Psychosocial morbidity among women with nausea and vomiting of pregnancy: prevalence and association with anti-emetic therapy

Unlike severe nausea and vomiting of pregnancy (NVP), it is not known whether milder forms of NVP have been associated with psychosocial morbidity. We undertook the study to explore the prevalence of psychosocial morbidity by severity of NVP, and determine whether, after correction for severity of nausea/vomiting, there is a relationship between psychosocial morbidity and women's decisions to take anti-emetics as a reflection of their distress due to NVP. From 1996-97, an NVP Healthline was advertised. Callers underwent semi-structured interviews about both their NVP and associated psychosocial morbidity in a previous pregnancy. Most of the 3201 callers resided in Canada, worked outside the home, reported on planned pregnancy (a median of) 4 years before, and described severe (> 5 episodes/day of) nausea and vomiting. More severe nausea/vomiting was associated with more frequent feelings of depression, consideration of termination of pregnancy, adverse effects on women's relationships with their partners or their partners' everyday lives, and the perceived likelihood that NVP would harm their baby (p < 0.0001). However, all psychosocial factors were reported by a clinically important proportion of women with mild nausea/vomiting (0-1 episodes/day). The severity of vomiting was most closely related to women's decisions to take anti-emetics, but other psychosocial factors were also independently associated with anti-emetic therapy. We conclude that psychosocial morbidity is evident across the spectrum of severity of nausea and vomiting among women with NVP. The severity of nausea or vomiting does not appear adequately to reflect the distress caused by NVP, as reflected by women's decisions to take anti-emetic therapy.     

Psychosocial morbidity among women with nausea and vomiting of pregnancy: Prevalence and association with anti-emetic therapy

Unlike severe nausea and vomiting of pregnancy (NVP), it is not known whether milder forms of NVP have been associated with psychosocial morbidity. We undertook the study to explore the prevalence of psychosocial morbidity by severity of NVP, and determine whether, after correction for severity of nausea/ vomiting, there is a relationship between psychosocial morbidity and women's decisions to take anti-emetics as a reflection of their distress due to NVP. From 1996–97, an NVP Healthline was advertised. Callers underwent semi-structured interviews about both their NVP and associated psychosocial morbidity in a previous pregnancy. Most of the 3201 callers resided in Canada, worked outside the home, reported on planned pregnancy (a median of) 4 years before, and described severe (> 5 episodes/day of) nausea and vomiting. More severe nausea/vomiting was associated with more frequent feelings of depression, consideration of termination of pregnancy, adverse effects on women's relationships with their partners or their partners' everyday lives, and the perceived likelihood that NVP would harm their baby (p < 0.0001). However, all psychosocial factors were reported by a clinically important proportion of women with mild nausea/vomiting (0–1 episodes/day). The severity of vomiting was most closely related to women's decisions to take anti-emetics, but other psychosocial factors were also independently associated with anti-emetic therapy.

We conclude that psychosocial morbidity is evident across the spectrum of severity of nausea and vomiting among women with NVP. The severity of nausea or vomiting does not appear adequately to reflect the distress caused by NVP, as reflected by women's decisions to take anti-emetic therapy.     

Existence and severity of nausea and vomiting in pregnancy (NVP) with different partners.

Nausea and vomiting in pregnancy (NVP) is a widespread condition which may impact on the quality of life. Our objective was to understand the role of the placenta, which is mostly made up of fetal cells, in NVP. We examined the relationship between NVP and different partners in the same women. If a paternal contribution to placental function affects NVP, this could shed light on the genetics of the most common condition in pregnancy. We assessed nausea and vomiting in two groups of 100 women counselled by the Motherisk Program in Toronto, using a score from 1 (none) to 5 (severe with hyperemesis). The first group had >/=2 pregnancies with the same partner; the second had >/=2 pregnancies with >/=2 partners. Scores were averaged across pregnancies, partners and overall. Regression was used to separate numbers of pregnancies and partners. The 100 women having one partner reported an average score of 3.1 in their 261 pregnancies, which was similar to the score of 3.0 in 319 multi-partner pregnancies (p = 0.508). There was a positive (but weak) correlation between gravidity and NVP score (Spearman's rho = 0.21, p < 0.001) but not between partner and score. There was a linear increase in scores from 2.7 in the first pregnancy, to 4.0 in the tenth (rho = 0.948, p < 0.01). After controlling for number of pregnancies, number of partners was not associated with NVP scores (p = 0.302). NVP severity tends to increase with each successive pregnancy. Different partners have no impact on NVP severity.     

