Hyperemesis gravidarum: current perspectives

Hyperemesis gravidarum and the risk of offspring morbidity: a longitudinal cohort study

PURPOSE

Hyperemesis gravidarum has the potential to affect the long-term health of offspring. We examined whether maternal hyperemesis gravidarum was associated with the risk of hospitalization for childhood morbidity.

METHODS

We conducted a longitudinal cohort study of 1,189,000 children born in Quebec, Canada, between April 2006 and March 2021. The main exposure measure was maternal hyperemesis gravidarum requiring hospitalization in the first or second trimester. The outcome was any pediatric admission between birth and 16 years of age, with follow-up ending in March 2022. We used Cox regression models adjusted for maternal and socioeconomic factors to estimate hazard ratios (HR) and 95% confidence intervals (CI) for the association between maternal hyperemesis gravidarum and childhood hospitalization.

RESULTS

Among 1,189,000 children, 6904 (0.6%) were exposed to maternal hyperemesis gravidarum. Hospitalization rates at age 16 years were higher for children exposed to hyperemesis gravidarum than unexposed children (47.6 vs 43.9 per 100 children). Relative to no exposure, hyperemesis gravidarum was associated with a 1.21 times greater risk of any hospitalization before 16 years (95% CI 1.17-1.26). Hyperemesis gravidarum was associated with hospitalization for neurologic (HR 1.50, 95% CI 1.32-1.71), developmental (HR 1.51, 95% CI 1.29-1.76), digestive (HR 1.40, 95% CI 1.30-1.52), and allergic disorders (HR 1.39, 95% CI 1.24-1.56). When contrasted with preeclampsia, hyperemesis gravidarum was a stronger risk factor for these outcomes.

CONCLUSIONS

Maternal hyperemesis gravidarum is associated with an increased risk of childhood hospitalization, especially for neurologic, developmental, digestive, and atopic disorders.

WHAT IS KNOWN

• Hyperemesis gravidarum is associated with neurodevelopmental disorders in offspring. • However, the effect of hyperemesis gravidarum on other childhood morbidity is unclear.

WHAT IS NEW

• In this longitudinal cohort study of 1.2 million children, maternal hyperemesis gravidarum was associated with a greater risk of hospitalization before age 16 years. • Exposure to hyperemesis gravidarum was associated with developmental, neurologic, atopic, and digestive morbidity in childhood.

Prevalence of hyperemesis gravidarum and associated factors among pregnant women at comprehensive specialized hospitals in northwest Ethiopia: Multicenter cross-sectional study

Background

Hyperemesis gravidarum is one of the problems encountered among pregnant women due to persistent and excessive vomiting starting before the end of the 22nd week of gestation. The current study aimed to assess the prevalence of hyperemesis gravidarum and associated factors among pregnant women at comprehensive specialized hospitals in northwest Ethiopia.

Methods

A multi-facility-based cross-sectional study was conducted at comprehensive specialized hospitals from 1st June 2022 to 30th July 2022. The data were entered using EPI Data Version 4.6 statistical software and analyzed using SPSS Version 26. Descriptive statistics such as frequency, mean, and percentage were calculated. Univariable and multivariable binary logistic regression analyses were carried out to identify the associated factors of hyperemesis gravidarum.

Results

In all, 404 study participants were enrolled. About 16.8% of pregnant women were found to have hyperemesis gravidarum. Age < 20 year (AOR = 3.170; 95% CI: 1.119, 8.980), study participants who cannot read and write (AOR = 5.662; 95% CI: 2.036, 15.7470), grade 1-8 (AOR = 4.679; 95% CI: 1.778, 12.316), and grade 9-10 (AOR = 8.594; 95% CI: 3.017, 24.481), being housewife (AOR = 6.275; 95% CI: 1.052, 37.442), living in urban area (AOR = 2.185; 95% CI: 1.035, 4.609), having previous hyperemesis gravidarum (AOR = 2.463; 95% CI: 1.210, 5.012), having family history of hyperemesis gravidarum (AOR = 2.014; 95% CI: 1.002, 4.047), unplanned pregnancy (AOR = 2.934; 95% CI: 1.030, 8.351), having recent abortion (AOR = 2.750; 95% CI: 1.010, 7.483), and gravidity (AOR = 1.956; 95%CI: 1.023, 3.737) were factors associated with hyperemesis gravidarum.

Conclusion

The prevalence of hyperemesis gravidarum is higher. Low maternal age, lower educational level, being a housewife, being an urban resident, having previous hyperemesis gravidarum, having a family history, having an unplanned pregnancy, and having a recent abortion were significantly associated with hyperemesis gravidarum.

Helicobacter pylori infection in pregnant women: Gastrointestinal symptoms and pregnancy- related disorders

Helicobacter pylori (H. Pylori) is a gram-negative, flagellated and spiral-shaped bacterial pathogen that impacts approximately 46% among pregnant women globally and has been associated with various maternal-fetal complications. Iron deficiency anemia, fetal growth restriction, cardiovascular diseases, and insufficient nutrient absorption can be observed in pregnant women, as well as miscarriages and pregnancy-specific hypertensive disease, such as pre-eclampsia. Thus, the evidence supports the influence of H. pylori infection on fetal implantation/placentation failure, and positive strains of the cytotoxin-associated gene A of H. Pylori were reported as the most prevalent in these conditions. However, current knowledge indicates a relationship between this infection and the occurrence of hyperemesis gravidarum, characterized by frequent nausea and vomiting. Regarding the diagnosis of this bacterial infection, non-invasive approaches such as stool antigen test, urea breath test, and serological tests are more accepted during pregnancy, as they are easy to carry out and cost-effective. Finally, the bacteria eradication therapy should consider the risks and benefits for the pregnant woman and her child, with pharmacological intervention depending on the clinical presentation.

