes were compared in the two groups. The incidence of a delivery of a small-for-gestational-age (SGA) neonate below the 10th per centile was significantly higher in the HG group compared with unaffected pregnancies (8.7% vs 16.8%, p = 0.01). Hyperemesis gravidarum in a multi-ethnic population in North London is associated with SGA neonates.

Hyperemesis gravidarum and long-term health of the offspring

Nausea and vomiting of pregnancy is a very common occurrence, but the reported incidence of hyperemesis gravidarum (a more severe form of vomiting in pregnancy) is much lower, estimated to vary from 0.3-3.6%. Studies have shown that nausea and vomiting of pregnancy is associated with improved fetal outcomes, such as lower rates of miscarriage. However, there are limited data on outcomes associated with hyperemesis gravidarum, which have focused on pregnancy and neonatal outcomes. Recently, studies showed adverse health outcomes, such as a reduction in insulin sensitivity in childhood and increased incidence of psychological disorders in adulthood. The effects of hyperemesis gravidarum in the offspring need to be further examined throughout childhood, adolescence, and into adulthood, so that long-term disease risks can be evaluated.

Interpretation and management of hepatic abnormalities in pregnancy

The spectrum of liver disease in pregnancy includes liver disease unrelated to pregnancy, liver diseases that occur with increased frequency or severity in pregnancy, and liver disease specific to pregnancy. Diseases of the liver unique to pregnancy reliably occur at specific points in the gestational spectrum. Thus, gestational age, a comprehensive history, and a clinically driven diagnostic evaluation is critical in approaching a pregnant patient with abnormal liver chemistries or function. Early recognition of these conditions is important and although management may be expectant, some patients require targeted therapy or necessitate prompt delivery, which can be life-saving to both mother and child.

Hyperemesis gravidarum and birth outcomes-a population-based cohort study of 2.2 million births in the Norwegian Birth Registry

OBJECTIVE

To study associations between hyperemesis gravidarum (HG) and birth outcomes.

DESIGN

Population-based cohort study.

SETTING

Norway.

SAMPLE

Singleton births in the Norwegian Birth Registry, 1967-2009 (n = 2 270 363).

METHODS

Multiple logistic regression was applied to study associations between HG and dichotomous outcomes; multiple linear regression to study associations between HG, birthweight and gestational length. Generalised estimating equations were applied to obtain valid standard errors. Sub-analysis on data with available information on smoking was conducted (1999-2009).

MAIN OUTCOME MEASURES

Small and large for gestational age (SGA/LGA), Apgar score after 5 minutes, very preterm and preterm birth (VPTB/PTB), perinatal death, stillbirth, neonatal death, birthweight and gestational length.

RESULTS

No associations between HG and adverse pregnancy outcomes were observed in crude analyses, except for VPTB (odds ratio [OR] 0.79, 95% CI 0.67-0.93). In adjusted analysis, HG was associated with perinatal death (OR 1.27, 95% CI 1.08-1.48). Inverse associations were observed between HG and VPTB (OR 0.80, 95% CI 0.68-0.94) and LGA (OR 0.95, 95% CI 0.90-0.99). Sub-analyses showed no associations between HG and perinatal death (OR 1.29, 95% CI 0.91-1.83). The inverse associations between HG, VPTB and LGA were strengthened (OR 0.66, 95% CI, 0.48-0.91 and OR 0.86, 95% CI 0.79-0.93, respectively). Exposed babies had reduced birthweight and gestational length compared with unexposed, adjusted difference - 21.4 g and - 0.5 days, respectively. Adjustment for smoking slightly strengthened the impact of HG on birthweight.

CONCLUSIONS

Inverse associations for HG and VPTB and LGA were observed. HG was associated with slight reductions in birthweight and gestational age.

Hyperemesis gravidarum and pregnancy outcomes in the Norwegian Mother and Child Cohort - a cohort study

Background

Hyperemesis gravidarum (HG) characterized by excessive nausea and vomiting in early pregnancy, is reported to be associated with increased risks for low birthweight (LBW), preterm birth (PTB), small-for-gestational-age (SGA) and perinatal death. Conflicting results in previous studies underline the necessity to study HG’s potential effect on pregnancy outcomes using large cohorts with valid data on exposure and outcome measures, as well as potential confounders. This study aims to investigate associations between HG and adverse pregnancy outcomes using the Norwegian Mother and Child Cohort Study (MoBa).

