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Pre-emptive therapy for severe nausea and vomiting of pregnancy and hyperemesis gravidarum
Abstract
Nausea and vomiting of pregnancy (NVP) affects 80% of pregnancies. Its severe form, hyperemesis gravidarum (HG), results in dehydration, electrolyte imbalance, the need for hospitalisation and can, rarely, be fatal. This was a prospective, open-labelled, controlled, interventional study to evaluate the effectiveness of pre-emptive treatment of NVP symptoms in women who experienced severe NVP or HG in their previous pregnancy. Twenty-five women who reported severe symptoms of NVP with or without HG in their previous pregnancy were recruited and counselled to commence the use of antiemetics as soon as they became aware of the present pregnancy, and no later than the beginning of symptoms. They were followed-up prospectively through the index pregnancy for symptoms of NVP, and were counselled continuously as to how to modify antiemetic doses based on symptoms. A comparison group consisted of randomly selected women also counselled by us for NVP, who had also had severe NVP in the previous pregnancy, but who did not call before a planned pregnancy and thus could not be offered pre-emptive therapy. The recruited women commenced pre-emptive drug therapy for NVP before conception or up to 7 weeks' gestation, before the appearance of NVP symptoms in all cases. In comparison to the previous pregnancy, only eight of these 18 women experienced a HG again in the index pregnancy (P = 0.01). The majority of study the women had an improvement in severity of NVP symptoms compared to the previous pregnancy. In the comparison group (n = 35), symptoms in the index pregnancy remained severe in 28 cases (80%), decreased to moderate in six (16.6%) and decreased to mild in five cases (13.9%). There were five cases of HG in the previous pregnancy and three in the index pregnancy. The pre-emptive group was improved significantly compared to the control group (P = 0.01). Pre-emptive symptom management appears to be effective in preventing severe NVP in general, and HG in particular. Women who have experienced severe NVP in a previous pregnancy may benefit from taking antiemetics before, or immediately at the start of symptoms in a subsequent pregnancy.
... Risk factors for severe pregnancy sickness and HG include a family history of the condition (Vikanes et al 2010, Zhang et al 2011, Colodro-Conde et al 2016 and having suffered it before. The recurrence rate has been found to be anything between 15% and 81% depending on the definition of HG and study methods employed (Koren & Maltepe 2004, Trogstad et al 2005, Fejzo et al 2011, O'Hara 2013, Annagur et al 2014, Magtira et al 2015, Fiashci et al 2016. ...
... Studies which define HG purely on the basis of whether a woman had a hospital admission (Trogstad et al 2005, Annagür et al 2014, Fiashci et al 2016 find lower rates of recurrence -15%, 52% and 26% respectively -than those in which IV fluids are not a prerequisite for diagnosis. Studies which use self-reports from women about their symptoms alongside clinical information (Koren & Maltepe 2004, Fejzo et al 2011, O'Hara 2013, Magtira et al 2015 give higher recurrence rates of 68%, 81%, 80%, and 71% respectively. Where IV fluids are required as a diagnostic indicator, recurrence may be underestimated as these studies ignore cases where women may have been better managed in a second pregnancy and as such did not need to be admitted for fluids. ...
... The diagnostic criteria were chosen to reflect women's lived experience of HG. The requirement of IV fluid treatment as a diagnostic criterion was not used in the subsequent pregnancy as there is evidence that women who start treatment earlier in the next pregnancy can experience less severe symptoms of the illness (Koren & Maltepe 2004, Koren & Maltepe 2013, and may avoid hospital admission. ...
Objective: Hyperemesis gravidarum (HG) has a high recurrence rate so women are likely to suffer from it in a subsequent pregnancy. A lack of awareness in the first pregnancy can compound the condition and delay treatment. We aimed to examine how subsequent pregnancies differ and to explore what factors determine whether a woman has more or fewer hospital admissions. Design: A self-selected internet-based survey. Setting: Participants were all recruited principally through social media and UK-based. Sample: One hundred and seventy-two women who had had at least two HG pregnancies within the past ten years. Methods: Internet survey platform Survey Monkey. Main outcome measures: Questions were mostly asked using Likert-type scales with the option for additional free text responses. Results: Overall, the number of hospital admissions were lower in the later pregnancy. Women attributed this to having earlier access to antiemetics, more support with domestic duties and a reluctance to be separated from their children. Where admissions were higher, it was due to the added stress of child care and/or worse underlying symptoms, meaning women opting to be admitted as rehydration was the only thing which gave relief. Conclusions: Women are advised to start antiemetic treatment earlier in their next pregnancy and put in place sources of support to help with child care. Hospitals could improve services by providing rapid rehydration day units.
... Reported HG recurrence rates vary, from 15.2% in a Norwegian hospital registry study 8 A Canadian study 104 comparing women with NVP (PUQE score of 13 or above) who took pre-emptive antiemetics before pregnancy or before the onset of symptoms with those who did not, reported lower recurrence rate of HG in the group that took pre-emptive antiemetics. There was also a significant improvement in the PUQE score of NVP severity compared with the previous pregnancy in the pre-emptive group. ...
... Women who have experienced severe NVP in a previous pregnancy may benefit from initiating dietary and lifestyle changes and commencing antiemetics before or immediately at the start of symptoms in a subsequent pregnancy. 104 A small randomised study 105 in women with previous NVP demonstrated that pre-emptive treatment with antiemetics resulted in fewer women with moderate to severe NVP. ...
... NVP has been reported to reduce quality of life, impairing a woman's ability to function on a day-to-day basis, and negatively affects relationships with her partner and family. 81,104,[106][107][108][109][110][111][112][113][114][115][116][117] Women with HG are three to six times more likely than women with NVP to have low quality of life. 22 Persistent nausea is the symptom that most adversely affects quality of life. ...
Royal College of Obstetricians and Gynaecologists Green Top Guideline number 69 on the Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum
... Reported HG recurrence rates vary, from 15.2% in a Norwegian hospital registry study 8 A Canadian study 104 comparing women with NVP (PUQE score of 13 or above) who took pre-emptive antiemetics before pregnancy or before the onset of symptoms with those who did not, reported lower recurrence rate of HG in the group that took pre-emptive antiemetics. There was also a significant improvement in the PUQE score of NVP severity compared with the previous pregnancy in the pre-emptive group. ...
... Women who have experienced severe NVP in a previous pregnancy may benefit from initiating dietary and lifestyle changes and commencing antiemetics before or immediately at the start of symptoms in a subsequent pregnancy. 104 A small randomised study 105 in women with previous NVP demonstrated that pre-emptive treatment with antiemetics resulted in fewer women with moderate to severe NVP. ...
... NVP has been reported to reduce quality of life, impairing a woman's ability to function on a day-to-day basis, and negatively affects relationships with her partner and family. 81,104,[106][107][108][109][110][111][112][113][114][115][116][117] Women with HG are three to six times more likely than women with NVP to have low quality of life. 22 Persistent nausea is the symptom that most adversely affects quality of life. ...
https://www.pregnancysicknesssupport.org.uk/documents/HCPconferenceslides/womens-experience-2013-MOH.pdf
... Einarson et al. (1) argued that ondansetron, when used as an antiemetic during pregnancy, can cause stillbirth and birth complications such as hypospadias, duodenal atresia and pulmonary stenosis in newborn humans. Moreover, though statistically insignificant in comparison to the control groups, birth complications including spontaneous abortion with antiemetic treatment have been reported (1,9,14,38,39). On the other hand, studies also exist reporting that DMH and ondansetron used for treating hyperemesis gravidarum in humans had no effect on fetal development or adverse effects on the newborn (9,11,29,38,39). Pups born to rats in the DMH, ondansetron and control groups had normal sucking/rooting reflex, movement, color, anal and urethral openings and eye and ear opening times and none of them had any birth complications. ...
... Moreover, though statistically insignificant in comparison to the control groups, birth complications including spontaneous abortion with antiemetic treatment have been reported (1,9,14,38,39). On the other hand, studies also exist reporting that DMH and ondansetron used for treating hyperemesis gravidarum in humans had no effect on fetal development or adverse effects on the newborn (9,11,29,38,39). Pups born to rats in the DMH, ondansetron and control groups had normal sucking/rooting reflex, movement, color, anal and urethral openings and eye and ear opening times and none of them had any birth complications. ...
... Pups born to rats in the DMH, ondansetron and control groups had normal sucking/rooting reflex, movement, color, anal and urethral openings and eye and ear opening times and none of them had any birth complications. Results obtained in the present study are in agreement with the results of human studies (9,11,29,38,39). ...
Objective: To determine the effects of dimenhydrinate (DMH) and ondansetron, used as antiemetics during pregnancy, on the length of gestation, maternal weight gain during gestation and postnatal morphometric parameters of pups. Material and Methods: Thirty female Wistar albino rats were used in the study. Three groups comprising 10 rats each were studied: Group 1: control group; Group 2: DMH group; and Group 3: ondansetron group. Rats were impregnated and administered 115 mg/kg/day intramuscular, DMH group, or 10 mg/kg/day intraperitoneal, ondansetron group. The parameters pertaining to the cranium, thorax and limbs were measured between newborn and adulthood. Results: The increase in mean morphometric parameters during the postnatal period in the DMH group was less than the control group,whereas that in the ondansetron group exceeded the controls (p<0.05). Moreover, when data obtained between weeks 7 and 11 were analyzed for males and females separately, morphometric parameters increased at a slower rate in the DMH than the control group and morphometric parameters increased at a higher rate in the ondansetron than the control group in either sex (p<0.05). Conclusion: DMH and ondansetron used during gestation affect weight gain during gestation, and morphometric development of pups during newborn and lactation periods and adulthood.
... In an attempt to improve the management of NVP, in 1995 the Motherisk Program at the Hospital for Sick Children in Toronto, Ontario, initiated an NVP Counseling Helpline and developed evidence-based guidelines to optimize fluid and caloric intake, while minimizing stimuli of nausea and vomiting. In 2004 we hypothesized that the preemptive use of antiemetics in women who had experienced severe NVP in the previous pregnancy may mitigate the severe symptomatology [7] in a manner similar to other conditions, such as chemotherapy-induced nausea and vomiting, motion sickness, or cyclic vomiting [8][9][10]. We are not aware of any other published intervention study on the preemptive effects of antiemetic modalities on the course and severity of NVP. ...