Esophagogastrectomy for Long-Segment Recurrent Esophageal Stricture Following Hyperemesis Gravidarum

An esophageal stricture is an abnormal tightening of the esophageal lumen. Benign strictures are often caused by gastroesophageal reflux disease (GERD) and are more common in patients over 40 years. When caused by GERD, these strictures develop when acid from the stomach regurgitates into the esophagus, leading to inflammation, fibrosis, and eventual narrowing of the lumen. This case report aims to highlight the importance of obtaining a detailed history in discovering the underlying cause of these strictures. We present a unique case of a young female presenting with dysphagia several months after experiencing Hyperemesis gravidarum. She was found to have a long esophageal stricture that would eventually recur within a few weeks of therapeutic intervention. The pathological report confirmed benign disease, but she ultimately would require surgical intervention for her condition.

Promising Sources of Plant-Derived Polyunsaturated Fatty Acids: A Narrative Review

(1) Background: Polyunsaturated fatty acids (PUFAs) are known for their ability to protect against numerous metabolic disorders. The consumption of oily fish is the main source of PUFAs in human nutrition and is commonly used for supplement production. However, seafood is an overexploited source that cannot be guaranteed to cover the global demands. Furthermore, it is not consumed by everyone for ecological, economic, ethical, geographical and taste reasons. The growing demand for natural dietary sources of PUFAs suggests that current nutritional sources are insufficient to meet global needs, and less and less will be. Therefore, it is crucial to find sustainable sources that are acceptable to all, meeting the world population's needs. (2) Scope: This review aims to evaluate the recent evidence about alternative plant sources of essential fatty acids, focusing on long-chain omega-3 (n-3) PUFAs. (3) Method: A structured search was performed on the PubMed search engine to select available human data from interventional studies using omega-3 fatty acids of non-animal origin. (4) Results: Several promising sources have emerged from the literature, such as algae, microorganisms, plants rich in stearidonic acid and GM plants. However, the costs, acceptance and adequate formulation deserve further investigation.

Association between body mass index in the first half of pregnancy and gestational diabetes: A systematic review

Gestational diabetes mellitus is a more common complication in pregnancy and rising worldwide and screening for treating gestational diabetes mellitus is an opportunity for preventing its complications. Abnormal body mass index is the cause of many complications in pregnancy that is one of the major and modifiable risk factors in pregnancy too. This systematic review aimed to define the association between body mass index in the first half of pregnancy (before 20 weeks of gestation) and gestational diabetes mellitus. Web of Science, PubMed/Medline, Embase, Scopus, ProQuest, Cochrane library, and Google Scholar databases were systematically explored for articles published until April 31, 2022. Participation, exposure, comparators, outcomes, study design criteria include pregnant women (P), body mass index (E), healthy pregnant women (C), gestational diabetes mellitus (O), and study design (cohort, case–control, and cross-sectional). Newcastle–Ottawa scale checklists were used to report the quality of the studies. Eighteen quality studies were analyzed. A total of 41,017 pregnant women were in the gestational diabetes mellitus group and 285,351 pregnant women in the normal glucose tolerance group. Studies have reported an association between increased body mass index and gestational diabetes mellitus. Women who had a higher body mass index in the first half of pregnancy were at higher risk for gestational diabetes mellitus. In the first half of pregnancy, body mass index can be used as a reliable and available risk factor to assess gestational diabetes mellitus, especially in some situations where the pre-pregnancy body mass index is not available.

Hematological Parameters to Predict the Severity of Hyperemesis Gravidarum and Ketonuria

OBJECTIVE

 Hyperemesis gravidarum (HG) is a pregnancy complication that can progress with persistent nausea and vomiting. The aim of the present study is to evaluate the relationship between hematological parameters and HG.

METHOD

 A total of 532 pregnant women with HG who were admitted to the Department of Obstetrics and Gynecology between March 2019 and February 2021, and 534 healthy pregnant women with characteristics similar to those of the case group were included in the study. The hematological parameters of both groups were compared. In addition, the hematological parametersof patients with HG according to the severity of ketonuria were compared.

RESULTS

 The mean age of the HG group (n = 532) was 26.3 ±  4.1 years, and that of the control group (n = 534) was 25.9 ±  4.8 years. Among patients with HG, 46% (n = 249) had ketone (+), 33% (n = 174), ketone (++), and 21% (n = 109), ketone (++ + ). The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were higher in the HG group than in the control group: 3.8 (2.8-5.8)/3.2 (2.6-4.0); p < 0.001; and 135.2 ±  30.4/108.9 ±  62.2; p < 0.001 respectively. The neutrophil count, NLR, and PLR were higher in the group with ketone (++ + ) than in the groups with ketone (+) or ketone (++): 7.6 ±  1.9/5.5 ±  2.4; p < 0.001; 3.8(2.8-4.6)/2.9(2.3-3.6); p < 0.001; and 149.9 ±  48.0/135.9 ±  65.7; p < 0.001 respectively. The mean corpuscular hemoglobin (MCH) level, the NLR, and the PLR were identified as independent predictors of the presence of HG and the level of ketone positivity in HG patients.

CONCLUSION

 The NLR and PLR were high in patients with HG, suggesting the its inflammatory activity. They may be important markers associated with the presence and severity of HG.

Links between Thyroid Disorders and Glucose Homeostasis

Thyroid disorders and diabetes mellitus often coexist and are closely related. Several studies have shown a higher prevalence of thyroid disorders in patients with diabetes mellitus and vice versa. Thyroid hormone affects glucose homeostasis by impacting pancreatic β-cell development and glucose metabolism through several organs such as the liver, gastrointestinal tract, pancreas, adipose tissue, skeletal muscles, and the central nervous system. The present review discusses the effect of thyroid hormone on glucose homeostasis. We also review the relationship between thyroid disease and diabetes mellitus: type 1, type 2, and gestational diabetes, as well as guidelines for screening thyroid function with each disorder. Finally, we provide an overview of the effects of antidiabetic drugs on thyroid hormone and thyroid disorders.

