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.     

Factors associated with elective termination of pregnancy among Canadian and American women with nausea and vomiting of pregnancy

Case reports have associated severe nausea and vomiting of pregnancy (NVP) with elective termination of pregnancy. Therefore, our objective was to explore the determinants of consideration of termination and actual termination of pregnancy among women with NVP. From 1996 to 1997, callers to an advertised NVP Healthline underwent a semi-structured interview. From callers who retrospectively reported on NVP in a previous pregnancy, a nested unmatched case-control study was performed. Callers were divided into three groups: those who reported having electively terminated their pregnancy due to NVP, those who considered termination due to NVP and those who never considered termination. The severity of nausea and vomiting, and frequency of psychosocial morbidity, were compared between cases and controls, and multivariate logistic regression analysis was used to determine factors independently associated with termination and/or consideration of termination of pregnancy due to NVP. Of 3201 callers with NVP, 413 women reported having considered termination of pregnancy for NVP, 108 reported termination due to NVP and 2609 reported never having considered termination for NVP. The following factors were independently associated with a woman's consideration of termination of pregnancy due to NVP: unplanned pregnancy (p = 0.002), multiparity (p = 0.0001), more severe vomiting (p = 0.003), feelings of depression (p < 0.0001) and reported adverse effects of NVP on both her partner's daily life (p = 0.04) and her relationship with her partner (p = 0.0003). The following factors were independently associated with actual termination of pregnancy due to NVP: unplanned pregnancy (p < 0.0001), multiparity (p = 0.03) and feelings of depression (p = 0.001). There were no significant interactions between factors. Consideration of termination, or actual termination of pregnancy, due to NVP are associated with psychosocial circumstances, which should be taken into consideration when managing these women.     

A novel method for the evaluation of the severity of nausea and vomiting of pregnancy

The symptomatology of nausea and vomiting of pregnancy (NVP) ranges from mild to very severe. The most advanced method to measure the burden of NVP, the Rhode's scores, incorporates physical signs (length and number of episodes of nausea, number and volume of vomits, and number of retching) with measures of distress caused by these symptoms. However, this system has been validated only for symptoms that occurred in the past 12 h, thus obviating its wide clinical use, and particularly its retrospective use. OBJECTIVE: To examine whether the severity of the physical symptoms of NVP correlate with the degree of stress caused by them, and to develop simple scores that can be used clinically. METHODS AND RESULTS: We prospectively scored 283 women with NVP using the Rhode's system. There was excellent and highly significant correlation between the physical symptoms and their degrees of distress. Subsequently, we examined two simple scoring systems, one with three and one with five physical symptoms. Both yielded distribution of severity of NVP not different from the one found with the use of the full Rhode's score. CONCLUSION: A scoring system based on all five physical symptoms, or only on three (length of nausea, number of episodes of nausea and number of vomits) yielded accurate estimates of severity and changes in severity of NVP. Unlike the Rhode's score, this simple method can be used clinically to evaluate the severity and changes in NVP.     

Discordance between physical symptoms versus perception of severity by women with nausea and vomiting in pregnancy (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.     

Validation studies of the Pregnancy Unique-Quantification of Emesis (PUQE) scores.

The Pregnancy-Unique Quantification of Emesis (PUQE) is a scoring system to quantify the severity of nausea and vomiting of pregnancy (NVP). Based on quantification of the 3 physical symptoms of NVP (nausea, vomiting and retching), PUQE closely correlates with the validated but much more complex Rhodes' score. We examined the ability of PUQE to predict four independent aspects of NVP: (a) pregnant women's ability to take multivitamins. (b) rates of emergency room visits and hospitalisation for NVP. (c) health cost of NVP. (d) women's self scores of well-being in NVP. Using large prospective cohorts of women for each end point, severity of NVP measured by PUQE had significant predictive value for all 4 aspects sought. PUQE has been validated through 4 independent clinical outcomes of direct importance and relevance for NVP. The simplicity of PUQE and the ease of its execution make it a practical tool for both clinical follow-up and research.     