... Twenty-five women per group were estimated to be necessary to identify a 40% reduction in the rate of HG with 80% power and an alpha of 0.05. The effect size of 40% was based upon the results of our previous study [7]. To account for loss to follow-up, 30 patients were randomized to each group. ...
... < 0.01). Women whose peak PUQE scores were in the severe range [13,14,19] had median WB score of 1.5/10, those with moderate PUQE scores [7][8][9][10][11][12] had median WB scores of 5/10, and those with mild symptoms (PUQE < or equal to 6) had median WB scores of 7.5/10. ...
. To determine whether the initiation of treatment (preemptive treatment) before the symptoms of nausea and vomiting of pregnancy (NVP) versus when the symptoms begin can improve the outcome in patients at a high risk for recurrence of severe NVP. . Prospective, randomized controlled trial. . Preemptive therapy conferred a significant reduction in HG as compared to the previous pregnancy ( = 0.047). In the preemptive arm, there were 2.5-fold fewer cases of moderate-severe cases of NVP than those in the control group (15.4% versus 39.13%) in the first 3 weeks of NVP ( = 0.05). In the preemptive group, significantly more women had their NVP resolved before giving birth (78.2% versus 50%) ( < 0.002). . Preemptive treatment with antiemetics is superior to the treatment that starts only when the symptoms have already occurred in decreasing the risk of severe forms of NVP.
... [2,3] The frequency of hyperemesis gravidum is between 0.3% and 10% in pregnancies. [4,5] If not treated, serious complications may arise in mother due to severe emesis such as dehydration, disorder in electrolyte-fluid balance, significant loss of weight, Wernicke's encephalopathy, renal failure, hepatic function disorder and secondary depressions. [3,4,6] Doxylamine, pyridoxine, antihistamines, H1 receptor blockers and phenothiazines are all reliable and effective drugs for slight, mild and severe nausea and emesis during pregnancy. ...
... The pregnant women hospitalized in the clinic for pregnancy nausea-emesis and HG were had rehydration treatment by 0.9% NaCl and 10% dextrose solution. [3,5,6,9] Vitamin complex (Bemiks C) was applied by intravenous administration once a day. Dimenhydrinate and metoclopramide were used in the treatment since they are widely used in the treatment of nausea and emesis during pregnancy, [1,3] reliable, [2,4] effective, [7] cost-efficient and easily accessible. ...
... This is likely to result in improved quality of life and maternal health, as well as better family relationships. 16,22 In Nigeria with unacceptably high maternal morbidity and mortality rates, PCPs are mainly involved in the management of pregnancyrelated problems of the first trimester, it is therefore imperative that they have access to evidence-based guidelines on management of NVP care during early pregnancy. There is however no clinical guideline on nausea and vomiting management in primary care setting and thus a dearth of studies on Knowledge, Attitude and Practice (KAP) of PCPs regarding management of NVP in our locality and in Nigeria, hence reason for our study. ...
... 27 An opinion that medical treatment of NVP should only be considered with severe symptom should not be, since treatment of early symptoms is thought to reduce the risk of progression to severe symptoms, as well as reduces the risk of hospitalization. 20,22 The attitude shown by respondents in this study might be due to concerns on the safety of use of medications during pregnancy. Historically, clinicians have shown reluctance to prescribing medications to pregnant women due to concerns of teratogenicity. ...
Background
Nigeria has one of the highest maternal morbidity and mortality rates in the world. A strategic approach to reverse this trend is timely recognition and prompt treatment of pregnancy related diseases at primary care levels. This study assessed the knowledge, attitude and treatment practices of primary care providers (PCPs) on Nausea and Vomiting of Pregnancy (NVP) at primary care settings in Osun State, south-west Nigeria.
Study design
The study employed a descriptive cross-sectional design and two-stage sampling technique. Assessment of the study outcomes (level of knowledge, attitude and practice) was done using a validated questionnaire and were categorized based on performance scores. Data was collected using a pre-tested questionnaire to elicit information on socio-demographic characteristics, level of knowledge of NVP, attitudes on roles and specific tasks in caring for NVP and practices in the management of NVP. The data collected was analyzed using descriptive and inferential statistics. Bivariate analysis comprised Chi-square test on association between level of knowledge of NVP and job cadres while correlation test assessed strength of relationship between level of knowledge of NVP and years of experience. Analytical statistics considered a p < 0.05 to be statistically significant.
Results
Of the 250 PCPs enrolled into the study, only 1.2% demonstrated good knowledge of NVP and its recommended management modalities. There was a statistically significant association between the level of knowledge of PCPs and job cadres (χ² = 2.840, p = 0.039) while correlation showed a statistically positive relationship between level of knowledge and years of experience (r = 0.272, p = 0.001). Less than half [22 (8.8%)], [47 (18.8%)] and [3 (1.2%)] of the nurses, community workers and doctors respectively agreed NVP is a purely natural phenomenon and requires no treatment, while more than half [36 (14.4%)] of the health assistants agreed that NVP is natural and requires no treatment. Almost all the respondents had recommended pharmacological measures for the treatment of NVP during their professional practice and encountered complications with their use.
Conclusion
The level of knowledge of NVP and its management was very low among the PCPs. An educational tool aimed at bridging the knowledge gap may lead to improved care.
... [2,9] Furthermore, vitamin B6 has been known to possess antiemetic effects since 1942. [34][35][36][37][38][39] Hypotheses to describe the antiemetic effects of pyridoxine include prevention/treatment of vitamin B6 deficiency, intrinsic antinausea properties, and/or augmentation the antinausea properties of antihistamines. [34][35][36][37][38][39] Although, our study had some limitation; we did not evaluate either the dose-response or the effect of continuation of therapy on the chronic pain due to the difficulty of patients' follow-ups, and also single sex population might be another limitation of this study. ...
... [34][35][36][37][38][39] Hypotheses to describe the antiemetic effects of pyridoxine include prevention/treatment of vitamin B6 deficiency, intrinsic antinausea properties, and/or augmentation the antinausea properties of antihistamines. [34][35][36][37][38][39] Although, our study had some limitation; we did not evaluate either the dose-response or the effect of continuation of therapy on the chronic pain due to the difficulty of patients' follow-ups, and also single sex population might be another limitation of this study. Anyway, good pain control after surgery is important to prevent negative outcomes such as persistent postsurgical pain. ...
Background
Development of new multimodal analgesic regimens have led to substantial improvement in postoperative pain relief. We designed this study to compare the effect of combined vitamin B complex—gabapentin versus gabapentin alone on postoperative pain in women undergoing cesarean section under spinal anesthesia.
Methods
One hundred twenty-eight women who underwent cesarean section under spinal anesthesia were randomized to receive orally 300 mg gabapentin (group G) or 300 mg of gabapentin plus 2 vitamin B complex (group GB) tablets 30 minutes before surgery. Postoperative pain intensity and total analgesic consumption during 12 hours after surgery, vomiting, and drowsiness during recovery were assessed.
Results
The pain intensity in the gabapentin plus vitamin B complex group was lower than gabapentin group during 12 hours after surgery (95% CI: 1.4–2.2; P < .001). Meanwhile, the total analgesic consumption in this group was less than gabapentin alone (95% CI: 1.07–1.24; P = 0.034). The incidence of vomiting in patients who receive combined gabapentin—vitamin B complex group was similar to gabapentin alone (P = .206). The difference of the distribution of the relative frequency of sedation according to Ramsay sedation scores in patients between 2 groups were insignificant (P = .82). All newborns in our study were free of any adverse effects.
Conclusion
Addition of vitamin B complex to gabapentin reduced intensity of postoperative pain and also the total amount of analgesic consumption within the first 12 hours postoperative following cesarean section.
... [2,3] The frequency of hyperemesis gravidum is between 0.3% and 10% in pregnancies. [4,5] If not treated, serious complications may arise in mother due to severe emesis such as dehydration, disorder in electrolyte-fluid balance, significant loss of weight, Wernicke's encephalopathy, renal failure, hepatic function disorder and secondary depressions. [3,4,6] Doxylamine, pyridoxine, antihistamines, H1 receptor blockers and phenothiazines are all reliable and effective drugs for slight, mild and severe nausea and emesis during pregnancy. ...
... The pregnant women hospitalized in the clinic for pregnancy nausea-emesis and HG were had rehydration treatment by 0.9% NaCl and 10% dextrose solution. [3,5,6,9] Vitamin complex (Bemiks C) was applied by intravenous administration once a day. Dimenhydrinate and metoclopramide were used in the treatment since they are widely used in the treatment of nausea and emesis during pregnancy, [1,3] reliable, [2,4] effective, [7] cost-efficient and easily accessible. ...
Objective
Metoclopramide and dimenhydrinate are used commonly in the treatment of nausea-emesis and hyperemesis gravidarum during the first trimester.
Methods
This retrospective study included 233 pregnant women who were diagnosed as hyperemesis gravidarum during first trimester between July 4, 2005 and May 27, 2009 at the Clinic of Obstetrics and Gynecology, Simav State Hospital (Simav, Kütahya, Turkey). The pregnant women were separated into groups according to their metoclopramide or dimenhydrinate use. The pregnant women included in the study were chosen from the pregnant women who were healthy and had singleton pregnancy.
Results
While 113 pregnant women were treated by metoclopramide and 120 pregnant women by dimenhydrinate. Spontaneous abortion was found as 6.2% in the pregnant women who used metoclopramide and as 4.2% who used dimenhydrinate, and stillbirth rate was 1.8 and 0.8%, respectively. Low birth weight rates were 8.0% in metoclopramide group and 5.8% in dimenhydrinate group, and preterm labor rates were 5.3% and 5.0%, respectively.