Hyperemesis gravidarum in the primary care setting: cross-sectional study of GPs

BACKGROUND

Hyperemesis gravidarum (HG), if untreated, can lead to malnutrition, dehydration, and Wernicke's encephalopathy. Foetal complications include low birth weight and neurodevelopmental delay. Recent evidence supports increased rates of termination of pregnancy and suicidal ideation. Drivers included difficulty in accessing medications, which thus contributed to poor perception of care.

AIM

To identify factors that may influence prescribers' confidence and knowledge regarding pharmacological therapy for HG.

DESIGN & SETTING

Cross-sectional study of qualified GPs and GP trainees in Wales.

METHOD

Distribution of a 22-item online survey. Statistical analysis was carried out using SPSS.

RESULTS

In total, 241 responses were received, with 216 included in the analysis (59% qualified GPs, 41% GP trainees). In total, 93% of responders correctly identified cyclizine as being safe in pregnancy, but no other drug recommended in the Royal College of Obstetrics and Gynaecology guidance was considered safe by more than 58%. Those reporting higher confidence levels in managing HG were more likely to correctly report guideline-recommended drugs as safe in pregnancy (P = 0.04). Additional qualifications related to obstetrics and gynaecology (O&G) and/or prior clinical experience increased confidence levels (P = 0.0001 and P = 0.0002, respectively). Only 19% of participants routinely screened for signs of mental health complications, and prior experience or education did not increase likelihood of this happening. The majority of participants (87%) would like additional education and/or access to evidence-based resources.

CONCLUSION

This study demonstrates a demand for improved dissemination of evidence-based education on HG to support those working in primary care. The extent to which HG is covered in pre-existing educational programmes should also be revisited.

Beyond Fish Oil Supplementation: The Effects of Alternative Plant Sources of Omega-3 Polyunsaturated Fatty Acids upon Lipid Indexes and Cardiometabolic Biomarkers-An Overview

Cardiovascular diseases remain a global challenge, and lipid-associated biomarkers can predict cardiovascular events. Extensive research on cardiovascular benefits of omega-3 polyunsaturated fatty acids (n3-PUFAs) is geared towards fish oil supplementation and fish-rich diets. Nevertheless, vegetarianism and veganism are becoming more popular across all segments of society, due to reasons as varied as personal, ethical and religious values, individual preferences and environment-related principles, amongst others. Due to the essentiality of PUFAs, plant sources of n3-PUFAs warrant further consideration. In this review, we have critically appraised the efficacy of plant-derived n3-PUFAs from foodstuffs and supplements upon lipid profile and selected cardiometabolic markers. Walnuts and flaxseed are the most common plant sources of n3-PUFAs, mainly alpha-linolenic acid (ALA), and feature the strongest scientific rationale for applicability into clinical practice. Furthermore, walnuts and flaxseed are sources of fibre, potassium, magnesium, and non-essential substances, including polyphenols and sterols, which in conjunction are known to ameliorate cardiovascular metabolism. ALA levels in rapeseed and soybean oils are only slight when compared to flaxseed oil. Spirulina and Chlorella, biomasses of cyanobacteria and green algae, are important sources of n3-PUFAs; however, their benefits upon cardiometabolic markers are plausibly driven by their antioxidant potential combined with their n3-PUFA content. In humans, ALA is not sufficiently bioconverted into eicosapentaenoic and docosahexaenoic acids. However, evidence suggests that plant sources of ALA are associated with favourable cardiometabolic status. ALA supplementation, or increased consumption of ALA-rich foodstuffs, combined with reduced omega-6 (n6) PUFAs intake, could improve the n3/n6 ratio and improve cardiometabolic and lipid profile.

Association between hyperemesis gravidarum and psychological symptoms, psychosocial outcomes and infant bonding: a two-point prospective case-control multicentre survey study in an inner city setting

OBJECTIVES

To assess if there is any association between hyperemesis gravidarum (HG), psychological morbidity and infant bonding and to quantify any psychosocial consequences of HG.

DESIGN

Two-point prospective case-control, multicentre survey study with antenatal and postnatal data collection.

SETTING

Three London hospitals.

PARTICIPANTS

Pregnant women at ≤12 completed weeks gestation recruited consecutively over 2 years. Women with HG were recruited at the time of admission; controls recruited from a low risk antenatal clinic. 106 women were recruited to the case group and 108 to the control. Response rates at antenatal data collection were 87% and 85% in the case and control groups, respectively. Postnatally, the response rate was 90% in both groups.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes were psychological morbidity in the antenatal and postnatal periods, infant bonding in the postnatal period and psychosocial implications of HG. Secondary outcomes were the effects of severity and longevity of HG and assessment of correlation between Edinburgh Postnatal Depression Scale scores and maternal-to-infant bonding scores.

RESULTS

Antenatally, 49% of cases had probable depression compared with 6% of controls (OR 14.4 (5.29 to 39.44)). Postnatally, 29% of cases had probable depression versus 7% of controls (OR 5.2 (1.65 to 17.21)). There was no direct association between HG and infant bonding. 53% of women in the HG group reported needing four or more weeks of sick leave compared with 2% in the control group (OR 60.5 (95% CI 8.4 to 2535.6)).

CONCLUSIONS

Long-lasting psychological morbidity associated with HG was evident. Significantly more women in the case group sought help for mental health symptoms in the antenatal period, however very few were diagnosed with or treated for depression in pregnancy or referred to specialist perinatal mental health services. HG did not directly affect infant bonding. Women in the case group required long periods off work, highlighting the socioeconomic impact of HG.

Nausea, vomiting and poor appetite during pregnancy and adverse birth outcomes in rural Nepal: an observational cohort study

Background

Nausea and vomiting are experienced by a majority of pregnant women worldwide. Previous studies have yielded conflicting results regarding their impact on birth outcomes and few studies have examined this relationship in settings with limited resources. We aimed to determine the effect of nausea, vomiting and poor appetite during pregnancy on birth outcomes in rural Nepal.