Methods

All singleton pregnancies in MoBa from 1998 to 2008 were included. Multivariable regression was used to estimate relative risks, approximated by odds ratios, for PTB, LBW, SGA and perinatal death. Linear regression was applied to assess differences in birthweight and gestational age for children born to women with and without HG. Potential confounders were adjusted for.

Results

Altogether, 814 out of 71,468 women (or 1.1%) had HG. In MoBa HG was not associated with PTB, LBW or SGA. Babies born to women with HG were born on average 1 day earlier than those born to women without HG; (−0.97 day (95% confidence intervals (CI): -1.80 - -0.15). There was no difference in birthweight when maternal weight gain was adjusted for; (23.42 grams (95% CI: -56.71 - 9.86). Babies born by women with HG had lower risk for having Apgar score < 7 after 1 minute (crude odds ratio was 0.64 (95% CI: 0.43 - 0.95)). No differences between the groups for Apgar score < 7 after 5 minutes were observed. Time-point for hospitalisation slightly increased differences in gestational age according to maternal HG status.

Conclusions

HG was not associated with adverse pregnancy outcomes. Pregnancies complicated with HG had a slightly shorter gestational length. There was no difference in birth weight according to maternal HG-status. HG was associated with an almost 40% reduced risk for having Apgar score < 7 after 1 minute, but not after 5 minutes. The clinical importance of these statistically significant findings is, however, rather limited.

Hyperemesis gravidarum and fetal gender: a retrospective study

This retrospective study of 9,980 women who delivered at the James Paget Hospital, Norfolk, UK, over 5 years, aimed to primarily determine whether the incidence of hyperemesis gravidarum (HG) is higher in the presence of a female fetus. The results showed that more women with HG had a female fetus compared with women without HG. Also found was that heavy ketonuria was more prevalent in women with a female fetus compared with women with a male fetus, and the mean number of admissions per woman was also higher in women with a female fetus compared with women with a male fetus. It can be concluded that women presenting with HG are more likely to have a female fetus and that women with HG and a female fetus tend to a higher level of ketonuria and an increased number of hospital admissions.

A prospective cohort study investigating associations between hyperemesis gravidarum and cognitive, behavioural and emotional well-being in pregnancy

Objectives

To investigate the association between hyperemesis gravidarum and altered cognitive, behavioural and emotional well-being in pregnancy.

Methods

The study cohort consisted of 3423 nulliparous women recruited in the Screening for Pregnancy Endpoints (SCOPE) study performed in Auckland, New Zealand; Adelaide, Australia; Cork, Ireland; Manchester and London, United Kingdom between November 2004 and August 2008. Women were interviewed at 15±1 weeks' gestation and at 20±1weeks' gestation. Women with a diagnosis of hyperemesis gravidarum (HG) were compared with women who did not have a diagnosis of HG. Main outcome measures included the Short form State- Trait Anxiety Inventory (STAI) score (range 6–24), Perceived Stress Scale score (PSS, range 0–30), Edinburgh Postnatal Depression Scale (EPDS) score (range 0–30 or categories a–c) and behavioural responses to pregnancy score (limiting/resting [range 0–20] and all-or-nothing [range 0–28]).

Results

During the study period 164 women suffered from HG prior to their 15 week interview. Women with HG had significantly higher mean STAI, PSS, EPDS and limiting response to pregnancy scores compared to women without HG. These differences were observed at both 15±1 and 20±1 weeks' of gestation. The magnitude of these differences was greater in women with severe HG compared to all women with HG. Women with severe HG had an increased risk of having a spontaneous preterm birth compared with women without HG (adjusted OR 2.6 [95% C.I. 1.2, 5.7]).

Conclusion

This is the first large prospective study on women with HG. Women with HG, particularly severe HG, are at increased risk of cognitive, behavioural and emotional dysfunction in pregnancy. Women with severe HG had a higher rate of spontaneous preterm birth compared to women without HG. Further research is required to determine whether the provision of emotional support for women with HG is beneficial.

Consequences of hyperemesis gravidarum for offspring: a systematic review and meta-analysis

BACKGROUND

There is evidence that hyperemesis gravidarum (HG) is associated with a predominance of female fetuses, lower birthweights and shorter gestational ages at birth. As the adverse effects of prematurity and low birthweight on disease risk in later life have become increasingly clear, the repercussions of HG might not be limited to adverse perinatal outcomes.

OBJECTIVES

To summarise the evidence on short- and long-term outcomes of pregnancies with HG.