Conclusion
We have found that there was no difference between the pregnant women who used metoclopramide and dimenhydrinate in terms of early period complications and perinatal outcomes.
Keywords
Nausea, emesis, pregnancy, first trimester.
... Pre-emptive treatment Some women say they are less likely to want another pregnancy because of the severe NVP they suffered previously; 1 some women ask healthcare professionals if anything can be done to ensure that they do not have to endure similar symptoms in their next pregnancy. In a recent study, 26 25 women who had a history of severe NVP with or without hyperemesis gravidarum were offered anti-emetic therapy either as soon as they became aware of the present pregnancy or no later than the beginning of NVP symptoms. A control group of 35 women with similar histories of NVP did not receive pre-emptive treatment. ...
... For women who have had severe NVP or hyperemesis gravidarum in a previous pregnancy, pre-emptive treatment with safe and effective medication started as soon as NVP develops has been shown in one study 26 to reduce the risk of developing severe symptoms in the current pregnancy. In reducing the incidence of hyperemesis gravidarum, a most unpleasant and medically significant condition, pre-emptive treatment could reduce hospital admissions and hence costs to the National Health Service. ...
... Common symptoms of discomfort during the first trimester are nausea, vomiting [4,10], dizziness [10], frequent urination, fatigue [4], breast tenderness, heavy vaginal discharge, and mood swings [11]. Approximately 50-80% of pregnant women experience nausea and vomiting, which are the two most common symptoms, during the first trimester [12,13]. The exact mechanism underlying nausea and vomiting in pregnancy remains unknown. ...
... This study presents that 98.3% of the participants feel fatigue, which is similar to the findings (approximately 90%) reported by Rodriguez et al. [33] and Chou et al. [34]. This study shows that the incidence of nausea and vomiting is 88.09% and 65.11% respectively, which is similar to the findings (50-80%) of Koren and Maltepe [12] and of Koch et al. [13]. ...
The purpose of this study was to explore correlations among constitution, stress, and discomfort symptoms during the first
trimester of pregnancy. We adopted a descriptive and correlational research design and collected data from 261 pregnant women during their first trimester in southern Taiwan using structured questionnaires. Results showed that (1) stress was significantly and positively correlated with Yang-Xu, Yin-Xu, and Tan-Shi-Yu-Zhi constitutions, respectively; (2) Yin-Xu and Tan-Shi-Yu-Zhi constitutions had significant correlations with all symptoms of discomfort, while Yang-Xu had significant correlations with all symptoms of discomfort except for “running nose”; (3) Tan-Shi-Yu-Zhi constitution and stress were two indicators for “fatigue”; Tan-Shi-Yu-Zhi was the indicator for “nausea”; Yang-Xu and Yin-Xu were indicators for “frequent urination.” Our findings also indicate that stress level affects constitutional changes and that stress and constitutional change affect the incidence of discomfort. This research can help healthcare professionals observe these discomforts and provide individualized care for pregnant women, to nurture pregnant women into neutral-type constitution, minimize their levels of discomfort, and promote the health of the fetus and the mother.
... Other treatment aspects of interest, but out of scope for this study, include the impact of adequate antiemetic treatment on symptoms and maternal weight gain and are of interest for future studies on the efficacy of medications in the treatment of HG. For example, there is some evidence showing that starting antiemetic treatments early in pregnancy can reduce the overall severity of HG, which might have a beneficial effect on neonatal outcomes as well (48,49) . ...
The present study aimed to investigate the association between hyperemesis gravidarum (HG) severity and the effect of early enteral tube feeding on cardiometabolic markers in offspring cord blood. We included women admitted for HG, who participated in the MOTHER randomized controlled trial (RCT) and observational cohort. The MOTHER RCT showed that early enteral tube feeding in addition to standard care did not affect symptoms or birth outcomes. Among RCT and cohort participants, we assessed how HG severity affected lipid, c-peptide, glucose and free thyroxine cord blood levels. HG severity measures were: severity of vomiting at inclusion and three weeks after inclusion, pregnancy weight gain and 24-hour energy intake at inclusion, readmissions and duration of hospital admissions. Cord blood measures were also compared between RCT participants allocated to enteral tube feeding and those receiving standard care. Between 2013-2016, 215 women were included: 115 RCT and 100 cohort participants. Eighty-one cord blood samples were available. Univariable, not multivariable regression analysis showed that lower maternal weight gain was associated with higher cord blood glucose levels ( β :−0.08, 95% CI:−0.16;-0.00). Lower maternal weight gain was associated with higher apolipoprotein-B cord blood levels in multivariable regression analysis ( β :−0.01, 95% CI:−0.02;−0.01). No associations were found between other HG severity measures or allocation to enteral tube feeding and cord blood cardiometabolic markers. In conclusion, while lower maternal weight gain was associated with higher apolipoprotein-B cord blood levels, no other HG severity measures were linked with cord blood cardiometabolic markers, nor were these markers affected by enteral tube feeding.
... Higher doses have been studied, but they do not improve NVP and were associated with a higher hospitalization rates for rehydration (110). Preemptive antinausea medication has been reported to be more efficacious than therapy after symptoms of NVP (111). Other antihistamines such as dimenhydramine, diphenhydramine, and meclizine are considered as either replacement or additive for doxylamine. ...
... 6,7 Furthermore, there is evidence suggesting that early treatment and lifestyle preparation strategies may reduce the overall severity of the condition. 8,9 For such interventions to be appropriately implemented, the recurrence rate must be understood. 6 Both overestimating and underestimating the recurrence rate can have substantial impacts on people's lives. ...
Introduction:
Hyperemesis gravidarum (HG) complicates 1% of pregnancies and has a major impact on maternal quality of life and wellbeing. We know very little about HG's long-term impact after an affected pregnancy, including recurrence rates in future pregnancies, which is essential information for women considering subsequent pregnancies. In this study, we aimed to prospectively measure the recurrence rate of HG and the number of postponed and terminated subsequent pregnancies due to HG. We also aimed to evaluate if there were predictive factors that could identify women at increased risk for HG recurrence, postponing and terminating subsequent pregnancies.
Material and methods:
We conducted a prospective cohort study. A total of 215 women admitted for HG to public hospitals in the Netherlands were enrolled in the original MOTHER randomized controlled trial and associated observational cohort. Seventy-three women were included in this follow-up study. Data were collected via an online questionnaire. Recurrent HG was defined as vomiting symptoms accompanied by any of the following: multiple medication use, weight loss, admission, tube feeding or if nausea and vomiting symptoms were severe enough to affect life and/or work. Outcome measures were recurrence, postponing and termination rates due to HG. Univariable logistic regression analysis was used to identify predictive factors associated with HG recurrence, postponing and terminating subsequent pregnancies.
Results:
Thirty-five women (48%) became pregnant again of whom 40% had postponed their pregnancy due to HG. HG recurred in 89% of pregnancies. One woman terminated and eight women (23%) considered terminating their pregnancy because of recurrent HG. Twenty-four out of 38 women did not get pregnant again because of HG in the past. Univariable logistic regression analysis identifying possible predictive factors found that having a western background was associated with having weight loss due to recurrent HG in subsequent pregnancies (OR 12.9, 95% CI: 1.3-130.5, P=0.03).
Conclusions:
High rates of HG recurrence and a high number of postponed pregnancies due to HG were observed. Women can be informed of a high chance of recurrence to enable informed family planning.
... We excluded 12 studies because they collected retrospective data rather than supplying prospective information to calculate a recurrence rate [19][20][21][24][25][26][27][28][29][30][31][32]. One reference was an abstract for an already excluded study [33]. ...
Objective:
We aimed to identify determinants that predict hyperemesis gravidarum (HG) disease course and severity.
Study design:
For this study, we combined data of the Maternal and Offspring outcomes after Treatment of HyperEmesis by Refeeding (MOTHER) randomized controlled trial (RCT) and its associated observational cohort with non-randomised patients. Between October 2013 and March 2016, in 19 hospitals in the Netherlands, women hospitalised for HG were approached for study participation. In total, 215 pregnant women provided consent for participation. We excluded women enrolled during a readmission (n = 24). Determinants were defined as patient characteristics and clinical features, available to clinicians at first hospital admission. Patient characteristics included i.e. age, ethnicity, socio-economic status, history of mental health disease and HG and gravidity. Clinical features included weight loss compared to pre-pregnancy weight and symptom severity measured with Pregnancy Unique Quantification of Emesis (PUQE-24) questionnaire and the Nausea and Vomiting in Pregnancy specific Quality of Life questionnaire (NVPQoL). Outcome measures were measures of HG disease severity present at 1 week after hospital admission, including weight change, PUQE-24 and NVPQoL scores. Total days of admission hospital admission and readmission were also considered outcome measures.
Results:
We found that high PUQE-24 and NVPQoL scores at hospital admission were associated with those 1 week after hospital admission (difference (β) 0.36, 95 %CI 0.16 to 0.57 and 0.70,95 %CI 0.45-1.1). PUQE-24 and NVPQoL scores were not associated with other outcome measures. None of the patient characteristics were associated with any of the outcome measures.
Conclusion:
Our findings suggest that the PUQE-24 and NVPQoL questionnaires can identify women that maintain high symptom scores a week after admission, but that patient characteristics cannot be used as determinants of HG disease course and severity.
... We excluded 12 studies because they collected retrospective data rather than supplying prospective information to calculate a recurrence rate [19][20][21][24][25][26][27][28][29][30][31][32]. One reference was an abstract for an already excluded study [33]. ...