Methods

Observational cohort study using data collected in two randomized, community-based trials to assess the effect of influenza immunization during pregnancy on reproductive and respiratory outcomes among pregnant women and their offspring. Pregnant women in Sarlahi District, Nepal were recruited from 2011 to 2013. Exposure was defined as nausea, vomiting or poor appetite at any point during pregnancy and by trimester; symptoms were recorded monthly throughout pregnancy. Adverse outcomes were low birth weight (LBW), preterm birth and small for gestational age (SGA). Adjusted relative risks (aRR) with 95% CIs are reported from Poisson regressions with robust variance.

Results

Among 3,623 pregnant women, the cumulative incidence of nausea, vomiting or poor appetite was 49.5% (n = 1793) throughout pregnancy and 60.6% (n = 731) in the first trimester. Significantly higher aRRs of LBW and SGA were observed among women experiencing symptoms during pregnancy as compared to symptom free women (LBW: aRR 1.20; 95% CI 1.05 1.28; SGA: aRR 1.16; 95% CI 1.05 1.28). Symptoms in the first trimester were not significantly associated with any of the outcomes. In the second trimester, we observed significantly higher aRRs for LBW and SGA (LBW: aRR 1.17; 95% CI 1.01 1.36; SGA: aRR 1.16; 95% CI 1.05 1.29) and a significantly lower aRR for preterm birth (aRR 0.75; 95% CI 0.59 0.96). In the third trimester, we observed significantly higher aRRs for LBW and SGA (LBW: aRR 1.20; 95% CI 1.01 1.43; SGA: aRR 1.14; 95% CI 1.01 1.29).

Conclusions

Symptoms of nausea, vomiting or poor appetite during pregnancy are associated with LBW, SGA and preterm birth in a setting with limited resources, especially beyond the first trimester.

Trial registration

Prospectively registered at ClinicalTrials.gov on Dec 17, 2009 (NCT01034254).

An Atypical Case of a Common Pregnancy Issue: Appendicitis-Like Hyperemesis Gravidarum

Hyperemesis gravidarum (HG) is a severe subtype of nausea and vomiting in pregnancy (NVP) that typically affects women in their first trimester of pregnancy. Because HG is a diagnosis of exclusion, a thorough work-up ruling out organic causes must be performed. Herein, we describe a case of a pregnant woman with HG who presented with intractable pain mimicking appendicitis. While her clinical picture and ultrasound findings were only mildly consistent with appendicitis, the only therapy that provided pain relief was empiric antibiotic treatment that was prescribed due to a mildly elevated procalcitonin of 0.61. Thereby, the detection and treatment of concurrent organic causes is important as it may provide significant symptomatic relief in cases of concurrent HG.

Hyperemesis Gravidarum in First-Trimester Pregnant Saudi Women: Is Helicobacter pylori a Risk Factor?

Introduction

Hyperemesis gravidarum (HG) is a serious complication of pregnancy involving nausea and vomiting which affects all facets of the lives of many women. Helicobacter pylori infection has been linked to HG in some regions of the world. However, the prevalence of H. pylori in Saudi Arabian pregnant women and its link to HG has not been the subject of previous research. Detecting and treating H. pylori infection in women early in their pregnancies may lower the likelihood of adverse maternal outcomes. This study aims to assess the connection between the pathogenesis of HG and H. pylori infection in this population.

Methods

Forty-five pregnant women with HG were recruited from the outpatient clinic for antenatal care in the Gynecology and Obstetrics Department at King Abdulaziz University Hospital. Forty-five pregnant women without HG were matched as controls. Both groups underwent testing for the H. pylori antigen in stool samples.

Results

A statistically significant difference (P < 0.05) was observed between the cases and controls in terms of the occurrence of H. pylori. Thirty-eight women in the HG group (84.4%) tested positive for H. pylori, while the same was true of only 20 of the controls (44.4%). The mean level of blood hemoglobin in positive cases was significantly lower than that in negative cases (9.56 ± 1.29 vs. 11.90 ± 1.18 g/dl, P = 0.012).

Conclusion

H. pylori may play a contributing role in the presence of HG in the study population. It may be included with other investigations of HG, especially with cases that do not respond to conventional management and continue into the second trimester. Women with H. pylori were also more likely to suffer from anemia compared to those without the infection. For this reason, those working with pregnant women should pay close attention to those infected with H. pylori. Additional large case–control studies are necessary to better understand the part H. pylori plays and the pathogenesis of HG.

The Role of Microbiomes in Pregnant Women and Offspring: Research Progress of Recent Years

Pregnancy is a complicated and delicate process, the maternal body undergoes changes on hormones, immunity, and metabolism during pregnancy to support fetal development. Microbiomes in the human body mainly live in the intestine, and the human gut microbiomes are complex, which composed of more than 500 to 1500 different bacteria, archaea, fungi, and viruses. Studies have shown that these microbiomes are not only involved in the digestion and absorption of food but also indispensable in regulating host health. In recent years, there has been increasing evidence that microbiomes are important for pregnant women and fetuses. During pregnancy, there will be great changes in gut microbiomes. Regulating gut microbiomes is beneficial to the health of the mother and the fetus. In addition, many complications during pregnancy are related to gut microbiomes, such as gestational diabetes, obesity, preeclampsia, digestive disorders, and autoimmune diseases. Moreover, the microbiomes in mother's milk and vagina are closely related to the colonization of microbiomes in the early life of infants. In this review, we systematically review the role of maternal microbiomes in different gestational complications, and elucidate the function and mechanism of maternal microbiomes in the neural development and immune system of offspring. These will provide a clear knowledge framework or potential research direction for researchers in related fields.

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.

Long-term cardiovascular morbidity following hyperemesis gravidarum: A Norwegian nationwide cohort study

OBJECTIVE

To investigate whether exposure to hyperemesis gravidarum (hyperemesis) is associated with subsequent maternal cardiovascular morbidity.

DESIGN

Nationwide cohort study.

SETTING

Medical Birth Registry of Norway (1967-2002) linked to the nationwide Cardiovascular Disease in Norway project 1994-2009 (CVDNOR) and the Cause of Death Registry.

