Hyperemesis Gravidarum: Incidence, Recurrence, Hospitalizations, Outpatient Care and Effect on Family Planning

Hyperemesis gravidarum (HG), severe and intractable vomiting of pregnancy, affects approximately 1% of pregnancies. The symptoms prevent sufficient intake of food and liquids, causing suffering and requiring treatment such as intravenous hydration, nutrition or medication. The present thesis aimed at elucidating various aspects of HG in Finland: incidence, outpatient visits and hospitalizations, readmissions, and recurrence, as well as effects on family planning and associations between maternal, environmental, and pregnancy-related factors and HG. The data were collected from health care registers: the Hospital Discharge Register, the Medical Birth Register, the Register of Induced Abortions, and the Sterilization Register. Women with deliveries in 2004–2017 were included in the study. 9,315 women diagnosed with HG in any pregnancy were chosen as case women, and 428,150 women never diagnosed with HG as reference women. Incidence of HG was 1.3%. Readmission rate due to HG was 60% (both outpatient visits and hospitalizations), and rehospitalization rate was 17%. HG recurred in 24% of pregnancies following an initial HG pregnancy. Obesity, living in municipalities with higher population count, assisted reproductive technology (ART), multiple gestation, and female sex of the fetus were associated with higher risk of HG, whereas smoking was associated with a lower risk. Higher parity, multiple gestation, and female sex of the fetus were associated with higher risk of readmission, while higher maternal age, BMI ≥ 35, smoking and ART were associated with lower risk. Female fetus was associated with higher risk of recurring HG, and smoking was associated with lower risk of recurrence. Women with HG had more pregnancy terminations and sterilizations compared to women never diagnosed with HG, but HG did not reduce the overall number of deliveries. HG is relatively rare, whereas common nausea and vomiting during pregnancy affects the majority of pregnancies, and interview studies have described how it has frustrated and discouraged women with HG if their symptoms have been misinterpreted as “normal”, leading to insufficient recognition of HG and delayed access to care. The results of the present thesis highlight the importance of identifying and treating the HG efficiently.Hyperemesis gravidarum (HG) tarkoittaa vakavaa raskauspahoinvointia, jota esiintyy noin yhdessä sadasta raskaudesta. HG-oireet aiheuttavat kärsimystä, voivat estää riittävän syömisen ja juomisen, ja tila vaatii usein suonensisäistä nesteytystä ja ravitsemusta sekä lääkehoitoa. Tässä väitöstutkimuksessa selvitettiin HG:n ilmaantuvuutta, toistuvaa hoidon tarvetta, HG:n toistumista seuraavissa raskauksissa, vaikutusta perhesuunnitteluun sekä erilaisten taustatekijöiden ja HG:n välisiä yhteyksiä. Tutkimusaineisto koottiin Terveyden ja hyvinvoinnin laitoksen ylläpitämistä Hoitoilmoitusrekisteristä, Syntyneiden lasten rekisteristä, Raskaudenkeskeytysrekisteristä ja Steriloimisrekisteristä. Tutkimukseen valittiin naiset, joilla oli v. 2004–2017 vähintään yksi synnytys: 9 315 naista, joilla oli HG-diagnoosi vähintään yhdessä raskaudessa sekä verrokkihenkilöiksi 428 150 naista, joilla ei ollut HG-diagnoosia yhdessäkään raskaudessa. HG:n ilmaantuvuus oli 1,3 %. Näistä raskauksista 60 % vaati useamman kuin yhden poliklinikkakäynnin tai sairaalahoitojakson HG:n vuoksi, ja 17 %:ssa raskauksista useamman sairaalahoitojakson. HG toistui 24 %:ssa aiempaa HG-raskautta seuranneista raskauksista. Lihavuus, kotikunnan korkea asukasluku, hedelmöityshoidot, monisikiöraskaus ja tyttösikiö olivat yhteydessä korkeampaan ja tupakointi matalampaan HG:n riskiin. Uudelleensynnyttäjyys, monikkoraskaus ja tyttösikiö liittyivät suurempaan hoidon tarpeeseen ja korkeampi ikä, tupakointi ja hedelmöityshoidot pienempään. Tyttösikiö oli yhteydessä suurempaan ja tupakointi pienempään HG:n toistumisriskiin. HG:n kokeneilla naisilla oli enemmän raskaudenkeskeytyksiä ja sterilisaatioita kuin verrokkihenkilöillä, mutta HG ei vähentänyt synnytysten määriä. Normaaliin raskauspahoinvointiin verrattuna HG on melko harvinainen ja huonosti tunnettu tila, ja HG-potilaat ovat kuvanneet, miten turhauttavaa ja masentavaa on, jos hyperemeesiä luullaan tavalliseksi pahoinvoinniksi. HG:n tunnistaminen on tärkeää sekä oikean diagnoosin että hoitoon pääsyn ja hoidon onnistumisen varmistamiseksi