Around 1 % of pregnancies develop Hyperemesis Gravidarum (HG), causing high physical and psychological morbidity. Reports on HG recurrence rate in subsequent pregnancies vary widely. An accurate rate of recurrence is needed for informed reproductive decision making. Our objective is to systematically review and aggregate reported rates for HG subsequent to index pregnancies affected by HG. We searched databases from inception as per the protocol registered on PROSPERO. No language restrictions were applied. Inclusion was not restricted based on how HG was defined; reports of severe NVP were included where authors defined the condition as HG. We included descriptive epidemiological, case control and cohort study designs. Eligibility screening was performed in duplo. We extracted data on populations, study methods and outcomes of significance. A panel of patients reviewed the results and provided discussion and feedback. Quality was assessed with the JBI (2017) critical appraisal tool independently by two reviewers. We performed the searches on 1st November 2019. Our search yielded 4454 unique studies, of which five (n = 40,350 HG cases) matched eligibility criteria; One longitudinal and four population-based cohort studies from five countries. Follow-up ranged from 2 to 31 years. Definition of HG and data collection methods in all the studies created heterogeneity. Quality was low; studies lacked valid and reliable exposure, and/or follow-up was insufficient. Meta-analysis was not possible due to clinical and statistical heterogeneity. This systematic review found five heterogeneous studies reporting recurrence rates from 15 to 81%. Defining HG as hospital cases may have introduced detection bias and contribute to clinical heterogeneity. A prospective longitudinal cohort study using an internationally agreed definition of HG and outcomes meaningful to patients is required to establish the true recurrence rate of HG.
... Nevertheless, prevention of HG in women who experienced HG in their previous pregnancies might be plausible. For example, a small (n = 60) open label randomized controlled trial (RCT) in women with a history of severe NVP or HG showed that pre emptive combination of doxylamine (an antihistamine) and pyri doxine (vitamin B6) taken from the time of a positive pregnancy test led to fewer instances of substantial nau sea or vomi ting in early pregnancy compared with treat ment following initial manifestation of nausea symptoms (15% versus 39%); the pre emptive treatment was also associated with a smaller likelihood of recurrent HG in subsequent pregnancies (32% versus 55%) 138 . Due to its small size, lack of extensive baseline characteristics reported, open label nature and lack of pre published protocol, the findings of this study should be interpreted with caution, but the study provides an incentive for further investigation of pre emptive strategies. ...
Nausea and vomiting of pregnancy (NVP) is a common condition that affects as many as 70% of pregnant women. Although no consensus definition is available for hyperemesis gravidarum (HG), it is typically viewed as the severe form of NVP and has been reported to occur in 0.3-10.8% of pregnant women. HG can be associated with poor maternal, fetal and child outcomes. The majority of women with NVP can be managed with dietary and lifestyle changes, but more than one-third of patients experience clinically relevant symptoms that may require fluid and vitamin supplementation and/or antiemetic therapy such as, for example, combined doxylamine/pyridoxine, which is not teratogenic and may be effective in treating NVP. Ondansetron is commonly used to treat HG, but studies are urgently needed to determine whether it is safer and more effective than using first-line antiemetics. Thiamine (vitamin B1) should be introduced following protocols to prevent refeeding syndrome and Wernicke encephalopathy. Recent advances in the genetic study of NVP and HG suggest a placental component to the aetiology by implicating common variants in genes encoding placental proteins (namely GDF15 and IGFBP7) and hormone receptors (namely GFRAL and PGR). New studies on aetiology, diagnosis, management and treatment are under way. In the next decade, progress in these areas may improve maternal quality of life and limit the adverse outcomes associated with HG.
... Knowing this provides women with an opportunity to plan their care and treatment in advance with their doctor, which may help to reduce the overall severity and burden of the condition. 75 Box 4 outlines elements of a pre-pregnancy care plan. 78 Some evidence indicates that pre-emptive medication, started before the onset of symptoms, may reduce the duration and severity of symptoms in subsequent pregnancies. ...
... Nausea and vomiting of pregnancy (NVP) affects up to 85 per cent of pregnant women 1,2 and its severe end, hyperemesis gravidarum (HG), affecting up to 2 per cent of pregnant women 2 is typically associated with weight loss greater than 5 per cent of pre-pregnancy weight, dehydration, electrolyte imbalances, need for hospitalization and nutritional deficiencies. [1][2][3][4][5][6] Studies in children born in areas of famine in Netherland and China reveal long term adverse effects on foetal brain neurodevelopment, 7,8 raising concerns that children exposed in utero to HG may also be adversely impacted due to prolonged deficiencies of nutrients essential for brain development. ...
Background
Pregnancy outcome following hyperemesis gravidarum (HG) has been sparsely reported. This review article aims at critically reviewing the first prospective study of foetal long-term neurodevelopment after maternal HG.
Aims
This review aimed at critically appraising the first prospective human study that aimed at investigating long term child neurodevelopment after exposure to maternal HG.
Methods
In this study, women with nausea and vomiting of pregnancy treated with doxylamine–pyridoxine (Diclectin) or with no pharmacotherapy were prospectively recruited. Their children (ages 3 6/12 to 6 11/12 years) were assessed for development using standardized psychological tests. The study cohort was divided into 2 groups: 1) severe NVP necessitating hospitalization of the woman for rehydration and electrolyte corrections (n=22) and 2) all other cases of nausea and vomiting of pregnancy (n=197).
Results
Children of hospitalized mothers achieved significantly lower IQ scores than the rest of the children on verbal, performance and full scale IQ. In multivariable linear regression duration of hospitalization, maternal depression and maternal IQ were significant predictors for these outcomes.
Conclusion
This first prospective human study documented that HG is associated with an increased risk for lower cognitive outcome among HG- exposed offspring. More research is needed to examine whether early use of anti-emetics may prevent hospitalization, leading to favourable child neurodevelopment.
... Our participants' opinion is at odds with the findings from the first RCT into the potential benefits of early nasogastric tube feeding, which demonstrated no benefit in an unselected population of women admitted to hospital for HG [16]. As regards other early medical interventions, there is some support for the notion of a preemptive approach to HG: a small study among women with a history of severe NVP and HG demonstrated significantly less severe symptoms in the subsequent pregnancy among women who had been randomly assigned to preemptive Diclectin compared to those assigned to commencing medication after symptoms developed [17,18]. ...
Introduction:
Hyperemesis gravidarum (HG) medical therapies are currently of limited effect, which creates a larger role for patient preferences in the way HG care is arranged. This is the first study using in-depth interviews to investigate patients' preferences and experiences of HG treatment.
Materials and methods:
We conducted individual in-depth interviews among women who had been hospitalized for HG in North Holland at least once in the past 4 years. We asked them about their experiences, preferences, and suggestions for improvement regarding the HG treatment they received. The sample size was determined by reaching data saturation. Themes were identified from analysis of the interview transcripts.
Results and discussion:
13 women were interviewed. Interviewees emphasized the importance of early recognition of the severity of HG, increasing caregivers' knowledge on HG, early medical intervention, and nasogastric tube feeding. They valued a single room in hospital, discussion of treatment options, more possibilities of home-treatment, psychological support during HG and after childbirth, and more uniform information and policies regarding HG treatment.
Conclusion:
Further research is needed to establish whether the suggestions can lead to more (cost) effective care and improve the course of HG and outcomes for HG patients and their children.
... While there has been some research looking at the early, pre-emptive use of medication at reducing severity of symptoms in subsequent pregnancies (Koren & Maltepe 2004, Koren & Maltepe 2013, to date there has not been any research looking at the impact of early aggressive treatment on hospital admission rates. However, there are authors who propose this to be the case and the Green-top guidelines now advocate for early intervention in the community for cases of NVP (Dean 2014, RCOG 2016. ...
... The second trial [15] with larger population and adequate settings revealed it to be efficacious in both mild and moderate forms of NVPs. Systematic reviews of randomized and/or control trials reveals pyridoxine improves mild to moderate nausea with little effect on vomiting [1,16]. Hence, used in combination with other antiemetics in the treatment of Hyperemesis Gravidarum. ...
Nausea and vomiting are common symptoms experienced by 50– 90% of women’s in early pregnancy. ‘Morning sickness’ is a misnomer frequently used to describe nausea and vomiting in pregnancy (NVP), although the symptoms may persist the whole day and/or night. Pregnant women experience these symptoms mainly in the first trimester between 6 and 12 weeks of gestation, few of them continue till 20 weeks of gestation while in few others it continues throughout the pregnancy. The problem peaks at 9-week gestation, and approximately 60% of NVPs resolve by the end of first trimester. In a very small minority of these patients, the symptoms become severe leading to dehydration, weight loss, excessive vomiting, and mandate hospital admission; this condition is known as Hyperemesis Gravidarum.
Fairweather D.V proposed the most widely used definition of Hyperemesis Gravidarum (HG). He defined HG based on the symptoms, vomiting exceeding three times a day with significant ketonurea or weight loss more than or equal to 5% of pre pregnancy weight, electrolytic imbalance or fluid depletion, and onset occurs at 4 to 8 weeks of pregnancy till 14 to 16 weeks. Nausea and vomiting in pregnancy is of multifarious etiology (fluctuating levels of progesterone, estrogens, Thyroid Stimulating Hormone (TSH), slow peristaltic movement of Gastrointestinal (GI) tract); however, the exact mechanism remains still unclear.
Given the uncertainty in treatment of NVPs, both patients and healthcare practitioners often fear the use of antiemetic medications in pregnancy due to the potential risk to fetus and mother. The manifestation of nausea and vomiting in pregnancy is different among each woman, so its management should be tailored similarly. An early treatment of nausea and vomiting is important and beneficial since it prevents a more severe form of occurring, or a possible hospitalization, and prevents both emotional and psychological problems. It is very important for the women and the healthcare providers to understand that a safe and effective NVP treatment benefits both fetus and mother, thus all the treatment options should be open and considered.
Nonetheless, given the widespread prevalence of nausea and vomiting, its adverse effects and effects on psychological conditions of pregnant women, it is necessary to be treated effectively and safely during embryonic and fetal developmental stages. First trimester exposure is important to be assessed to monitor the teratogenic potential of the drug; however, randomized control trials are rarely conducted for pregnant women for ethical reasons. Whereas the epidemiological studies done are observational and lack population strength to establish safety and risk involved. This review will mainly focus on pharmacological drugs used in treatment of NVP, and explore their safety and efficacy and evidence based practice. There have been many studies examining the safety of drugs used in NVPs and few of them are covered in this review. The dietary, lifestyle modifications, and nonpharmacological approaches are not covered in this section.