POPULATION

Women in Norway with singleton births from 1967 to 2002, with and without hyperemesis, were followed up with respect to cardiovascular outcomes from 1994 to 2009.

METHODS

Cox proportional hazards regression model was applied to estimate hazard ratios (HRs) with 95% confidence interval (CI).

MAIN OUTCOME MEASURES

The first hospitalisation due to nonfatal stroke, myocardial infarction or angina pectoris, or cardiovascular death.

RESULTS

Among 989 473 women with singleton births, 13 212 (1.3%) suffered from hyperemesis. During follow-up, a total of 43 482 (4.4%) women experienced a cardiovascular event. No association was found between hyperemesis and the risk of a fatal or nonfatal cardiovascular event (adjusted HR 1.08; 95% CI 0.99-1.18). Women with hyperemesis had higher risk of hospitalisation due to angina pectoris (adjusted HR 1.28; 95% CI 1.15-1.44). The risk of cardiovascular death was lower among hyperemetic women in age-adjusted analysis (HR 0.73; 95% CI 0.59-0.91), but the association was no longer significant when adjusting for possible confounders.

CONCLUSION

Women with a history of hyperemesis did not have increased risk of a cardiovascular event (nonfatal myocardial infarction or stroke, angina pectoris or cardiovascular death) compared to women without.

Hyperemesis Gravidarum in the context of migration: when the absence of cultural meaning gives rise to "blaming the victim"

Background

Hyperemesis gravidarum (HG) is a rare complication of pregnancy that involves persistent nausea and extreme vomiting to an intensity that differentiates HG from nausea and vomiting commonly experienced during pregnancy. Research has suggested potential biological and psychological etiological pathways for HG, but the augmented prevalence in immigrant populations, which is 4.5 times higher, remains unclear. Studies show that in order to better address the psychosocial needs of immigrant patients with HG, we must first improve our understanding of how they experience their illness. The objective of this study was to understand the meaning and experience of HG among immigrant women in Canada.

Methods

Our “qualitative comparative analysis design” involved a sample of 15 pregnant mothers following their hospitalization for HG, including 11 immigrant women and 4 Canadian-born women recruited for comparison purposes. We used the Edinburgh Perinatal Depression Scale to assess distress, and the McGill Illness Narrative Interview Schedule to explore how pregnant women understood and experienced their HG and the health services that they received.

Results

With the exception of a few women whose mothers suffered from HG, immigrant women and their loved ones did not have cultural knowledge to attribute meaning to HG symptoms. This left them vulnerable to criticism from family, as well as feelings of self-doubt, stress, and anxiety. We interpret this phenomenon as ‘victim blaming’. Immigrant women’s experience of HG was also characterised by high levels of depressive symptoms (40%) which they linked to the severity of their symptoms, high levels of stress associated with adapting to their new country, social isolation, and loss of female family members. Furthermore, in contrast to Canadian-born women, immigrant women frequently reported feeling that their symptoms were minimized by hospital emergency room medical staff, which led to delays in obtaining appropriate health care. However, once admitted to hospital, they perceived the care provided by dieticians and nurses as helpful in managing their symptoms.

Conclusions

Wider awareness of the impact of HG may improve the quality of family support for immigrant women. There is a need to improve the delays and appropriateness of clinical care.

Women's perspectives on the management and consequences of hyperemesis gravidarum - a descriptive interview study

OBJECTIVE

Hyperemesis gravidarum (HG) affects 0.3-3% of pregnant women and is a leading cause of hospitalization in early pregnancy. The aim of the study was to investigate women's treatment and management of HG, as well as the consequences of HG on women's daily life.

DESIGN AND SETTING

A cross-sectional study based on a structured telephone interview and an online questionnaire. Participants were recruited by social media and by the Norwegian patient's organization for HG.

SUBJECTS

Norwegian women that experienced HG.

MAIN OUTCOME MEASURE

Women's perspectives on management and consequences of HG.

RESULTS

The study included 107 women. Maternal morbidity was profound; about 3/4 of participants were hospitalized due to HG, and the majority showed clinical signs of dehydration (79%), ketonuria (75%), and >5% weight loss (84%). Antiemetics were used by >90% and frequently prescribed "as needed". Metoclopramide (71%) and meclozine (51%) were most commonly used. Participants described HG as having severe psychosocial consequences and profound impact on daily activities. Almost two out of five reported thoughts of elective abortion, and 8 women had at least one elective pregnancy termination due to HG. Overall, 20 women (19%) changed GPs due to dissatisfaction with HG management.

CONCLUSION

Despite the high psychosocial burden and major impact on daily activities, many women with HG reported a lack of support from healthcare professionals and suboptimal management. Greater awareness and knowledge among healthcare professionals is needed to improve care for women with HG. Key Points There is a paucity of studies on management and the consequences of HG on women's daily lives and psychosocial burden. We found that: • Many women described HG as one of their worst life experiences with profound morbidity. • Many women reported suboptimal management of HG and lack of support from healthcare professionals. • Greater understanding of patient perspectives among healthcare professionals is important to improve care and management for HG patients.

Ginger in gastrointestinal disorders: A systematic review of clinical trials

Ginger, the rhizome of Zingiber officinale, which is used as a spice globally has a long history of medicinal use that stimulates investigators to assess its potential roles as an adjuvant therapy or alternative medicine in a range of diseases. Anti-inflammatory, antioxidant, antitumor, and antiulcer effects of ginger have been proven in many scientific studies, and some of the ancient applications of ginger as a home remedy has been confirmed in human. In this review, we summarized the current evidence on the effects of ginger consumption on gastrointestinal disorders based on clinical trials. Our data indicate that divided lower daily dosage of 1500 mg ginger is beneficial for nausea relief. Because of limited number of studies on some other gastrointestinal disorders, the results may not be as much powered as to find significant results. Therefore, more extensive and well-controlled human studies of ginger or its standard extracts are required to demonstrate its efficacy as a gastroprotective agent. Dose-finding studies should be undertaken to accurately determine the effective dose and preparation of ginger in further clinical trials protocol.