Relationship between vitamin use,smoking, and nausea and vomiting of pregnancy

BACKGROUND: Nausea and vomiting in pregnancy (NVP) is a common complaint but risk factors for NVP are not well characterized. METHODS: Occurrence of NVP was studied by questionnaires given to pregnant women at their first visit to the antenatal care unit and were returned around gestational week 28. RESULTS: Analysis of 3675 completed questionnaires was made. Nausea and vomiting in pregnancy was reported by 79% of the women, approximately half of which had been vomiting. Various therapies (drugs, acupuncture, acupressure) were tried by 18% of the women with NVP, of which the majority used drugs, most notably antihistamines (specifically meclozine). Hospitalization occurred in 1% of all women. Nausea and vomiting in pregnancy caused 28% of all sick-leaves during the first 28 weeks of pregnancy. Low maternal age and parity 1+ independently increased the risk for NVP. Smoking before pregnancy and using vitamins in early pregnancy were associated with a decreased risk for NVP. Women working outside the home had a lower rate of NVP than housewives and women out of work. CONCLUSIONS: Nausea and vomiting in pregnancy is a common complaint with a significant impact on leave of absence from work. The study identifies a number of factors that are related to the occurrence of NVP and that may give hints on the etiology of the condition.     

Maternal alcohol and tobacco consumption and their association with nausea and vomiting during pregnancy.

Nausea and vomiting during pregnancy (NVP) has been associated with favorable pregnancy outcome, though little is known about factors influencing its occurrence. In this study, information on NVP in 210 patients at a west coast health maintenance organization was obtained. Smoking and alcohol consumption before and during pregnancy were also estimated in two personal interviews during gestation. In all, 72% of the subjects had NVP in the first 4 months of pregnancy. Smokers had significantly less NVP than non-smokers (52% vs. 79%). Furthermore, NVP in smokers was negatively associated with alcohol consumption before and during pregnancy, with the stronger relation being for alcohol reported in the 6 months before pregnancy; only 46% of smokers drinking more than 1/2 fl. oz. of absolute alcohol daily in this period reported NVP, while 68% of smokers drinking less had NVP. For non-smokers, there was no relation between alcohol use in any period and NVP. The risk of NVP associated with pre-pregnancy drinking was not related to any change in alcohol consumption after conception. These results suggest an interaction between NVP, smoking, and reported alcohol consumption. The association of favorable pregnancy outcome with NVP may be in part a reflection of moderation in maternal alcohol and tobacco use.     

Oxidative stress is associated with clinical severity of nausea and vomiting of pregnancy

Our objective was (1) to evaluate total oxidant status (TOS) and total antioxidant status (TAS) in women with nausea and vomiting of pregnancy (NVP) compared with healthy pregnant controls, and (2) to explore any possible relationship between oxidative stress and clinical severity of the disease. Fifty-three women with NVP and 35 healthy pregnant women were enrolled in the study. Of these 53 women, 25 women were classified as mild and 28 women were classified with moderate/severe NVP. The severity of the disease was assessed by Rhodes' index. Plasma levels of TOS and TAS were determined by using automated methods. TOS was significantly higher and TAS was significantly lower in women with NVP ( P < 0.0001, for both). The moderate/severe NVP group had higher levels of TOS and lower levels of TAS than the women with mild NVP ( P < 0.0001, for both). Moreover, Rhodes' index showed positive correlation with TOS (r = 0.563; P < 0.0001) and negative correlation with TAS (r = -0.595; P < 0.0001). These findings indicate that oxidative stress is increased in NVP. There was a strong relationship between oxidative stress and the clinical severity of the disease. Therefore, we suggest that the levels of TOS and TAS can be used as additional markers in the diagnosis and clinical severity of NVP.     

Pre-emptive therapy for severe nausea and vomiting of pregnancy and hyperemesis gravidarum.

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.     

Nausea and vomiting in early pregnancy: relationship with anxiety and depression

OBJECTIVE: To investigate the association between either depression or anxiety early in pregnancy, and nausea and vomiting, in a clinical sample. METHODS: Anxiety and depression scores of 230 women were investigated by using the Hospital Anxiety and Depression Scale. Nausea and vomiting of pregnancy (NVP) were scored by using the Rhode's system. These scores and demographic data were compared and P < 0.05 was considered significant. RESULTS: A significant correlation between Rhode's score and both anxiety (r=0.388, P < 0.001) and depression score, (r=0.351, P < 0.001) was found. Gestational age showed and inverse correlation with anxiety scores (P=0.019). There was no significant correlation between demographic data and anxiety/depression scores, or Rhode's scores. CONCLUSION: There is an association between anxiety and depression early in pregnancyand severity of NVP.     