... Women who have had NVP in a previous pregnancy are more likely to have recurrence of NVP in subsequent pregnancies with the severity of NVP typically increasing in subsequent pregnancies. A 2004 study demonstrated that initiating any antiemetic treatment prior to or on first day of symptoms effectively lessened the severity of symptoms and reduced the recurrence of HG in women who experienced NVP in a previous pregnancy [6]. Because of the high recurrence rate of NVP symptoms (75-85 %), it is important for women to receive early treatment to reduce the severity of symptoms, with the aim of preventing the need for hospitalization and improving quality of life [3]. ...
Nausea and vomiting of pregnancy (NVP) affects up to 85 % of all pregnancies. Effective treatment can greatly improve a woman's quality of life, reduce the risk for maternal and fetal complications, and reduce healthcare costs. Unfortunately, many women receive either no pharmacological treatment or are recommended therapies for which fetal safety and efficacy have not been established. First-line treatment of NVP, as recommended by several leading healthcare and professional organizations, is the combination of doxylamine and pyridoxine. This combination, formulated as a 10 mg/10 mg delayed-release tablet, was approved by the US Food and Drug Administration (FDA) for the treatment of NVP in April 2013 under the brand name Diclegis(®), and has been on the Canadian market since 1979, currently under the brand name Diclectin(®). The efficacy of Diclegis(®)/Diclectin(®) has been demonstrated in several clinical trials, and, more importantly, studies on more than 200,000 women exposed to doxylamine and pyridoxine in the first trimester of pregnancy have demonstrated no increased fetal risk for congenital malformations and other adverse pregnancy outcomes. The present review aims to present the scientific evidence on the effectiveness and fetal safety of Diclegis(®)/Diclectin(®) for the treatment of NVP to justify its use as first-line treatment for NVP.
... 40 The effectiveness and safety of Diclectin have been documented in a large number of studies. [44][45][46] The pharmacokinetics of Diclectin was compared between pregnant and nonpregnant women and no difference was found in the apparent clearances of doxylamine and pyridoxal 5'-phosphate (the active metabolite of vitamin B 6 ) between the two groups. Therefore, the scientists concluded that there was no pregnancy-induced effect in the apparent clearances of either doxylamine or pyridoxal 5'-phosphate in women during the first trimester of pregnancy, despite the existence of nausea and vomiting. ...
Nausea and vomiting in pregnancy can have serious adverse effects on the quality of a woman's life, affecting her occupational, social, and domestic functioning, and her general well-being; therefore, it is very important to treat this condition appropriately and effectively. Evidence-based algorithms support the use of oral pyridoxine alone or combined with doxylamine as first-line treatment. Promethazine or dimenhydrinate, known as a second-line treatment, should be added to the first-line treatment or should be added only to pyridoxine according to different algorithms. In most of the world, there is a lack of approved medicines using this combination approach known as the first-line treatment. Therefore, compounding pharmacists should supply the demand by compounding 10-mg pyridoxine hydrochloride and 10-mg doxylamine succinate slow-release capsules. Since transdermal promethazine does not exist world wide, and, since this medicine has significant added values compared to the oral/rectal dosage forms, compounding pharmacists should offer physicians transdermal promethazine as a second-line therapy in nausea and vomiting in pregnancy. This review summarizes the nausea and vomiting in pregnancy problems and discusses the compounding opportunities that exist in this common and wide-spread pathology in order to improve a woman's quality of life.
... 21 In another example, a 2004 study showed the benefits of pre-emptive therapy in women who had previously experienced severe NVP. 22 While this was not an RCT, this study may assist health care providers in designing a treatment plan. ...
With 80% of pregnant women suffering from some degree of "morning sickness," or nausea and vomiting of pregnancy (NVP), symptom management is a major challenge. A recent Cochrane systematic review of randomized controlled trials concluded that, to date, there is no strong evidence of effectiveness for practically any therapeutic agent used for management of NVP. Because of fears of teratogenicity and litigation, RCTs are rarely conducted in pregnancy. In the absence of the best possible evidence from RCTs, well planned and executed prospective observational studies should be used as the best available evidence to guide clinical practice.
ABSTRAK: Kehamilan merupakan pertumbuhan dan perkembangan janin intrauterin mulai sejak konsepsi dan berakhir sampai permulaan persalinan. Kehamilan menimbulkan perubahan-perubahan fisiologi yang terjadi di seluruh sistem organ, sebagian besar perubahan pada tubuh ibu kebanyakan disebabkan oleh kerja hormonal. Perubahan yang terjadi pada ibu hamil dapat menimbulkan ketidaknyamanan dalam kehamilan, salah satunya adalah mual muntah. Berdasarkan hasil penelitian 50-90% wanita hamil mengalami mual pada trimester pertama. Penanganan mual muntah selama masa kehamilan dapat dilakukan melalui tindakan farmakologi maupun non farmakologi. Salah satu terapi non farmakologi yaitu dengan aromaterapi Jahe. Tujuan penelitian ini adalah untuk mengetahui Pengaruh pemberian Aromatherapi Jahe Terhadap Mual Muntah Pada Ibu Hamil Trimester I. Desain penelitan quasy experiment, dengan jenis rancangan pre -post test control group design. Penelitian ini dilakukan di Wilayah Kerja Puskesmas Purbaratu Kota Tasikmalaya Tahun 2019. Sampel dipilih secara purposive sampling dan didapatkan jumlah sampel 36 responden. Hasil penelitian Sebagian besar responden tidak mengalami mual muntah setelah diberikan aromaterapi jahe yaitu sebanyak 12 orang (66.7%) dan hasil uji Mann Whitney bahwa pada kelompok perlakuan diperoleh nilai p<0,05 dengan demikian terdapat pengaruh pemberian aromaterapi jahe terhadap mual muntah pada ibu hamil trimester I di Wilayah Kerja Puskesmas Purbaratu Kota Tasikmalaya. ABSTRAK: Kehamilan merupakan pertumbuhan dan perkembangan janin intrauterin mulai sejak konsepsi dan berakhir sampai permulaan persalinan. Kehamilan menimbulkan perubahan-perubahan fisiologi yang terjadi di seluruh sistem organ, sebagian besar perubahan pada tubuh ibu kebanyakan disebabkan oleh kerja hormonal. Perubahan yang terjadi pada ibu hamil dapat menimbulkan ketidaknyamanan dalam kehamilan, salah satunya adalah mual muntah. Berdasarkan hasil penelitian 50-90% wanita hamil mengalami mual pada trimester pertama. Penanganan mual muntah selama masa kehamilan dapat dilakukan melalui tindakan farmakologi maupun non farmakologi. Salah satu terapi non farmakologi yaitu dengan aromaterapi Jahe. Tujuan penelitian ini adalah untuk mengetahui Pengaruh pemberian Aromatherapi Jahe Terhadap Mual Muntah Pada Ibu Hamil Trimester I. Desain penelitan quasy experiment, dengan jenis rancangan pre -post test control group design. Penelitian ini dilakukan di Wilayah Kerja Puskesmas Purbaratu Kota Tasikmalaya Tahun 2019. Sampel dipilih secara purposive sampling dan didapatkan jumlah sampel 36 responden. Hasil penelitian Sebagian besar responden tidak mengalami mual muntah setelah diberikan aromaterapi jahe yaitu sebanyak 12 orang (66.7%) dan hasil uji Mann Whitney bahwa pada kelompok perlakuan diperoleh nilai p<0,05 dengan demikian terdapat pengaruh pemberian aromaterapi jahe terhadap mual muntah pada ibu hamil trimester I di Wilayah Kerja Puskesmas Purbaratu Kota Tasikmalaya.
Hyperemesis gravidarum (HG) is characterized by severe gestational nausea and vomiting, leading to dehydration, electrolyte imbalance and nutritional deficits. HG adversely affects the health and wellbeing of the woman. However, the detrimental impact of HG on fetal brain development has not been addressed.
We evaluate herein the emerging evidence suggesting that HG interferes with human brain development, and discuss putative mechanisms. Evidence emerges from prospective developmental studies in offspring exposed in utero to HG, from studies of pregnancy outcome after in utero exposure to famine, as well as evidence on specific nutritional deficiencies affecting fetal brain development.
Nausea and vomiting (NVP) of pregnancy are common among women. The purpose of this study was to determine the incidence of nausea and vomiting in pregnancy and the self- care measures adopted by women attending a maternal clinic. A descriptive cross sectional study was carried out utilizing an interviewer-administered questionnaire to consenting pregnant women attending the maternal clinic of Central Hospital, Agbor; Delta state – Nigeria. Of the 521 gravid women included in the study, 221 (42.4%) were within the age group of 27 and 32 years and had secondary level of education 238(45.7%).The mean gravidity of the participants was 2.68±1.54, mean gestational age at the time of the study was 24.68 weeks ± 7.40 and the mean gestational age at which nausea and vomiting were observed, and was 6.30 weeks ± 3.82. Three hundred and fifteen (60.5%) of the women experienced the symptoms of nausea and vomiting of pregnancy. Taking “bitterkola” (Garcinia kola) (22.9%) either alone or in combination with other substances was the most frequently occurring measure to control nausea and vomiting. Other measures taken included taking “native chalk” (18.8%), Ginger (5.6%) bitter leaves (Amygdala vernonia) (7.6%), fruits (19.9%), chewing gum (4.7%), taking sweets (9.4%), taking drugs (3.7%) and rest (4.7%).Over 20% of the study population with nausea and vomiting opined that nausea and vomiting had a negative impact on their lives; however only 7.5% are discouraged from getting pregnant as a result of nausea and vomiting. Use of self-care measures was associated with educational level of the respondents (P=0.004). The rate of nausea and vomiting was high in the studied participants and Bitterkola (Garcinia kola) was the most commonly used agent for its prevention. The respondents who experienced nausea and vomiting reported its huge negative impact on their lives.