Inpatient Glycemic Management of the Pregnant Patient

PURPOSE OF REVIEW

There is a rising prevalence of type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM) in pregnancy. Reaching and maintaining glycemic targets during and after this time are important for both the health of the mother and her baby.

RECENT FINDINGS

Based on recently published guidelines from various societies, we review the diagnosis of diabetes in pregnancy, types of therapies available to maintain euglycemia, important keys to management of T1DM, T2DM, and GDM, and strategies for reaching inpatient glycemic targets during the peripartum period. Care for pregnant patients with T1DM is especially challenging, and providers should be aware of the varying insulin requirements at different stages of pregnancy and how to reduce hypoglycemia and avoid diabetic ketoacidosis. Insulin sensitivity fluctuates throughout pregnancy due to physiologic changes, especially during labor and delivery and immediately post-partum. We review recommendations regarding how to manage this dynamic time and present our own institution's inpatient management protocol. Finally, we review management of diabetes post-partum, including medications, breast-feeding, and continued monitoring and screening. With the collaborative efforts of the patient and an interdisciplinary team and in-depth knowledge of the most up-to-date management principles, it is possible to achieve euglycemia during this critical time of a mother and baby's life.

Effect of Nausea and Vomiting on Anxiety and Depression Levels in Early Pregnancy

Objective

Nausea and vomiting of pregnancy (NVP) have been reported to be associated with distinct physiological responses to psychosocial stress. In this study, we aimed to evaluate the impact of nausea and vomiting on anxiety and depression during pregnancy.

Materials and Methods

Eighty-three pregnant women with nausea and vomiting and 83 healthy pregnant women were included. All participants completed the demography- and pregnancy-related questionnaire, including Rhodes Index of Nausea and Vomiting, Beck Anxiety Inventory (BAI), and Edinburgh Postnatal Depression Scale (EPDS).

Results

The median BAI and EPDS levels were 13 (min-max: 0-43) and 7 (min-max: 0-20) for the study group and 4 (min-max: 0-26) and 4 (min-max: 0-16) for control group, respectively. A univariate analysis revealed a statistically significant increase in terms of BAI levels (p<0.001) between the groups, but no significant difference was observed in terms of EPDS. In a logistic regression analysis, both anxiety (p=0.018) and depression (p=0.022) were found to be affected by NVP. The BAI levels of the NVP group correlated with the severity of NVP.

Conclusion

According to the results of the present study, women with severe NVP experienced a higher level of anxiety and depression, which necessitates an extra awareness from healthcare professionals in order to be able to contribute effectively.

A meta-analysis of the association between Helicobacter pylori (H. pylori) infection and hyperemesis gravidarum

BACKGROUND

Hyperemesis gravidarum remains a common, distressing, and significant yet poorly understood disorder during pregnancy. The association between maternal Helicobacter pylori (H. pylori) infection and hyperemesis gravidarum has been increasingly recognized and investigated. This study thus aimed to provide an updated review and meta-analysis of the topic.

METHODS

Using the search terms (H. pyloriOR Helicobacter ORHelicobacter pyloriOR infection) AND (pregnancy OR emesis OR hyperemesis gravidarum OR nausea OR vomiting), a preliminary search on the PubMed, Ovid, Web of Science, Google Scholar, and WanFang database yielded 372 papers published in English between January 1st, 1960 and June 1st, 2017.

RESULTS

A total of 38 cross-sectional and case-control studies, with a total of 10 289 patients were eligible for review. Meta-analysis revealed a significant association between H. pylori infection and hyperemesis gravidarum during pregnancy, with a pooled odds ratio of 1.348 (95% CI: 1.156-1.539, P < .001). Subgroup analysis found that serologic and stool antigen tests were comparable methods of detecting H. pylori as they yielded similar odds ratios.

LIMITATIONS

Although the studies did not have high heterogeneity (I²  = 28%), publication bias was observed, and interstudy discrepancies in the diagnostic criteria adopted for hyperemesis gravidarum limit the reliability of findings. Also, 15 of the included studies were from the same country (Turkey), which could limit the generalizability of current findings. The prevalence of H. pylori infection varies throughout the world, and there may also be pathogenic differences as most strains of H. pylori in East Asia carry the cytotoxin-associated gene A gene.

CONCLUSION

H. pylori infection was associated with an increased likelihood of hyperemesis gravidarum during pregnancy. Given the high prevalence of H. pylori infections worldwide, detecting H. pylori infection and the eradication of maternal H. pylori infection could be part of maternal hyperemesis gravidarum management. Further confirmation with robust longitudinal studies and mechanistic investigations are needed.

Ambulatory versus inpatient management of severe nausea and vomiting of pregnancy: a randomised control trial with patient preference arm

OBJECTIVE

To determine whether ambulatory (outpatient (OP)) treatment of severe nausea and vomiting of pregnancy (NVP) is as effective as inpatient (IP) care.

DESIGN

Non-blinded randomised control trial (RCT) with patient preference arm.

SETTING

Two multicentre teaching hospitals in London.

PARTICIPANTS

Women less than 20 weeks' pregnant with severe NVP and associated ketonuria (>1+).

METHODS

Women who agreed to the RCT were randomised via web-based application to either ambulatory or IP treatment. Women who declined randomisation underwent the treatment of their choice in the patient preference trial (PPT) arm. Treatment protocols, data collection and follow-up were the same for all participants.

MAIN OUTCOME MEASURES

Primary outcome was reduction in Pregnancy Unique Quantification of Emesis (PUQE) score 48 hours after starting treatment. Secondary outcome measures were duration of treatment, improvement in symptom scores and ketonuria at 48 hours, reattendances within 7 days of discharge and comparison of symptoms at 7 days postdischarge.