Pregnancy and oral health: utilisation of dental services during pregnancy in northern Greece

BACKGROUND: Recent studies have shown that gingivitis and periodontal infection during pregnancy represent an independent risk factor for pre-term birth. However, little is known about the prevalence and correlates of dental attendance during pregnancy. METHODS: During the first 3 days postpartum, an anonymous questionnaire was administered to 425 women in order to explore their dental condition and utilisation of dental health services during pregnancy, as well as their perceptions on the potential associations between dental care during pregnancy and pregnancy outcomes. RESULTS: Almost half of the respondents (46.8%) reported symptoms of gingivitis during their pregnancy. Pregnancy gingivitis was independently associated with non-Greek ethnicity (p=0.008), multiparity versus primiparity (p<0.005), lower economic class versus middle and upper classes (p=0.001), and the lack of routine primary dental care (p=0.005). Some 27.3% reported a visit to the dentist during their pregnancy. The majority (72.2%) believed that dental treatment during pregnancy might have a negative affect on pregnancy outcome. The presence of pregnancy gingivitis and the belief that dental treatment during pregnancy is safe were both independently associated with visiting a dentist during pregnancy (p<0.0005 for both). CONCLUSIONS: Despite the increased prevalence of dental problems among pregnant women, few women seek dental services in this population, which can be primarily attributed to women's erroneous beliefs regarding the safety of dental examination. Therefore, there is an imperative need to offer oral health education and develop preventive programs for women of reproductive age.     

Oral misoprostol vs. vaginal gemeprost prior to surgical termination of pregnancy in nulliparae

BACKGROUND: To compare the efficacy and side-effects of intravaginal gemeprost with those of oral misoprostol for cervical ripening prior to first-trimester pregnancy termination in nulliparous women. METHODS: Retrospective analysis of surgical terminations of pregnancy performed before 90 days of gestation. Intravaginal gemeprost 1 mg or oral misoprostol 800 micro g was administered 2 h before the procedure. RESULTS: In total, 746 women were enrolled into the study, 84 received intravaginal gemeprost and 662 oral misoprostol. Median baseline cervical dilatation was significantly greater in women who received misoprostol before the operation than in those who received gemeprost (7 mm vs. 3 mm; p < 0.0001). The incidence of fever, vomiting and diarrhea was not different between the two groups. The incidence of abdominal pain with request for pain medication, emergency admission to operating room due to vaginal bleeding, hospital stay longer than 24 h and surgical repair of cervical injury due to Hegar dilatation was significantly higher among the gemeprost group than the misoprostol group. CONCLUSIONS: In cervical priming prior to first-trimester pregnancy termination in nulliparous women, oral misoprostol is more effective and is associated with fewer side-effects and complications than intravaginal gemeprost.     

Determinants of women's decision making on whether to treat nausea and vomiting of pregnancy pharmacologically

Nausea and vomiting of pregnancy (NVP) affects up to 80% of all women to some degree during their pregnancies. Diclectin (doxylamine and pyridoxine [vitamin B6]) has been on the Canadian market for many years and is indicated as the drug of choice for the treatment of NVP. However, some women choose not to treat NVP with pharmacologic measures, perhaps due to a persistent fear of teratogenic risk. The objective of this study was to determine the factors that influence a woman's decision not to treat NVP with pharmacologic measures. Fifty-nine women recruited from the Motherisk Nausea and Vomiting Helpline completed a questionnaire. All were informed that Diclectin was considered safe for use during pregnancy. At a follow-up telephone call, 34% were not using any pharmacologic treatment, and of those who were taking the drug, 26% were using less than the recommended dose. Reasons cited for not using the medication were insufficient safety data, preference for non-pharmacologic methods, and being made to feel uncomfortable by the physician. Of the women who did use Diclectin, the most convincing reassuring information that it was safe to use came from friends and family. Many other factors play a large role in a women's decision making.     

Nausea and vomiting of pregnancy: endocrine basis and contribution to pregnancy outcome.