Background: While "constitution" is a commonly used term, its abstraction is often the source of confusion and misunderstanding. It is rarely scientifically measured in modern medicine, which implies that most people are not aware of the current state of their own constitution and are thus unable to receive appropriate evidence-based nursing care. Individual constitution is an influencing factor on pregnancy symptoms based on relevant theories. Purpose: This study was designed to explore correlations between women's Chinese medical constitution before pregnancy and discomfort symptoms during the first trimester of pregnancy. Methods: A descriptive and correlational design was adopted and 235 women were recruited in their first pregnancy trimester from four hospitals in southern Taiwan. Structured questionnaires used a Demographic Data Sheet, Traditional Chinese Medical Constitutional Scale (TCMCS), and Evaluation of Uncomfortable Symptoms During the First Trimester of Pregnancy to collect data. Results: Results of this study indicated that (1) 42.55 % of participants had a "normal" constitution; 26.81% had a "mixed" constitution that was either deficient in yin-xie or yang-qi as well as tan-shi-yu-zhi; 7.23% had a tan-shi-yuzhi constitution; 5.97% had a yin-xie deficient constitution; 3.40% had a yang-qi deficient constitution; 14.04% had a mixture of any two constitutions; (2) the top three discomforts reported during the first trimester of pregnancy included fatigue, frequent urination and nausea, in descending order; (3) "frequent urination," "fatigue," "heavy vaginal discharge," "dizziness," and "mood swings" had significantly positive correlations with yin-xie deficiencies, yang-qi deficiencies, and a tan-shi-yu-zhi constitution. Swelling pain in the breasts had a significantly positive correlation with a tan-shi-yu-zhi constitution. Conclusions: This research is the first to acquire evidence-based data regarding correlations between constitution before pregnancy and uncomfortable symptoms during the first trimester for pregnant women. This can assist healthcare professionals to provide more suitable perinatal nursing care before pregnancy through integrating traditional Chinese medicine and western medicine. Such can enhance the comfort of women undergoing pregnancy and promote the health of both the fetus and mother.
Objective: We aimed to research the effects of Dimenhydrinate (DMH) and Ondansetron, used during pregnancy, on the organs of young rats in postnatal period in terms of histopathologically. Material and Methods: In the study, 30 Wistar-Albino type female rats have been used. The rats have been divided into three groups: group 1 (control, n: 10), group 2 (DMH, n: 10) and group 3 (ondansetron, n: 10). We kept them together for pregnancy starting from the first day of pregnancy, a dose of 115 mg/kg/day intramuscular DMH (group 2) and 10 mg/kg/day intraperitoneally ondansetron (group 3) have been given to pregnant rats for a week. As for the control group (group 1), a dose of intramuscular 0.9% NaCl has been given for the same period of time. After birth, the numbers of babies have been ascertained. Brain, lung, heart, liver and kidney tissues have been taken from the babies of each group during their newborn, lactation and adulthood periods. After histologic tissue follow-up methods, the preparates have been painted with Haematoxylin-Eosin (H&E) and then evaluated underlight microscope. Results: There was no significant difference between the controls and experiment groups in point of histopathological change on the organs of the young rats. Conclusion: It has been concluded that DMH and ondansetron treatment during pregnancy period has no histopathological effect on the organs of the young rats.
Nausea and vomiting during pregnancy are extremely common, presenting in 50% to 90% of all gravidas. The most common presentation of this complex is between the fourth and seventh weeks of pregnancy, when 70% of those affected develop symptoms. Vomiting abates in 90% of cases by the 16th week of pregnancy. A more severe variant associated with greater morbidity, hyperemesis gravidarum (pernicious vomiting of pregnancy), affects between 0.3% and 2% of pregnancies. Definitions of hyperemesis gravidarum (HG) vary considerably, but HG is best described as vomiting in pregnancy that is sufficiently severe to produce weight loss, dehydration, starvation ketoacidosis, alkalosis from loss of hydrochloric acid in vomitus, and hypokalemia. A transient rise in liver enzymes is seen in 15% to 25% of women who are hospitalized with HG. Although the etiology of HG has not been identified, a number of factors have been suggested as contributory, including high or rapidly rising serum concentrations of serum chorionic gonadotropin or estrogens, seropositivity to Helicobacter pylori, thyrotoxicosis, upper gastrointestinal dysmotility, and psychological factors. Eating disorders have also been associated with HG. Goodwin has postulated that nausea and vomiting during pregnancy is not a single condition but a syndrome with multiple potential etiologies, such as vestibular mechanism, “background” gastrointestinal motility dysfunction, or hormonal sensitivity, among others, each of which may respond to a different targeted therapy.
Fifty to 80% of pregnant women suffer from nausea and vomiting during pregnancy (NVP), also known as morning sickness; ranging from mild discomfort to hyperemesis gravidarum (HG). The treatment options for NVP range from conservative measures, such as reassurance and diet manipulation in the mildly symptomatic women, to drug therapy and if necessary, in severe and intractable cases, total parenteral nutrition or even therapeutic pregnancy termination. Drug free treatments, including acupuncture, acupressure, ginger and hypnosis are also presented. Medicinal therapy addressed in this chapter includes vitamins such as pyridoxine, dopamine antagonists, serotonin antagonists, antihistamines and corticosteroids.
Nausea and vomiting occur in up to 80% of normal pregnancies. Hyperemesis gravidarum, resulting in dehydration and ketonuria, is a more severe and disabling condition affecting up to 1.5% of pregnancies. This condition is poorly understood and treatment strategies remain largely supportive with the aims of relieving symptoms and preventing complications of the disease. Treatment is supportive with intravenous hydration, antiemetics and correction of vitamin deficiency to minimize complications. There are good data to support the safety and usefulness of some kinds of antiemetics such as antihistamine, phenothiazines metoclopromide and specific HHT3 antagonists in hyperemesis gravidarum. But there is little evidence on which to choose the optimum therapy. This review discusses the diagnosis and management of hyperemesis gravidarum and the prevention, recognition and treatment of the serious complication.
El 45-89% de las mujeres embarazadas presenta náuseas y/o vómitos. Su tratamiento es dietético: bebidas ligeras, alimentos que no produzcan rechazo y de cuatro a seis comidas al día. La piridoxina o vitamina B6 (750 mg/d) es más eficaz en los vómitos que en las náuseas. Se asocian los antieméticos (doxilamina, metopimazina, metoclopramida). También están recomendadas la homeopatía, la acupuntura o la acupresión (punto P6). Su persistencia tras 14 semanas de amenorrea (SA) obliga a buscar una causa psicológica u orgánica. El tratamiento del ptialismo es ineficaz. El tratamiento del estreñimiento es, de entrada, dietético (enriquecimiento de la dieta en fibras alimentarias, entre 5-15 g/24 h: frutas, verduras crudas y cocidas en cada comida); primero se emplean los laxantes osmóticos (lactulosa, macrogol, sorbitol) alternados con laxantes formadores de masa fecal (mucílago). Los laxantes lubricantes y de contacto (vía rectal) pueden asociarse, así como los laxantes estimulantes empleados con prudencia. La pirosis aparece al final del embarazo (en decúbito dorsal y por la noche). Las prescripciones dietéticas y posturales son esenciales. Primero se prescriben los alginatos y, en caso de fracaso, son eficaces la ranitidina y sobre todo el omeprazol. Si la clínica persiste, pueden detectarse una esofagitis o una hernia discal en la esofagoscopia. El tratamiento de fondo de los calambres nocturnos es el magnesio administrado durante 2-3 semanas. El tratamiento sintomático está constituido por la quinina (150-300 mg por toma) o la asociación quinina-espino, no contraindicadas en una dosis inferior a 1,50 g/24 h. La relajación dolorosa de la sínfisis no tiene tratamiento eficaz; cura espontáneamente en el posparto. Las lumbalgias se curan mediante posturas que reducen la lordosis lumbar: los analgésicos son ineficaces. Mejoran mediante masajes locales o chorros de agua. La rinitis congestiva se trata con antihistamínicos: los vasoconstrictores locales están contraindicados. Las gingivitis hipertróficas se tratan mediante higiene bucal que sustituye al cepillado, los chorros dentales, los cepillos o los hilos dentales. El épulis es raro y raramente está indicada una intervención local, salvo si las hemorragias son importantes. Las estrías son frecuentes y su tratamiento es poco eficaz: masajes locales con leches y cremas hidratantes que corrigen la sequedad cutánea habitual.
Background:
Nausea and vomiting of pregnancy (NVP) is the most common medical condition during gestation, affecting 50%-90% of women during their first trimester, and many in the second and third trimester. NVP affects women's quality of life and exerts a large economic impact on patients, caregivers and society.
Objectives:
To estimate the overall economic burden of illness of NVP in the USA.
Methods:
A spreadsheet model was utilized to estimate this burden including direct and indirect costs. Costs are reported in 2012 US dollars and were estimated from the perspective of society. Cost centers included drug treatments for mild to severe NVP and hospitalizations for hyperemesis gravidarum (HG), as well as time lost from work and caregiver time. Clinical, epidemiologic, and economic data were obtained from the literature to populate the model. Rates of drug use were multiplied by unit costs and summed.
Results:
The estimated total economic burden in 2012 in the USA was $1,778,473,782 which included $1,062,847,276 (60%) in direct costs and $715,626,506 (40%) in indirect costs. Overall, the average cost to manage one woman for NVP was $1827. Costs increased with increasing severity of NVP. The estimates were conservative, as not all applicable costs could be included.
Conclusions:
NVP results in a significant economic impact, and hence effective therapy should be sought. Future prospective research should determine in more detail what resources are utilized in the USA to manage women with NVP.