RESULTS

152/174 eligible women agreed to participate with 77/152 (51%) recruited to the RCT and 75/152 (49%) to the PPT.Patients were initially compared in four groups (randomised IP, randomised OP, non-randomised IP and non-randomised OP). Comprehensive cohort analysis of participants in the randomised group (RCT) and non-randomised group (PPT) did not demonstrate any differences in patient demographics or baseline clinical characteristics. Pooled analysis of IP versus OP groups showed no difference in reduction in PUQE score at 48 hours (p=0.86). There was no difference in change in eating score (p=0.69), drinking score (p=0.77), well-being rating (p=0.64) or reduction in ketonuria (p=0.47) at 48 hours, with no difference in duration of index treatment episode (p=0.83) or reattendances within 7 days (p=0.52).

CONCLUSIONS

Ambulatory management is an effective direct alternative to IP management of severe NVP. The trial also demonstrated that many women requiring treatment for severe NVP have strong preferences regarding treatment setting, which may need to be considered by care providers, especially given the psychological impact of severe NVP.

TRIAL REGISTRATION NUMBER

http://www.isrctn.com/ISRCTN24659467 (March 2014).

Hospital admission for hyperemesis gravidarum in women at increased risk of spontaneous preterm birth

BACKGROUND

Progesterone administration prevents spontaneous preterm birth (sPTB) in women at increased risk. Progesterone concentration is lower in women with subsequent sPTB. Conversely, high concentrations of progesterone are implicated in the pathogenesis of hyperemesis gravidarum (HG). We hypothesized that women at increased risk of sPTB or spontaneous late miscarriage would be less likely to have a diagnosis of HG. To explore this hypothesis, we compared the incidence of HG in women at increased risk of sPTB and women with no identifiable risk factors.

METHODS

Women at increased risk of sPTB were identified from a specialist Preterm Birth Clinic (PTBC) database where criteria for PTBC attendance are previous cervical surgery, previous sPTB <34 weeks, previous spontaneous late miscarriage, incidental sonographic cervical shortening, and uterine anomaly. Hospital antenatal booking and coding records for the same time period were examined to identify HG admissions. Women with multiple gestations, trophoblastic disease, or pre-existing abnormal thyroid function were excluded. The incidence of HG among PTBC (n=394) and non-PTBC attendees (n=4762) was calculated.

RESULTS

The incidence of HG was lower in women at increased risk of sPTB (1.52%, n=6) compared with women with no identifiable risk factor for sPTB (3.33%, n=159; P=.049).

CONCLUSION

Hospital admission for HG is reduced in women with risk factors for sPTB compared with those without risk factors. Exploration of the pathogenesis of HG may improve understanding of the mechanisms underlying sPTB.

Treatment options for hyperemesis gravidarum

Hyperemesis gravidarum (HG) is a severe and prolonged form of nausea and/or vomiting during pregnancy. HG affects 0.3-2% of pregnancies and is defined by dehydration, ketonuria, and more than 5% body weight loss. Initial pharmacologic treatment for HG includes a combination of doxylamine and pyridoxine. Additional interventions include ondansetron or dopamine antagonists such as metoclopramide or promethazine. The options are limited for women who are not adequately treated with these medications. We suggest that mirtazapine is a useful drug in this context and its efficacy has been described in case studies. Mirtazapine acts on noradrenergic, serotonergic, histaminergic, and muscarinic receptors to produce antidepressant, anxiolytic, antiemetic, sedative, and appetite-stimulating effects. Mirtazapine is not associated with an independent increased risk of birth defects. Further investigation of mirtazapine as a treatment for HG holds promise to expand treatment options for women suffering from HG.

Hyperemesis gravidarum and long-term mortality: a population-based cohort study

OBJECTIVE

To investigate whether exposure to hyperemesis gravidarum (HG) is associated with increased maternal long-term mortality.

DESIGN

Population-based cohort study.

SETTING

Medical Birth Registry of Norway (1967-2002) linked to the Cause of Death Registry.

POPULATION

Women in Norway with singleton births in the period 1967-2002, with and without HG. Women were followed until 2009 or death.

METHODS

Cox proportional hazard regression model was applied to estimate hazard ratios (HRs) with 95% confidence interval (CI).

MAIN OUTCOME MEASURES

The primary outcome was all-cause mortality during follow up. Secondary outcomes were cause-specific mortality (cardiovascular mortality, deaths due to cancer, external causes or mental and behavioural disorders).

RESULTS

Of 999 161 women with singleton births, 13 397 (1.3%) experienced HG. During a median follow up of 26 years (25 902 036 person-years), 43 470 women died (4.4%). Women exposed to HG had a lower risk of long-term all-cause mortality compared with women without HG (crude HR 0.82; 95% CI 0.75-0.90). When adjusting for confounders, this reduction was no longer significant (adjusted HR 0.92; 95% CI 0.84-1.01). Women exposed to HG had a similar risk of cardiovascular death as women not exposed (adjusted HR 1.04; 95% CI 0.83-1.29), but a lower long-term risk of death from cancer (adjusted HR 0.86; 95% CI 0.75-0.98).

CONCLUSION

In this large population-based cohort study, HG was not associated with an increased risk of long-term all-cause mortality. Women exposed to HG had no increase in mortality due to cardiovascular disease, but had a reduced risk of death from cancer.

TWEETABLE ABSTRACT

Population-based cohort study: Hyperemesis was not associated with an increased risk of long-term mortality.

Hyperemesis Gravidarum is associated with substantial economic burden in addition to severe physical and psychological suffering

Hyperemesis gravidarum (HG) affects 1 % of all pregnant women and in western societies it is the most common cause for hospital admission during first trimester. The economic burden of the disease has barely been studied. To estimate the Israeli national burden of HG, Konikoff and co-workers obtained data retrospectively on hospital costs as well as loss of workdays from 184 women hospitalized due to HG from December 2010 until December 2013. Their findings emphasise the need for better treatment to reduce the burden of this disease both for the individual as well as the society.