Nausea and Vomiting of Pregnancy: Using the 24-hour Pregnancy-Unique Quantification of Emesis (PUQE-24) Scale

With up to 80% of pregnant women experiencing nausea and vomiting of pregnancy (NVP), it is critical to have a graded scale of its severity as a guide for appropriate treatment. In 2002 we introduced the Pregnancy-Unique Quantification of Emesis (PUQE) scoring system, which assessed the severity of nausea and vomiting in pregnancy (NVP) based on three physical symptoms: nausea, vomiting, and retching over the previous 12 hours. We present here validation of an extension of the original PUQE, by assessing NVP over 24 hours. This extension is deemed more clinically relevant, because assessment of symptoms over only 12 hours may encompass sleeping hours and hence may not adequately capture the length and severity of the symptoms. In this study we assessed the external validity of the new PUQE-24 by examining its ability to evaluate several characteristics associated with NVP: (a) ability to take multivitamin supplements; (b) rates of hospitalization and emergency room visits for severe symptoms; (c) sleep patterns; (d) liquid intake; and (e) the woman’s self-rated well-being scores. Data collected prospectively from 315 women counselled via the Motherisk NVP line were used for the validation. PUQE-24 showed strong correlation with all parameters examined except for sleep patterns and hydration status. The well-being score, however, correlated significantly with hydration status. Capturing 24 hours rather than 12 hours of symptoms may better direct management of NVP and predict its outcome.     

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.     

Nausea and Vomiting in Early Pregnancy of Adolescents: Relationship with Depressive Symptoms

Study ObjectiveTo determine the relationship between severity of nausea and vomiting during pregnancy (NVP) and depressive symptoms in pregnant adolescents.DesignProspective cross-sectional study.SettingA maternity research hospital outpatient clinic, Ankara, Turkey.ParticipantsA total of 200 pregnant adolescents.Interventions and Main Outcome MeasuresDemographic features and obstetric histories of the participants were assessed. The Rhodes test was performed to determine nausea and vomiting severity in a face-to-face interview, and the self-reported Edinburgh Postnatal Depression Scale was administered with supervision.ResultsThe Rhodes test results showed that 52/200 patients (26%) were classified with none, 83/200 patients (41.5%) with mild, 48/200 patients (24.0%) with moderate, and 17/200 patients (8.5%) with severe symptoms. The mean depression score in the severe vomiting group was significantly higher than that in the no NVP and mild NVP groups (P = .028 and .041, respectively). No differences were found between the other groups.ConclusionSevere nausea and vomiting was associated with greater depressive symptom severity in pregnant adolescents.     

A comparison of different severities of nausea and vomiting during pregnancy relative to stress, social support, and maternal adaptation

A cross-sectional and comparative research design with convenience sampling was used to recruit pregnant women from prenatal clinics in southern Taiwan between 2002 and 2003 to examine the differences in perceived stress, social support, and maternal psychosocial adaptation among women with different severities (mild or less than mild, moderate, and severe) of nausea and vomiting during pregnancy. A total of 150 pregnant women participated in this study. One-way analysis of variance indicated that perceived stress was significantly different among the 3 groups. The least significant difference post-hoc test revealed that pregnant women with mild nausea and vomiting had significantly lower stress than did pregnant women with severe nausea and vomiting. The severity of nausea and vomiting was significantly associated with the Prenatal Self Evaluation Questionnaire subscales for "acceptance of pregnancy" and "fear of helplessness and loss of control in labor." Social support and maternal psychosocial adaptation were not significantly different among these three groups. The degree of perceived stress and maternal psychosocial adaptation may be related to the severity of nausea and vomiting during pregnancy.     