Recurrence patterns of hyperemesis gravidarum

BackgroundHyperemesis gravidarum, excessive vomiting in pregnancy, affects approximately 0.3–3.0% of all pregnancies, but the risk is considerably higher in pregnancies following a hyperemetic pregnancy. The reported recurrence rate of hyperemesis gravidarum is wide, ranging from 15% to 81%, depending on study settings. Factors affecting recurrence of hyperemesis gravidarum are as yet insufficiently studied.ObjectiveTo evaluate the recurrence rate of hyperemesis gravidarum in subsequent pregnancies, to elucidate chronological patterns of recurrence of the condition, and to analyze maternal, environmental and pregnancy-related factors associated with recurring hyperemesis gravidarum.Study DesignOut of all pregnancies ending in delivery in Finland between 2004 and 2011, data of women who had at least one pregnancy ending in delivery following a pregnancy diagnosed with hyperemesis gravidarum were retrieved from Hospital Discharge Register and Medical Birth Register (1836 women, 4103 pregnancies; 1836 index pregnancies and 2267 subsequent pregnancies). The first pregnancy with hyperemesis gravidarum diagnosis was chosen as the index pregnancy, and recurrence rate was calculated by comparing the number of hyperemetic pregnancies which followed the index pregnancy to the total number of pregnancies which followed the index pregnancy. Recurrence patters of hyperemesis gravidarum were illustrated by presenting the chronological order of the women’s pregnancies beginning from the index pregnancy to the end of the follow-up period. The associations between recurring hyperemesis and age, parity, pre-pregnancy body mass index, smoking, marital and socioeconomic status, domicile, month of delivery, assisted reproductive technology (ART), sex and number of fetuses were analyzed in both the index pregnancies and in pregnancies following the index pregnancy.ResultsThere were 544 pregnancies with a hyperemesis diagnosis and 1723 pregnancies without a hyperemesis diagnosis following the index pregnancies. The overall recurrence rate of hyperemesis gravidarum in pregnancies following the index pregnancy was 24%. In case of more than one subsequent pregnancy, 11% of women were diagnosed with hyperemesis in all of their pregnancies. In the index pregnancies, recurrence of hyperemesis gravidarum was more common among women with parity of two than parity of one (adjusted OR=1.33, p=0.046). Overweight women (adjusted OR=0.58, p=0.036) or women who smoked after the first trimester (adjusted OR=0.27, pConclusionsIn the majority of pregnancies following an earlier hyperemetic pregnancy, hyperemesis gravidarum does not recur, but hyperemetic pregnancies occur in the next pregnancies with little predictability. Only few factors associated with recurring hyperemesis could be identified. Although estimating the probability of recurrence of hyperemesis gravidarum in a subsequent pregnancy based on a woman’s first hyperemetic pregnancy turned out not to be feasible, it is reassuring to know that hyperemesis does not appear to become more likely with each pregnancy and that after one pregnancy with hyperemesis, the following pregnancy may be different.</div

Sleep quality in women with nausea and vomiting of pregnancy: a cross-sectional study