SEARCH STRATEGY

A literature search was conducted in the electronic databases Medline and Embase.

SELECTION CRITERIA

Studies were included that reported on the fetal, neonatal and long-term outcome of pregnancies complicated by HG.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies and extracted data. Meta-analysis was performed using review manager.

MAIN RESULTS

Women with HG during pregnancy were more likely to have a female child (OR 1.27; 95% CI 1.21-1.34). They were also more likely to have a baby with low birthweight (LBW, <2500 kg; OR 1.42; 95% CI 1.27-1.58) that was small for gestational age (SGA; OR 1.28; 95% CI 1.02-1.60), and to deliver prematurely (OR 1.32; 95% CI 1.04-1.68). There was no association with Apgar scores, congenital anomalies or perinatal death. One study described an association between HG and testicular cancer in the offspring.

AUTHOR'S CONCLUSIONS

There is evidence that HG is associated with a higher female/male ratio of offspring and a higher incidence of LBW, SGA and premature babies. Little is known about the long-term health effects of babies born to mothers whose pregnancies were complicated by HG.

Pregnancy-related liver diseases

Liver diseases related to pregnancy may be associated with preeclampsia (liver dysfunction related to preeclampsia; hemolysis, elevated liver enzymes, and low platelets with or without preeclampsia [HELLP syndrome]; and acute fatty liver of pregnancy) or may not involve preeclampsia (hyperemesis gravidarum and intrahepatic cholestasis of pregnancy). Liver diseases associated with pregnancy have unique presentations, but it can be difficult differentiating these from liver diseases that occur coincidentally with pregnancy. Recently, advances have been made in the disease mechanism and intervention of pregnancy-related liver diseases. Early diagnosis and delivery remains the key element in managing the liver diseases associated with preeclampsia, but emerging data suggest that incorporating advance supportive management into current strategies can improve both maternal and fetal outcomes.

Maternal body composition, smoking, and hyperemesis gravidarum

PURPOSE

To study associations between maternal prepregnant body mass index (BMI), smoking, and hyperemesis gravidarum (hyperemesis).

METHODS

The sample consisted of 33,467 primiparous women from the Norwegian Mother and Child Cohort Study (1999-2008). Data on hyperemesis, BMI, education, maternal age, eating disorders, maternal and paternal smoking habits were obtained from questionnaires. All associations were studied by logistic regression.

RESULTS

Altogether, 353 (1.1%) women had hyperemesis. Among non-smokers, both underweight and obese women were more likely to develop hyperemesis than normal-weighted women: odds ratio (OR), 2.36; 95% confidence interval (95% CI), 1.43-3.88 and OR, 1.48; 95% CI, 1.00-2.20, respectively. No associations were found among smokers. Women who smoked daily (OR, 0.44; 95% CI, 0.32-0.60) or occasionally (OR, 0.64; 95% CI, 0.44-0.93) had lower risk of hyperemesis than non-smokers. No effect of partner's smoking habits was observed.

CONCLUSIONS

Both underweight and obesity were associated with hyperemesis, but only among non-smokers. Maternal prepregnant smoking reduced the risk of hyperemesis, whereas partner's smoking habits had no effect.

Understanding the stigma of hyperemesis gravidarum: qualitative findings from an action research study

BACKGROUND

Severe nausea and vomiting in pregnancy (hyperemesis gravidarum) can be a distressing and debilitating condition when it is uncontrolled. For all concerned, hyperemesis gravidarum can be difficult to treat satisfactorily, and women tend to be admitted to a hospital several times during early pregnancy. Our research objectives were to describe the experience of hyperemesis gravidarum from the perspective of affected women and to explore with health care professionals the barriers and facilitators to caring for women with the condition.

METHODS

A qualitative research design was used. A total of 18 women were interviewed, of whom 8 had two or more interviews. Seven focus groups were conducted with health care professionals. Thematic data analysis was undertaken.

RESULTS

The main themes emerging from the women's data were the effect and burden of the symptoms of the condition and feeling unpopular with staff. From the practitioner data, the main themes were the validity (or invalidity) of hospitalization for women, skepticism of the severity of symptoms, the psychological and social dimensions of the condition, and inadequate primary care services.

CONCLUSIONS

The main findings revealed that hyperemesis gravidarum is a debilitating condition and that the unhelpful attitudes of practitioners may affect whether women access timely and appropriate care. Many women appear to be unsupported by primary care services and are distressed when perceived either as "time wasters" or someone else's responsibility. We propose that a tailored assessment and care plan for each woman is needed to help them control their symptoms, which ideally should be delivered in the community.