For a majority of women, nausea and vomiting of pregnancy (NVP) is an unpleasant but normal feature of pregnancy. NVP has a largely unknown etiology, but it is widely agreed that physiological, psychological, genetic, and cultural components are contributing factors. The occurrence of NVP may be of benefit in pregnancy, and NVP-associated pregnancies are less likely to result in miscarriage, preterm delivery, or intrauterine growth retardation. It has been suggested that NVP is promoted by secretion of human chorionic gonadotrophin (hCG), largely on the basis of the coincidence between the onset of NVP and hCG secretion and the peaks of both at around 12 to 14 weeks' gestation. Concentrations of hCG that are above or below the normal range are associated with poor pregnancy outcomes. It seems that NVP and hCG are related and that nutrient restriction during critical periods of embryonic development may ensure production of hCG at optimal levels, protect placental development, and optimize nutrient partitioning between maternal and fetal tissues.     

Decision-making trajectories leading to termination of an unplanned pregnancy: specificities among adolescent and adult women

Objective: To describe the decision-making trajectories leading to termination of an unplanned pregnancy and to explore the differences according to women’s age.

Background: Although decision-making regarding abortion has been conceptualised as a multiphase event, the different trajectories leading to termination of an unplanned pregnancy remain unexplored.

Methods: In this cross-sectional study, 422 women (248 adolescents, 174 adults) who had an abortion were recruited. Data were collected through self-report questionnaires at 16 Portuguese healthcare services.

Results: Eight decision-making trajectories leading to termination of an unplanned pregnancy were identified according to the sequence: consideration (or not) to continue the pregnancy, conceal (or not) the decision from the family, the main decision-maker, and reasons for abortion. The most frequent trajectory included women who did not consider its continuation, did not conceal the reproductive decision from their family, were the main decision-maker and referred as reasons for abortion ‘education/job would be more difficult to continue’. Adolescents more frequently not considering pregnancy continuation, not concealing the decision from their family and referred as reasons for abortion the prioritisation of their academic plans and immaturity; or considering its continuation, but were pressured into abortion by their parents. Adults more frequently (not) considering pregnancy continuation, concealed the decision from their family and reported economic reasons for abortion; or considering its continuation, but were pressured into abortion by their partners.

Conclusion: Our study may contribute to more informed intervention by healthcare providers involved in supporting women’s decisions, highlighting the need to promote an informed, weighted, developmentally adapted and free decision-making process.     

Women with nausea and vomiting in pregnancy demonstrate worse health and are adversely affected by odours.

The objectives of this study were (1) to determine aversive stimuli that are related to nausea and vomiting in pregnancy (NVP); (2) to determine food and fluid intake in early pregnancy; and (3) to explore relationships between aversive stimuli and health measures. A total of 273 women in an antenatal setting completed a questionnaire survey, incorporating the Nausea and Vomiting in Pregnancy Instrument (NVPI); the General Health Questionnaire (GHQ); measures of perceived mood and illness; food and fluid intake; and open-ended questions relating to perceived aversive and helpful stimuli. Data was subjected to quantitative and qualitative analysis. A total of 57% of women reported aversive stimuli. Of these, the primary sense implicated was olfaction, with 72% reporting food smells. A number of women were affected by the odours of drinks (26%) and other products (31%). Women who were adversely affected by odours had higher severities of NVP, perceived illness and psychopathology scores on the GHQ. In conclusion, odour appears to be an important stimulus related to NVP, with perceived aversive smells related to the severity of nausea. Women severely affected by NVP demonstrated worse health. The role of olfaction in pregnancy and specifically in sufferers of severe NVP should be evaluated further.     

Nausea and vomiting in pregnancy: results of a survey that identified interventions used by women to alleviate their symptoms

Nausea and vomiting of pregnancy (NVP) affects most pregnant women. There are safe and effective treatments available; however, most women choose to avoid pharmacological therapies and try lifestyle and dietary changes to treat their condition. To date, no attempt has been made to quantify women's experience with a variety of interventions. This study aims to identify factors commonly reported by women that alleviate their symptoms of NVP. Five hundred women with NVP, calling a pregnancy healthline between February 1996 and July 1999, completed a questionnaire where they were asked to rate which of 21 factors helped and to what extent each factor helped to improve their NVP symptoms. For each item, the 'frequency' (percentage of women who indicated that item as an improvement) and 'mean importance' (mean importance score of women who indicated that item as an improvement) were multiplied to give the 'overall impact' score. All 500 women reported that dietary and lifestyle changes helped to improve their NVP symptoms. However, most items were rated low and only 31% of women reported benefit from the use of pharmacological treatment. In conclusion, this study has identified that NVP is a multifaceted condition. Lifestyle changes including validation, supportive counseling and dietary adjustments are important components, that can be used to counsel women with NVP, concomitantly with safe and effective treatment.     