BackgroundNausea and vomiting of pregnancy (NVP) deteriorates many aspects of daily lives of women. However, little is known about associations between NVP and sleep quality.MethodsWomen attending to routine mid-pregnancy visits in maternity health care clinics in Turku city area and surrounding municipalities, Finland, during 2011-2014, were invited to participate. A cohort of 1203 volunteers (mean age 30years, mean gestational week 16.6, mean BMI 24.4kg/m(2), nulliparous 46%) was recruited. The severity of NVP in the worst 12-h period of current pregnancy was assessed with Pregnancy Unique Quantification of Emesis Questionnaire (PUQE) and categorized accordingly into no/mild/moderate and severe NVP. Sleep disturbances during the past 3months were assessed with selected questions (difficulty falling asleep, night awakenings, too early morning awakenings and sleepiness during the day) from Basic Nordic Sleep Questionnaire (BNSQ). In addition, general sleep quality, as well as physical and mental quality of life (QoL) were rated with three visual analog scales (VAS). Associations between PUQE categories (severity of NVP) and sleep disturbances, general sleep quality, physical QoL and mental QoL were evaluated with multinomial regression analysis.ResultsAccording to PUQE, NVP was most frequently moderate (n=629, 52.3%), followed by mild (n=361, 30.0%) and severe (n=77, 6.4%). Only 11.3% had no NVP (n=136). The most frequent sleep disturbance was night awakenings (69.9%, n=837), followed by sleepiness during the day (35.7%, n=427), too early morning awakenings (12.0%, n=143) and difficulty falling asleep (7.1%, n=81). In adjusted analysis (age, parity, body mass index, smoking, employment), more severe NVP was associated with night awakenings (AOR 3.9, 95% CI 1.79-8.47, P<0.0001) and sleepiness during the day (AOR 4.7, 95% CI 2.20-9.94, P<0.0001). In VAS, women with more severe NVP rated worse general sleep quality and worse physical and mental QoL. However, in multivariable analysis, the association between the severity of NVP and physical and mental QoL was stronger than that of sleep .ConclusionsMore severe NVP is associated with sleep disturbances and in close relation to lower physical and mental QoL. Thus, in comprehensive care of women with NVP, also sleep quality should be evaluated

Readmissions due to hyperemesis gravidarum: a nation-wide Finnish register study

Purpose: To evaluate the burden of illness caused by hyperemesis gravidarum (HG) and association of readmissions due to HG with maternal, environmental and pregnancy-related factors, and different pregnancy outcomes.Methods: Data of women with HG diagnosis in Finland, 2005-2017, were retrieved from health-care registers. Associations between readmissions due to HG and age, gravidity, parity, pre-pregnancy body mass index (BMI), smoking, marital status, socioeconomic status, municipality population, assisted reproductive technology (ART), and number and sex of fetuses were analyzed in pregnancies resulting in delivery. Admissions and readmissions due to HG in deliveries, gestational trophoblastic disease, ectopic pregnancies, miscarriages and pregnancy terminations were calculated.Results: 10,381 pregnancies with HG diagnosis were identified: 9518 live births, 31 stillbirths, 8 cases of gestational trophoblastic disease, 16 ectopic pregnancies, 299 miscarriages, and 509 pregnancy terminations. Both outpatients and inpatients were included. Readmission occurred in 60% of pregnancies, inpatient readmission in 17%. Parity of ≥ 5, multiple gestation and female sex of fetus were associated with higher odds of readmission, maternal age 36-40 years, BMI ≥ 35 kg/m2, smoking and ART with lower odds of readmission. Of the 9549 pregnancies resulting in delivery, 33% involved at least one outpatient visit or inpatient episode after the first trimester, and 8% in the third trimester.Conclusion: The majority of women suffering from HG needed repeated medical care, often persisting after the first trimester. Our results provide practical information allowing clinicians to prepare for symptom duration beyond the first trimester and emphasize the importance of planning for eventual long-term treatment.</p

Incidence and risk factors of hyperemesis gravidarum: A national register‐based study in Finland, 2005–2017

IntroductionHyperemesis gravidarum is the most common reason for hospitalization in early pregnancy in pregnancies resulting in delivery. Several associative factors indicate that the etiology is likely to be multifactorial. To assess this, we used a unique procedure to compare hyperemetic pregnancies to non‐hyperemetic pregnancies both with different women and the same women's different pregnancies.Material and methodsData about all pregnancies resulting in delivery in Finland in 2005–2017 were retrieved from health care registers. Women who had hyperemesis gravidarum diagnosis in any pregnancy in the Finnish Hospital Discharge Register were chosen as cases (n = 9315) and other women (n = 428 150) as the reference group. Incidence of hyperemesis gravidarum was calculated and associations between hyperemesis and maternal, environmental and pregnancy‐related factors were analyzed in a novel setting by comparing case women's pregnancies diagnosed with hyperemesis to 1) reference group women's pregnancies and 2) case women's non‐hyperemetic pregnancies.ResultsOut of the 437 465 women who had at least one pregnancy resulting in delivery during the study period, 9315 women had at least one hyperemetic pregnancy. Total number of pregnancies resulting in delivery was 741 387 and 9549 of those were diagnosed with hyperemesis gravidarum, thus the incidence of hyperemesis gravidarum was 1.3%. In comparison 1), case women's hyperemetic pregnancies vs reference group's pregnancies, younger maternal age, higher gravidity, underweight and overweight were associated with increased risk of hyperemesis; in contrast, in comparison 2), case women's hyperemetic pregnancies vs their non‐hyperemetic pregnancies, higher age and obesity were associated with higher risk of hyperemesis, whereas the risk was lower as gravidity and parity increased. In both comparisons, smoking was associated with lower risk, whereas higher municipality population, assisted reproductive technology, multiple gestation and female sex of the fetus were associated with increased risk of hyperemesis.Conclusions​​​​​​​Our novel study setting provided new insights about risk factors: hyperemetic pregnancies differ both from pregnancies of women who had never been diagnosed with hyperemesis and from hyperemetic women's non‐hyperemetic pregnancies. Incidence of hyperemesis gravidarum in Finland was comparable to other countries.</div