Nausea and vomiting in health-related quality of life among Chinese pregnant women

BACKGROUND

Nausea and vomiting in pregnancy (NVP) is the most common pregnancy complication affecting women during the first trimester of pregnancy. The cause of NVP remains unknown and factors associated with the occurrence of NVP are contradictory. There is currently little information on its effects of NVP in general and specifically in the Chinese population.

AIMS

To assess the prevalence of NVP with different degree of severity and identify their relationship with health-related quality of life (HRQoL) and to determine its association with the sociodemographic and obstetric factors.

METHODS

In a prospective cross-sectional study, 396 women who attended the antenatal clinic between 10 and 14 weeks of gestation were invited to complete a structured questionnaire covering maternal characteristics, severity of NVP and their HRQoL. The status of NVP and HRQoL was measured by the frequency of symptoms and the Medical Outcomes Study Short-Form-36 (SF-36) respectively. Logistic regression analysis was performed to delineate the factors associated with NVP.

RESULTS

The prevalence of NVP was 90.9%. Almost all domains and dimensions of SF-36 were affected by the presence of NVP and its severity. Factors associated with the presence and severity of NVP were non-smoking, younger age and history of NVP in previous pregnancy.

CONCLUSIONS

The various degrees of severity of NVP significantly impair both physical and mental HRQoL in Hong Kong Chinese women. Awareness and care should be given to women with symptoms of nausea or retching alone, as well as vomiting.

The Hyperemesis Impact of Symptoms Questionnaire: development and validation of a clinical tool

BACKGROUND

The Hyperemesis Impact of Symptoms Questionnaire is a clinical tool designed to assess holistically the impact of the physical and psychosocial symptoms of hyperemesis gravidarum (HG) on individuals. Its purpose is to aid planning and implementation of tailored care for women with HG. To our knowledge no similar tool exists.

OBJECTIVE

To assess the validity and reliability of the HIS questionnaire.

DESIGN

As no similar tool exists, we compared the HIS with three tools that reflect its key areas: physical impact (Pregnancy Unique Quantification of Emesis--PUQE score and markers of severity of HG), psychological impact (Hospital Anxiety and Depression Score--HADS) and social impact (SF12 quality of life score).

SETTING

A large regional referral, women and children's hospital in the North West of England.

PARTICIPANTS

The HIS was evaluated on 50 women admitted to hospital with HG and 50 women recruited from ante-natal clinic without severe nausea and vomiting of pregnancy and with an uncomplicated pregnancy.

RESULTS

Good criterion validity was demonstrated by strong significant correlations with all three scores (PUQE, r=0.75, p<0.001, HADS, depression r=0.76, p<0.001, and SF12, mental component r=-0.65, p<0.001). The HIS showed good internal consistency, Cronbach alpha 0.87, split half 0.80.

CONCLUSIONS

There is evidence for the validity and reliability of the HIS to assess the impact of the physical and psychosocial symptoms of HG. Further research is currently underway to establish the clinical utility of the HIS questionnaire in the care of women hospitalised with HG.

Epidemiology of nausea and vomiting of pregnancy: prevalence, severity, determinants, and the importance of race/ethnicity

BACKGROUND

Studies that contributed to the epidemiology of nausea and vomiting of pregnancy have reported conflicting findings, and often failed to account for all possible co-variables necessary to evaluate the multidimensional associations. The objectives of this study were to: 1) Estimate the prevalence and the severity of nausea and vomiting of pregnancy during the 1st and the 2nd trimester of pregnancy, and 2) Identify determinants of presence and severity of nausea and vomiting of pregnancy during the 1st and 2nd trimesters separately, with a special emphasis on the impact of race/ethnicity.

METHODS

A prospective study including pregnant women attending the Centre Hospitalier Universitaire (CHU) Sainte-Justine or René-Laennec clinics for their prenatal care was conducted from 2004 to 2006. Women were eligible if they were > or = 18 years of age, and </= 16 weeks of gestation. Women were asked to fill out a 1st trimester self-administered questionnaire and were interviewed over the telephone during their 2nd trimester of pregnancy. Presence of nausea and vomiting of pregnancy was based on the reporting of pregnant women (yes/no); severity of symptoms was measured by the validated modified-PUQE index.