45% to 89% of pregnant women experience nausea and vomiting. The treatment is nutritional (well accepted food, 4 to 6 meals per day). Pyridoxine (750 mg/day) is more effective on vomiting than on nausea. Antiemetic drugs (metopimazine, metoclopramide) are more or less efficient; some authors recommend homeopathic drugs or acupuncture. Persistent vomiting after 14 amenorrhea weeks suggests a psychological or an organic cause. There is no effective treatment for ptyalism. Constipation is first treated with an appropriate diet (fruits and both fresh and cooked vegetables for each meal); lactulose, vaseline oil and mucilage (ispaghul) or macrogol can then be used. Pyrosis occurs in late pregnancy, mainly when lying on the back and during night time: alginates are first prescribed and if they are not efficient enough, ranitidine or omeprazole can be used. In case of persistent pyrosis, oesophagoscopy may help detecting oesophagitis or hiatal hernia. Night cramps are highly painful: basic treatment is magnesium supplements for 2 to 3 weeks. Quinine (150 to 300 mg per dosing) is a symptomatic treatment and is not contraindicated. There is no effective treatment for the pelvic girdle relaxation that spontaneously recovers post partum. Lumbosacral pain is treated by lumbar lordose reduction: antalgesic drugs are not efficient. Massages and hydrotherapy reduce such pain. The treatment of congestive rhinitis is based on antihistaminic drugs: local vasoconstrictive drugs are contraindicated. In hypertrophic gingivitis, tooth brushing should be replaced by hydrojet. Epulis is uncommon and rarely requires surgery, except in abundant bleeding. Striae albae are common and there is no really effective treatment; moisturizing milks and creams can be applied to reduce dry skin.
Nausea and vomiting of pregnancy (NVP) affects up to 85% of all pregnancies, yet many physicians are uncertain as to how to best treat their patients in the presence of controversial data on fetal risks. This review provides an update on the management of NVP, including pharmacological and non pharmacological approaches Due to a high rate of recurrent symptoms, it is important for women to receive early treatment to reduce the severity of symptoms with the aim of preventing hospitalization and improving quality of life.
Background
Nausea and vomiting of pregnancy (NVP) is the most common medical condition in pregnancy, affecting women worldwide. It is unclear whether its prevalence and severity NVP are variable across different nations and races.PurposeTo summarize global rates of NVP as reported in the literature using meta-analysis. Methods
We searched Medline, Embase and Cochrane databases for all peer-reviewed articles reporting rates of NVP and/or hyperemesis gravidarum (HG). No restrictions were imposed on publication year or language. Numbers of women, studies and NVP rates were extracted and aggregated using a random effects model. Outcomes included: overall rates (i.e., women suffering any nausea or vomiting or both) in early and in late pregnancy, rates of nausea only, symptom severity, and HG rates. ResultsWe identified 116 studies, rejecting 37 and accepting 79, of which 59 provided data for NVP (N=93,753 in 13 countries) and 26 for HG (N= 6,155,578). All developed regions of the world were represented (2 studies from Africa, 1 India; none from Latin America). Reported NVP rates varied from 35%-91% (median 69%); the meta-analytic average rate was 69.4% (CI95%:66.5%-72.3%). Among pregnant women, 32.7% had nausea without vomiting and 23.5% overall had NVP continuing into the third trimester. NVP was rated as mild in 40%, moderate in 46% and severe in 14% of cases. The prevalence of HG was 1.1% (CI95%:0.8%-1.3%), with a range of 0.3%-3.6%. Conclusions Almost 70% of women worldwide experience NVP, but reported rates vary widely. HG, the most severe form, affects 1.1%.
Abstract OBJECTIVE: To examine the influence of nausea and vomiting of pregnancy (NVP) on pregnancy outcomes. METHODS: Outcomes were compared for primigravidas with a current singleton gestation enrolled at <20 weeks' gestation in a maternity risk screening and education program (n=81,486). Patient-reported maternal characteristics and pregnancy outcomes were compared for women with and without NVP and within the NVP group for those with and without poor weight gain. RESULTS: 6.4% of women reported NVP as a pregnancy complication. Women reporting NVP were more likely to be younger, obese, single, and smoke. They had higher rates of preterm delivery, pregnancy induced hypertension, and low birth weight <2500 grams. Almost one-quarter of women with NVP had lower than recommended weight gain. Poor weight gain was associated with a higher incidence of adverse outcomes. Obesity, tobacco use, and poor pregnancy weight gain independently increased the odds of an adverse outcome. CONCLUSION: NVP and subsequent poor weight gain may be associated with adverse pregnancy outcomes.
An advanced state of nausea and vomiting, which are common symptoms of early pregnancy, is known as hyperemesis gravidarum and may result in dehydration, ketonuria, catabolism and require hospitalisation. Aetiological factors include increased hCG and steroids, multiple pregnancy and vitamin deficiency. Differential diagnosis of nausea and vomiting should be made and supportive treatment as well as antiemetic therapy is recommended. This review discusses aetiology and management modalities of hyperemesis gravidarum including fluid therapy, antiemetics, vitamins, psychological support and non-pharmacological measures.
Hyperemesis gravidarum is a severe and disabling condition with potentially life-threatening complications. It is likely to have a multifactorial etiology which contributes to the difficulty in treatment. Treatment is supportive with correction of dehydration and electrolyte disturbance, antiemetic therapy, prevention and treatment of complications like Wernicke's encephalopathy, osmotic demyelination syndrome, thromboembolism, and good psychological support. There are abundant data on the safety of antihistamines, phenothiazines, and metoclopromide in early pregnancy and treatment should therefore not be withheld on the basis of teratogenicity concerns. Thiamine replacement is indicated in hyperemesis gravidarum to prevent development of Wernicke's encephalopathy.
Introduction:
Nausea and vomiting in pregnancy remains the most common cause of hospitalization in the first half of pregnancy. Although the exact cause is largely unknown, an interaction of genetic, biological and psychological factors is plausible. An endocrine trigger for hyperemesis has been linked with both ovarian and placental hormones, but this association requires further clarification. The use of type-3 serotonin receptor antagonists is increasing but as yet there are no convincing data to demonstrate their superiority over the other antiemetics.
Areas covered:
A computerized search was conducted using PubMed, Embase, Cinahl, Lilacs, ISI Web of Science, the Cochrane Central Register of Controlled Trials (all from inception or 1960 to October 2010), and Research Registries of ongoing trials. The key words used were nausea, vomiting, emesis, hyperemesis gravidarum, morning sickness, pregnancy, pregnancy complications, treatment, efficacy, effectiveness, antiemetics, safety and teratogenesis.
Expert opinion:
The precise mechanism underlying hyperemesis gravidarum remains unclear, but appears to be multifactorial. As yet there is no evidence that any antiemetic class is superior to another with respect to effectiveness.
Although nausea and vomiting are common symptoms in early pregnancy, hyperemesis gravidarum (HG) is a rare complication of the first trimester of pregnancy. This condition is defined as intractable vomiting occurring before 20 weeks of gestation, with fluid and electrolyte disturbance, significant weight loss, and ketonuria, leading to hospitalization in the absence of other cause than pregnancy. Some biological disturbances found in HG, such as hyperthyroidism and hepatic cytolysis, which are correlated with the importance of vomiting, are without severe clinical consequences, but may represent diagnostic pitfalls. The aetiology is unknown, but human chorionic gonadotropin hormones likely play the first role. Psychological disturbance is currently seen as the result of the burden and stress of HG rather than a causal factor. Maternal outcome may be severe in the absence of treatment, but pregnancy outcome seems good, as far as the condition has been adequately controlled. The management of HG includes IV rehydration, thiamine supplementation, antiemetic drugs (doxylamine, metoclopramide and chlorpromazine being the first-line choices), and in severe cases, nasogastric or parenteral nutrition. A psychological support is often necessary.
The delayed-release combination of doxylamine succinate and pyridoxine hydrochloride was the most commonly used antiemetic (Bendectin) approved by FDA for nausea and vomiting of pregnancy (NVP) until its removal of the market in 1983. The drug is widely used today in Canada (Diclectin). The pharmacokinetics of Diclectin has never been described in humans.
To compare the pharmacokinetics of Diclectin to oral solutions of its two components.
A randomized, cross over, open label design, comparing the pharmacokinetics of Diclectin to those of the oral solutions of the two components in 18 healthy adult, non pregnant women of childbearing age.
Diclectin exhibited similar oral bioavailability to those of the oral solutions. In contrast, the time-to-peak, (Tmax), reflecting the rate of absorption, was 3-6 times longer for the two components of the delayed-release drug confirming its delayed-release characteristics.
The pharmacokinetic profile of Diclectin well explains its documented delayed efficacy.
Nausea and vomiting occur in up to 80% of normal pregnancies. Hyperemesis gravidarum, resulting in dehydration and ketonuria, is a more severe, disabling and potentially life threatening condition affecting up to 1.5% of pregnancies. Treatment is supportive with intravenous rehydration, antiemetics and correction of vitamin deficiency to minimize complications. There are good safety data to support the use of antihistamines, phenothiazines and metoclopromide in hyperemesis gravidarum, though trials of efficacy are lacking and there is little evidence on which to chose the optimum therapy. This review discusses the diagnosis and management of hyperemesis gravidarum and the prevention, recognition and treatment of the serious complications of Wernicke encephalopathy, osmotic demyelination syndrome and thromboembolism.
Vomiting in pregnancy is a very common phenomenon, though not well understood. The extreme form, hyperemesis gravidarum can lead to severe complications. Articles published in the last decade in this field were searched and studied. Various aetiological factors were identified, the recent ones being the association of Helicobacter. pylori with hyperemesis, as well as the presence of cell free fetal DNA. The management of the condition involves symptomatic treatment along with antiemetic, pyridoxine and thiamine. Important role of alternative therapies like ginger and P6 acupoint stimulation in the treatment of hyperemesis has been identified.
Hyperemesis gravidarum occurs in 0.3% to 2% of pregnant women, although populations with significantly higher rates have been reported. In clinical practice, hyperemesis gravidarum is identified by otherwise unexplained intractable vomiting and dehydration. This article discusses the causes, presentation, diagnosis, and management of hyperemesis gravidarum.
Hyperemesis gravidarum is a common entity the cause of which has remained poorly defined. However, it probably is a classic example of the interplay between biologic, psychological and sociological variables. Current data on hyperemesis gravidarum and the pertinent literature for the last two decades are reviewed.