Nausea and vomiting of pregnancy and association with pregnancy outcome

The pattern of nausea and/or vomiting of pregnancy were investigated in a group of 414 predominantly white, upper middle-class women in Albany, New York; patterns were ascertained before their eighty-eighth day of gestation and followed up to the end of pregnancy. Of these, 89.4% reported at least some symptoms. This frequency is higher than reported previously, perhaps in part because extensive attempts were made in this study to ascertain symptoms. The incidence of vomiting was about 55%. Women with no symptoms of nausea and/or vomiting of pregnancy experienced a significantly greater proportion of nonviable pregnancy outcomes (fetal death). Increased intake of niacin during the first trimester was associated with decreased infant birth weight. This may be the result of quicker fetal maturation due to increased levels of protein intake.     

The outpatient management and special considerations of nausea and vomiting in pregnancy

With 50–90% of pregnant women experiencing nausea and vomiting of pregnancy (NVP), the burden of illness can become quite significant if symptoms are under-treated and/or under-diagnosed, thus allowing for progression of the disease. The majority of these women will necessitate at least one visit with a provider to specifically address NVP, and up to 10% or greater will require pharmacotherapy after failure of conservative measures to adequately control symptoms. As a result, initiation of prompt and effective treatment in the outpatient setting is ideal. Once NVP is diagnosed and treatment is started, it is crucial to track symptoms in order to assess for a decrease in or resolution of symptoms as well as an escalation in symptoms requiring additional therapy. Of note, co-existing gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and psychosocial factors may have a negative impact on the management of NVP. Ultimately, every woman has her own perception of disease severity and desire for treatment. It is critical that both the provider and patient be proactive in the diagnosis and management of NVP.     

Attitudes, management and consequences of nausea and vomiting of pregnancy in the United States and Canada

Background: Nausea and vomiting of pregnancy (NVP) affects a large proportion of pregnant women. In 1983, Bendectin^®, the only FDA-approved drug for NVP, was removed from the market by its manufacturer due to legal costs based on claims of teratogenicity, which were subsequently proven to be unsubstantiated. In Canada, a generic form of Bendectin^® (Diclectin^®; a doxylamine/pyridoxine combination) has continued to be available, with increasing use over the last few years. Objective: To characterize the attitudes, management and consequences of NVP among pregnant women in the USA, where no approved drug for NVP is available, and in Canada, where such a drug is available. Design: Prospective, observational study. Results: Women suffering from NVP (N=1444) were interviewed, of which 42% were American and 58% were Canadian. The two groups had similar maternal characteristics and a similar distribution of severity of NVP, although among Canadian women the NVP continued for slightly longer. American respondents were treated significantly more often by an obstetrician as their primary caregiver, were more commonly advised by their caregiver to change their diet and/or lifestyle and to use non-pharmacological agents to manage their NVP, and more often perceived anti-emetics as posing an increased risk for malformations (all P<0.001). Canadian respondents reported a family physician as their primary caregiver significantly more often, were more commonly advised to take anti-emetic medications and perceived their NVP as causing a concern to their unborn (all P<0.001). American women experienced significantly larger weight loss, more hospitalizations and more time lost from paid work. Conclusions: Lack of an approved drug for symptoms of NVP may be associated with unwarranted and preventable adverse health effects. Because this is an observational study, these associations do not necessarily prove causation.     

The termination of human pregnancy with prostaglandin analogs.

The investigational use of prostaglandins to establish a safe, alternative method for the termination of pregnancy has shown significant development in the United States. The introduction of second generation compounds was initiated by chemically attaching a methyl group in the 15 carbon position of prostaglandins E2 and F2alpha. These compounds prevented enzymatic degradation by the enzyme prostaglandin 15 dehydrogenase. (15S)-15 methyl prostaglandin E2 methyl ester administered by intramuscular injection has been used successfully to therapeutically terminate pregnancy in 208 women of gestational age six through 20 weeks. Side effects, not major and considered acceptable by the investigator, were vomiting, diarrhea and temperature elevations associated with shaking and chills. (15S)-15 methyl prostaglandin F2alpha (THAM), administered by intramuscular injection, has been used to terminate pregnancy in 283 women. Efficacy rates under optimal dosage regimens have reached 100% with a complete abortion rate of 96%. Gastrointestinal side effects of vomiting and diarrhea occurred, but temperature elevations with associated shaking and chills were infrequent. The mean time from initial therapy to abortion with both compounds has remained under 16 hours. A route of drug therapy for therapeutic termination of human pregnancy has been explored and developed which avoids invasion of the uterus.