Recall bias of the symptoms of nausea and vomiting of pregnancy

OBJECTIVE: Nausea and vomiting of pregnancy is the most common medical condition in pregnancy. Relatively little research has been conducted on this condition, and much of it is based on women's reports. Determinants that affect women's reports of their nausea and vomiting of pregnancy symptoms have not been elucidated. The purpose of this study was to assess the accuracy of recall by women of their symptoms of nausea and vomiting of pregnancy. STUDY DESIGN: Two hundred women who called the Motherisk nausea and vomiting of pregnancy counseling line in Toronto were asked about the severity of their nausea and vomiting of pregnancy symptoms with the use of the pregnancy unique quantification of emesis and nausea system (PUQE). The patients were asked the same questions again during a follow-up call, which took place up to 16 weeks later. RESULTS: There was a recall (or reporting) bias for nausea and vomiting, with women reporting significantly more severe symptoms during their follow-up call than they had reported originally. Multivariate analysis revealed that the severity of the symptoms affected the accuracy of recall positively, whereas the time that has elapsed affected it negatively. CONCLUSION: Retrospective evaluation of nausea and vomiting of pregnancy symptoms may produce a recall bias, which may distort the evaluation of the therapeutic effectiveness of antiemetics.     

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.     

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.     

Ginger to reduce nausea and vomiting during pregnancy: evidence of effectiveness is not the same as proof of safety

Ginger is a common traditional remedy taken by numerous women experiencing nausea and vomiting in pregnancy (NVP). There is considerable evidence to support its effectiveness as an anti-emetic, but also increasing concern over its safety. Ginger is a powerful herbal medicine which acts pharmacologically and thus has specific indications, contraindications, precautions and side-effects, the most notable of which is an anticoagulant action. Midwives and other professionals advising women in early pregnancy about strategies for coping with NVP should be aware of the risks and benefits of ginger in order to provide comprehensive and safe information to expectant mothers.This paper reviews some of the contemporary research evidence which demonstrates that ginger is not a universally appropriate or safe choice for women with NVP and offers a checklist for professionals advising expectant mothers.     

Nausea and Vomiting in Pregnancy Is Not Always Nausea and Vomiting of Pregnancy

The majority of pregnant women experience nausea and vomiting during pregnancy. However, nausea and vomiting in pregnancy is not always nausea and vomiting of pregnancy (NVP). The differential diagnosis of nausea and vomiting in pregnancy can be extensive and the underlying cause can sometimes be difficult to diagnose. However, the timing or onset of the symptoms is important in differentiating NVP from other causes. A thorough history and physical examination, with appropriate investigations, should be carried out in symptomatic women.     

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.     

Diclectin Therapy for Nausea and Vomiting of Pregnancy: Effects of Optimal Dosing

Objectives: (1) To quantify rates of suboptimal use of pyridoxine hydrochloride-doxylamine (Diclectin); and (2) to study responses to optimal doses of Diclectin in women previously taking a suboptimal dose.Methods: Women who called the Motherisk NVP helpline, and were taking only Diclectin (vitamin B₆ 10 mg and doxylamine 10 mg), were enrolled in the study and assessed for the severity of nausea and vomiting of pregnancy (NVP) with the Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system. Their Diclectin doses were subsequently increased according to body weight and individual symptoms. A follow-up phone call occurred within I to 3 weeks after the intervention, at which time the overall PUQE score was repeated, along with individual scoring of symptoms of nausea, vomiting, and retching.Results: Sixty-eight women were enrolled and completed the study. Despite moderate to severe NVP, defined by the validated PUQE scoring system, most women (50/68) were receiving 2 tablets a day of Diclectin instead of the recommended dose of 4 tablets a day. Following a mean doubling of the dose to 4 tablets a day, there was a significant decrease in length of nausea (from 4 to 3 hours, P < 0.001), frequency of vomiting (from mean 1.6 to 1.3 a day, P = 0.02), and overall PUQE score (from mean 7.5 to 6.1, P < 0.001).Conclusion: Women suffering from NVP are often given subtherapeutic doses of Diclectin. Women should receive a dosage according to their body weight and severity of their symptoms.     

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.