The symptoms of nausea and vomiting in pregnancy were described by 363 pregnant women who kept daily symptom diaries. All delivered a single live baby. The majority of information collected was prospective, with the median day from last menstrual period to initial interview by the study midwife being day 57. It was found that 80% of women had symptoms, 28% experienced nausea only, while 52% had nausea and vomiting. The mean number of days from last menstrual period to onset and cessation of symptoms was 39 and 84, respectively, and 40% of women's symptoms ended abruptly. Cessation of symptoms occurred at approximately the same day from the last menstrual period whether they had begun early or later, severely or mildly [corrected]. The median total number of hours of nausea per pregnancy in those 292 women experiencing symptoms was 56, with peak symptoms occurring in the ninth week. Eighty five per cent of women experienced days with two episodes of nausea. Fifty three per cent of episodes of vomiting occurred between 06.00 hours and 12.00 hours. The symptom complex can be defined as episodic daytime pregnancy sickness. Among the study population, 206 women were in paid employment. Seventy three of these women (35%) spent a mean of 62 hours away from their paid work because of symptoms of nausea and vomiting, showing the socioeconomic significance of this condition. The detailed information gathered should help in the investigation of the aetiology of nausea and vomiting during pregnancy.
To characterize a cohort of pregnant women who required hospital care owing to nausea and vomiting of pregnancy (NVP) and to identify variables that could serve as predictors of the need for hospital care.
A retrospective, observational study.
Between 1996 and 1997, women who suffered from NVP were invited to call the NVP Healthline at The Motherisk Program in Toronto. After obtaining verbal consent, callers were interviewed by trained counsellors through a structured questionnaire about their NVP experience in previous pregnancies. Univariate and multivariate analyses were used to identify factors that could predict the need for hospital care.
In total, 3,201 women were recruited;1,348 (43.8%) needed hospital care (treatment in the emergency room, day unit or hospital ward). The following characteristics were significantly associated with the need for hospital care: severity of vomiting (more than 5 times a day), use of more than one antiemetic medication, being primigravid, feeling depressed, having had an obstetrician as the primary health care provider and feeling that NVP had affected the partner's daily life.
Several factors, including the severity of physical symptoms of NVP and psychosocial factors, are associated with the need for hospital care. In addition to treatment of physical symptoms, it is important to address other factors associated with NVP.
Background
Nausea and vomiting in pregnancy (NVP) is a multifaceted condition that affects more than half of pregnant women and can range in severity from mild nausea to severe dehydration. Presently physicians evaluate mostly physical symptoms of NVP in trying to assess the severity of the condition. The objective of this study was to investigate how factors, other than the physical morbidity of nausea and vomiting, influence self-perception of NVP by affected women.
Methods
Five hundred women with NVP calling a 1–800 NVP Healthline were asked to rate their NVP severity and report their nausea duration and number of vomiting/retching episodes.
Results
Nausea and vomiting/retching correlated significantly but very poorly with self-assessment of NVP severity. There was also a correlation between nausea duration and vomiting/retching frequency however the correlations were weak and overall physical symptoms could only explain 14% of the variability of women's feelings and perceptions through multivariate analysis.
Conclusions
Physical symptoms weakly correlate with self-assessment of NVP severity. Other aspects of this condition, most probably psychosocial, influence women's perception of NVP severity.
In 1983, Bendectin was voluntarily removed from the market by Merrell Dow Pharmaceuticals Inc. because of the many product liability suits pending. Earlier, 10 to 25% of pregnancies were exposed to Bendectin and over the years the drug was used in as many as 33 million pregnancies. The scientific evidence available pointed to the safety of Bendectin. This article considers some of the effects of the withdrawal of the drug. In 1983, hospital admissions for excessive vomiting in pregnancy per thousand live births rose by 37% over 1980-82 ratios and by 50% in 1984. In the United States, hospitalization rose by similar amounts. A rough estimate of excess hospital costs over the years 1983-87 is $16 million for Canada and $73 million for the U.S. Such estimates do not take into consideration other costs, such as extra physician visits, increased absenteeism from work, and the effect on quality of life of the pregnant woman and her family. No decrease in rates of congenital malformations could be shown to offset this increased cost to society.
This study determined the advice reported to be received by women suffering from nausea and vomiting of pregnancy (NVP) from their caregivers regarding management, the teratogenic risk perception of these women and their choice of antiemetic drug use in pregnancy. A secondary objective was to determine prospectively the effect of counseling on malformation risk perception in women with NVP. The women were prospectively followed-up and questioned about the use of pharmacotherapy or other management choices as well as their perception of teratogenic risk through structured telephone interviews. The results showed that at the initial call, around 6 weeks of gestation, over three quarters of the 260 participants reported that therapy of NVP increased their teratogenic risk. This risk perception was decreased significantly after counseling. Women who reported their physicians' advice to change their diet and/or lifestyle attributed an increased risk for major malformations with antiemetics for NVP (P = 0.001), whereas women who reported advice to take antiemetic medications known to be safe to the fetus attributed no change in risk for major malformations with drugs for NVP (P = 0.002). We came to the conclusion that women are commonly hesitant to treat NVP pharmacologically due to unfounded fears of teratogenic risk. Evidenced-based counseling resulted in reduced numbers of women who considered drug therapy for NVP to increase the risk of major malformations.
Despite evidence of fetal safety, most antiemetics are contraindicated in pregnancy. We summarise a risk-benefit analysis of the literature on safety and effectiveness of pharmacotherapy and nontraditional therapy for nausea and vomiting of pregnancy (NVP) to provide evidence-based guidelines on the management of NVP. The medical literature was scanned for controlled studies on the human teratogenicity and effect of various antiemetics in pregnant women. Data were pooled based on drug/therapy class and summarised to determine relative risk with 95% confidence interval (for malformations and failure rates for NVP) and homogeneity (chi-square test). Evidence from controlled trials has demonstrated the safety and efficacy of the following drugs for the treatment of varying degrees of NVP: doxylamine/pyridoxine+/-dicycloverine (dicyclomine), antihistamine H1 receptor antagonists, and phenothiazines (as a group). However, pooled data for doxylamine/pyridoxine+/-dicycloverine, H1 antagonists and phenothiazines were not homogeneous. Other therapies, such as pyridoxine alone, metoclopramide, ondansetron and the corticosteroids may be beneficial in managing NVP. However, limited efficacy studies and the paucity of well-controlled safety studies may limit the use of some of these agents among patients not responsive to first-line agents. Well-controlled safety and effectiveness trials in patients with NVP are lacking for nonpharmacological treatments (e.g. acupressure). NVP can be managed safely and effectively. Further trials must be conducted in order to determine the true effectiveness of certain agents in patients with NVP.
A delayed-release combination of doxylamine-pyridoxine (D-P) (Diclectin) is the only approved antiemetic medication for use in pregnancy in Canada. The standard recommended dose is up to 4 tablets a day, regardless of body weight or severity of symptoms. The objective of this study was to determine the incidence of adverse maternal and fetal effects and pregnancy outcome in 225 women taking Diclectin at the recommended (n = 123) or higher than recommended (n = 102) doses. In this observational, prospective study, one-third (33.6%) of women reported having adverse effects (sleepiness, tiredness, and/or drowsiness) temporally related to the medication. There was no association between the dose per kg and rates of reported maternal adverse effects with doses ranging from 0.1 mg/kg to 2.0 mg/kg (1-12 tablets). Nausea and vomiting of pregnancy (NVP) was reported as severe by the majority (75.8%) of women. Mean birth weight (BW) was 3,400 g and gestational age (GA) 39 weeks. Multivariate analysis revealed that only prepregnancy weight and GA predicted lower BW, not the dose of D-P or the severity of NVP. There were two pregnancies with major malformation, a finding that is consistent with the rates of birth defects in the general population. It was concluded that the higher than standard dose of Diclectin, when calculated per kg of body weight, does not affect either the incidence of maternal adverse effects or pregnancy outcome. If needed, Diclectin can be given at doses higher than 4 tablets/day to normalize for body weight or optimize efficacy.
The morbidity of nausea and vomiting of pregnancy varies substantially. In addition to the physical symptoms, the emotional and psychosocial stress must be considered. The method available today to measure the severity of nausea and vomiting of pregnancy stems from chemotherapy-induced symptoms and is too complicated to use clinically. We sought to establish a simple and clinically relevant method for evaluation of the severity of nausea and vomiting of pregnancy that can be used for both clinical practice and research.
Women with nausea and vomiting of pregnancy were scored by use of the "gold standard" Rhodes' score, which includes 8 items. The Rhodes' score was compared with several short versions of 3 to 4 items. Patients were subsequently followed up a week later to monitor changes in scores. Changes in the Rhodes' scores were correlated with changes in the simplified scores.
There was a very tight correlation between the Rhodes' score and the new pregnancy-unique quantification of emesis and nausea (PUQE) scoring system, which was based on the 3 items that included the number of daily vomiting episodes, the length of nausea per day in hours, and the number of retching episodes (r = 0.904; P <.0001). The distribution of severity of cases (between none, mild, moderate, and severe) did not differ between the Rhodes' and the PUQE. Comparing the changes in Rhodes' scores after a week of follow-up versus changes in the new PUQE score, there was a very high agreement (r = 0.95;P <.0001).
The new PUQE score yields similar results to the gold standard, but more cumbersome, Rhode's score. Clinicians and researchers can easily use PUQE.
Although the cause of nausea and vomiting of pregnancy is not known, there is strong evidence linking human chorionic gonadoptropin or estrogens. Evidence is presented to show that the incidence and severity of nausea and vomiting of pregnancy is linked to temporal and pathologic alterations in these hormones during pregnancy. The way in which the pregnant woman responds to the primary stimulus to nausea and vomiting of pregnancy appears to depend on her susceptibility mediated by vestibular, gastrointestinal, olfactory, and behavioral pathways. Conceiving of nausea and vomiting of pregnancy as a syndrome suggests new pathways of investigation and possible therapies.
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The safety and effectiveness of ondansetron for the treatment of nausea and vomiting (NVP)
- A Einarson
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- D Kennedy
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