RESULTS

Of the 367 women included in the study, 81.2% were Caucasians, 10.1% Blacks, 4.6% Hispanics, and 4.1% Asians. Multivariate analyses showed that race/ethnicity was significantly associated with a decreased likelihood of reporting nausea and vomiting of pregnancy (Asians vs. Caucasians OR: 0.13; 95%CI 0.02-0.73; and Blacks vs. Caucasians OR: 0.29; 95%CI 0.09-0.99).

CONCLUSION

Our study showed that race/ethnicity was associated with the reporting of nausea and vomiting of pregnancy in the 1st trimester of pregnancy.

Pregnancy-associated liver disorders

Liver disorders associated with pregnancy include hyperemesis gravidarum (HG), intrahepatic cholestasis of pregnancy (ICP), preeclampsia, syndrome of hemolysis, elevated liver enzymes and low platelets (HELLP), and acute fatty liver of pregnancy (AFLP). These conditions are relatively common and unique to pregnancy and are more likely to occur at certain terms of gestation specific to each condition. They can be associated with significant maternal and fetal morbidity and mortality. Although managing such patients may be very challenging, spontaneous resolution of the disease occurs shortly after termination of the pregnancy, usually without hepatic sequellae. Early diagnosis and timely treatment is a key to therapeutic success. This article explores the clinical features, pathophysiology, and management of these disorders.

Variations in prevalence of hyperemesis gravidarum by country of birth: a study of 900,074 pregnancies in Norway, 1967-2005

OBJECTIVE

To estimate the prevalence of hyperemesis gravidarum (HG) in women living in Norway by their country of birth, and explore whether the variations in the occurrence of HG could be explained by the differences in maternal sociodemographic factors.

DESIGN

This was a cross-sectional study.

METHODS

All primiparous women registered in the Medical Birth Registry of Norway (MBRN) from 1967 through June 2005 (N=900,074) comprised the sample. Data on HG, age, plurality and sex of the fetus were obtained from the MBRN and linked to the data on country of birth and maternal education obtained from Statistics Norway. Independent associations between country of birth and HG were studied by multiple logistic regression with and without adjustment for potential confounders.

RESULTS

The overall prevalence of HG in primiparous women in Norway during the study period was 0.89% (95% confidence interval (CI) 0.88-0.92). Women born in Western Europe had the lowest prevalence of HG (0.8%), whereas those born in India and Sri Lanka had the highest (3.2%). Women born in Africa (except North Africa) and India or Sri Lanka were 3.4 (95% CI 2.7- 3.5) and 3.3 (95% CI 2.6-3.4) times more likely to develop HG than women born in Norway, after adjustment for potential confounders.

CONCLUSIONS

Substantial variations in the prevalence of HG in Norway by country of birth cannot be explained by the differences in maternal sociodemographic factors.

Hyperemesis in pregnancy: an evaluation of treatment strategies with maternal and neonatal outcomes

OBJECTIVE

The objective of the study was to evaluate the use of interventions such as a peripherally inserted central catheters (PICC) line or nasogastric (NG)/nasoduodenal (ND) tube with the use of medications alone in the management of pregnancies with hyperemesis.

STUDY DESIGN

Subjects were identified with confirmed intrauterine pregnancy, admitted with hyperemesis gravidarum (HEG) between 1998 and 2004. Medical records were then abstracted for information with regard to therapy. Subjects were assigned on the basis of the management plan: medication alone, PICC line, or NG/ND tube. Outcomes were compared between groups.

RESULTS

Ninety-four patients met study criteria and had complete outcome data available. Of those, 33 had a PICC line placed (35.1%), 19 had a NG/ND placed (20.2%), and 42 were managed with medication alone (44.7%). These groups were similar with respect to gestational age at delivery, Apgar score, and mean birthweight. Maternal complications were significantly higher among those with PICC lines. Of patients managed with PICC lines, 66.4% (P < .001) required treatment for infection, thromboembolism, or both. Adjusted odds ratio for a PICC line complication was 34.5 (5.09, 233.73).

CONCLUSION

Maternal complications associated with PICC line placement are substantial despite no difference in neonatal outcomes, suggesting that the use of PICC lines for treatment of HEG patients should not be routinely used.

The Hyperemesis Beliefs Scale (HBS): a new instrument for assessing beliefs about severe nausea and vomiting in pregnancy

OBJECTIVE

The purpose of this research was to validate the Hyperemesis Beliefs Scale (HBS), a new instrument for assessing patient perception factors of hyperemesis gravidarum (HG) that influence reported patient satisfaction with medical care.