The Effectiveness of Ginger in the Prevention of Nausea and Vomiting during Pregnancy and Chemotherapy

The rhizomes of Zingiber officinale (ginger) have been used since ancient times as a traditional remedy for gastrointestinal complaints. The most active ingredients in ginger are the pungent principles, particularly gingerols and shogaols. Various preclinical and clinical studies have evaluated ginger as an effective and safe treatment for nausea and vomiting in the context of pregnancy and as an adjuvant treatment for chemotherapy-induced nausea and vomiting. Here, we provide an update and analysis of ginger use for the prevention of nausea and vomiting, with a focus on the types and presentations of ginger available. We also examine the pharmacokinetic properties of ginger and highlight the type and posology of ginger and its metabolites.

Barriers and Challenges in Hyperemesis Gravidarum Research

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

The Connections of Pregnancy-, Delivery-, and Infant-Related Risk Factors and Negative Life Events on Postpartum Depression and Their Role in First and Recurrent Depression

Introduction. The aim of this study is to assess how negative life events and adverse experiences with pregnancy, delivery, the infant(s), and breastfeeding cessation impact on postpartum depression (PPD), specifically in first lifetime and recurrent depression. Method. The study group comprised 104 mothers with a current episode of PPD and a control group of 104 mothers who did not have current PPD. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) was used for data collection. The course of the depression, adverse experiences, and breastfeeding were assessed by self-reports. Results. In age-adjusted multivariate analyses, mental and physical problems during pregnancy or delivery, postpartum problems with the infant and breastfeeding cessation, and negative life events during the previous 12 months were associated with postpartum depression. Eighteen percent (18%) of the mothers had first depression and 82% recurrent depression. Mental and physical problems during pregnancy or delivery were associated with both first lifetime and recurrent depression. Nevertheless, negative life events and infant/breastfeeding issues associated only with recurrent depression. Conclusion. Factors associated with pregnancy and delivery have an impact on PPD, but in recurrent depression other postnatal and psychosocial factors are also important risk factors.

Nausea in pregnancy: attitudes among pregnant women and general practitioners on treatment and pregnancy care

OBJECTIVE

Nausea and vomiting during pregnancy (NVP) is very common, and may have great impact on a woman's life. The aim of this study was to explore thoughts and attitudes among Norwegian pregnant women and GPs on treatment of NVP and pregnancy care.

DESIGN

Focus-group study.

SETTING AND SUBJECTS

Separate focus-group discussions were conducted with pregnant women and GPs.

RESULTS

Two focus-group discussions were conducted with pregnant women and two with GPs. The GPs thought it was important to normalize NVP symptoms. However, the women felt their distress due to NVP was trivialized by the GPs. The women were sceptical towards the use of medicines while pregnant, and avoidance was sought despite being ill. The GPs appeared uncertain with respect to medical treatment of NVP, which was stated to be considered only after progression to quite severe symptoms. Sick leave seemed to be an important part of the treatment regime applied by the GPs. The women had good experiences with graded sick leave.

CONCLUSION

This Norwegian study identifies attitudes among GPs and pregnant women that may act as obstacles to appropriate care for women with NVP. The pregnant women and the GPs seemed to talk at cross-purposes; GPs' normalization of the symptoms made the women feel that their distress due to NVP was trivialized by the GPs. Our results indicate that pregnant women with NVP requiring medical treatment probably need comprehensive and reassuring information about treatment options before considering using any medicines.

KEY POINTS

Nausea and vomiting during pregnancy (NVP) is very common, and considered to be of clinical significance for 35% of women. While the GPs agreed on the importance of normalizing the symptoms, the women felt their distress was trivialized, and missed being properly evaluated. Both the GPs and the women showed a reluctant attitude to medical treatment of NVP. The GPs gave the impression of considering medical treatment only after progression of symptoms to becoming quite severe.

Acute Fatty Liver of Pregnancy and its Differentiation from Other Liver Diseases in Pregnancy

Background: There are a number of threatening liver diseases that occur during pregnancy. Acute fatty liver of pregnancy is a rare disease associated with high maternal and foetal mortality. Case Report: We report on a young gravida 1 woman who presented to our level 1 perinatal centre in the 36 + 5 week of pregnancy with an isolated elevation of transaminases together with diffuse upper abdominal complaints. After comprehensive diagnostic work-up we performed an emergency delivery by Caesarean section. This was followed by interdisciplinary management. Discussion: The differentiation from other liver diseases seems not to be obvious in all cases. Here we consider the following differential diagnoses: hyperemesis gravidarum, intrahepatic gestational cholestasis, preeclampsia, HELLP syndrome. Conclusion: Rapid diagnosis and delivery as well as interdisciplinary aftercare are necessary in order to reduce maternal and foetal mortality.

Determination of metal ion contents of two antiemetic clays use in Geophagy

Nausea is usually associated with early to late stages of pregnancy. Geophagy-deliberate consumption of soil is a common method of managing gravidae-induced discomfort. To control nausea, pregnant women in Nigeria commonly eat baked clay called "Eko" and another type of clay that induces buccal constriction called "Omumu". The metal contents in Eko and Omumu, digested under different pH conditions (acidic, alkaline and neutral), were investigated using Inductively Coupled Plasma Optical Emission Spectroscopy (ICPS-OES). We identified and quantitate the elements present and speculate on their potential impact on maternal and fetal health upon gestational exposure beyond the acceptable exposure levels and the Millennium Contaminant Level Goals (MCLG) set by the United States Environmental Protection Agency (USEPA). Specifically, our result indicates unacceptably high levels of aluminum in Eko and Omumu (>10-fold greater than the highest desirable levels set by the USEPA). The aluminum concentrations were influenced by the pH condition in which the samples were digested. Dietary exposure to aluminum at such high levels may be deleterious to maternal health and fetal development. Therefore consumption of Eko and Omumu as an antidote to reduce nausea during pregnancy should be discouraged. Future studies are planned to investigate specific impacts on fetal and maternal health and likely teratogenicity in rodent models.