METHODS

Patients' beliefs and their perception of their physicians' beliefs about the causal explanations of HG, seriousness of the illness, and the impact of the illness upon patients' daily lives were determined using a newly developed hyperemesis beliefs scale (HBS) in a sample of 96 women. Exploratory factor analyses of the patient and physician versions of the HBS were performed separately using principal factor analysis extraction and oblique rotation in SPSS.

RESULTS

Exploratory factor analyses of patient and physician versions of the HBS demonstrated broad support for the hypothesized factor structure. However, two key differences appeared in the two versions of the HBS. First, the patient items exhibited two causal factors (general and personal), whereas the physician items showed only a single causal factor. Second, in the patient version, items assessing the impact of HG on the babies' health loaded separately from the rest of the items in the HBS, whereas the analyses of the corresponding physician items indicated that the baby items loaded well on the degree of seriousness factor.

CONCLUSION

This scale may be of value in facilitating further research on HG illness representations, patient-physician relationship and patient satisfaction. Specifically, the HBS design provides data to show whether patient-physician agreement on particular measures is associated with better patient satisfaction outcomes.

Hyperemesis gravidarum: une cause rare d'encéphalopathie de Wernicke

INTRODUCTION

Wernicke encephalopathy - most often observed in alcoholic patients - is due to severe thiamine deficiency.

CASE

We report here the case of a 30-year-old woman who presented with hyperemesis and vomiting during the first trimester of pregnancy (hyperemesis gravidarum). Hyperemesis can lead to severe, symptomatic thiamine deficiency and to severe dehydration with prerenal azotemia.

DISCUSSION

Wernicke encephalopathy is a rare complication of hyperemesis gravidarum. It should be diagnosed as early as possible to prevent long-term complications.

Nutrition for healthy pregnancy outcomes

Many healthcare professionals and their patients are aware of the importance of proper nutrition during pregnancy, but may not be aware of specific nutritional recommendations on how to achieve a healthy pregnancy outcome. This review article aims to discuss the implications maternal nutritional status and weight gain have in both the short and long terms. Babies born to mothers with inadequate weight gain are more likely to be premature and small for gestational age (SGA). They are also predisposed to obesity and metabolic problems later in life. Women with excessive weight gain during pregnancy are at increased risk for developing type II diabetes later in life. Their offspring also have increased body fat as babies and during childhood. Pregnant women need to be informed about appropriate weight gain and how to achieve this, and should be given specific nutritional recommendations and weight-gain goals.

Outcomes of pregnancies complicated by hyperemesis gravidarum

OBJECTIVE

To evaluate maternal and neonatal outcomes among women with hyperemesis during pregnancy.

METHODS

A population-based retrospective cohort study was conducted among women with singleton deliveries between 1988 and 2002. Hyperemetic pregnancies were defined as those requiring one or more antepartum admissions for hyperemesis before 24 weeks of gestation. Severity of hyperemesis was evaluated according to the number of antenatal hospital admissions (1 or 2 versus 3 or more) and according to weight gain during pregnancy (< 7 kg [15.4 lb] versus > or = 7 kg). Maternal outcomes evaluated included weight gain during pregnancy, gestational diabetes, gestational hypertension, labor induction, and cesarean delivery. Neonatal outcomes included 5-minute Apgar score of less than 7, low birth weight, small for gestational age, preterm delivery, and perinatal death. Logistic regression was used to generate adjusted odds ratios for all outcomes, and the odds ratios were converted to relative risks.

RESULTS

Of the 156,091 singleton pregnancies, 1,270 had an admission for hyperemesis. Compared to women without hyperemesis, infants born to women with hyperemesis and with low pregnancy weight gain (< 7 kg [15.4 lb]) were more likely to be low birth weight, small for gestational age (SGA), born before 37 weeks of gestation, and have a 5-minute Apgar score of less than 7. Compared with infants born to women without hyperemesis, rates of low birth weight and preterm delivery were substantially higher among infants born to women with hyperemesis and low pregnancy weight gain (4.2% versus 12.5% and 4.9% versus 13.9%, respectively). The outcomes among infants born to women with hyperemesis with pregnancy weight gain of 7 kg (15.4 lb) or more were not different from the outcomes among women without hyperemesis.

CONCLUSION

The results of this study suggest that the adverse infant outcomes associated with hyperemesis are a consequence of, and mostly limited to, women with poor maternal weight gain.

LEVEL OF EVIDENCE

II-2.