Usability of Pregnancy-Unique Quantification of Emesis questionnaire in women hospitalised for hyperemesis gravidarum: a prospective cohort study

Objectives Pregnancy-Unique Quantification of Emesis (PUQE) questionnaire is mainly used in outpatient care to assess the severity of nausea and vomiting of pregnancy (NVP). Our aim was to evaluate the usability of the Finnish-translated PUQE in hospitalised women with hyperemesis gravidarum (HG).Design Prospective cohort study.Setting University hospital in Finland.Participants Ninety-five women admitted due to HG for at least overnight.Primary and secondary outcome measures Categorised and continuous PUQE scores, physical and mental quality of life (QoL) and urine ketones at admission and at discharge, analysing the first admission and readmissions separately.Results The most common PUQE categories at admission were ‘moderate’ and ‘severe’, whereas at discharge they were ‘mild’ and ‘moderate’. Likewise, continuous PUQE scores improved between admission and discharge (pConclusions PUQE scores reflected alleviation of NVP severity in women hospitalised due to HG. Further, the decrease in PUQE score was associated with improved physical QoL and partly also with improved mental QoL. We therefore suggest PUQE as a complementary instrument for inpatient setting.</p

Lopu jo! : Apua raskauspahoinvointiin.

Lopu jo! -projekti toteutettiin osana Turun ammattikorkeakoulun Kymppi-hanketta. Muita taustaorganisaatioita ovat Varsinais-Suomen sairaanhoitopiiri, Turun sosiaali- ja terveystoimi sekä kolmannen sektorin toimijat. Projektin visiona oli raskauspahoinvoinnin hävittäminen maailmasta. Konkreettisena tavoitteena oli selvittää raskauspahoinvoinnin kotihoitokeinoja, tuoda tietoa odottaville äideille ja siten vähentää raskauspahoinvoinnin aiheuttamaa kärsimystä. Raskauspahoinvoinnista kärsii jopa 80 % raskaana olevista etenkin raskauden alkuvaiheessa. Pahoinvointi ei ole vaarallista äidille tai sikiölle, mutta se voi johtaa sairaalahoitoon ja estää äitiä iloitsemasta raskaudesta. Raskauspahoinvoinnin hoitoon on olemassa tehokkaita ja turvallisia keinoja, mutta raskaana olevat tuntevat keinoja melko vähän. Projektin yhteydessä toteutettiin interventiotutkimus: alkukartoituksessa selvitettiin strukturoidulla lomakekyselyllä raskauspahoinvoinnin hoitoa Turun äitiysneuvoloissa sekä odottavien äitien että neuvoloiden työntekijöiden kannalta. Interventiona koottiin tietopaketti raskauspahoinvoinnista internetsivuille osoitteeseen lopujo.fi ja toteutettiin erilaisia tiedotus- ja keskustelutilaisuuksia. Loppukartoituksessa tammikuussa 2011 selvitettiin, miten projekti on vaikuttanut raskauspahoinvoinnista kärsivien odottavien äitien tiedonsaantiin ja raskauspahoinvoinnin hoitoon. Alkukartoituksen tulosten perusteella suurin osa raskaana olevista haki apua ja tietoa raskauspahoinvoinnin hoitoon muualta kuin neuvolasta, useimmiten internetistä sekä ystäviltä ja tutuilta. Neuvoloissa annetaan lepoon ja syömiseen liittyviä ohjeita raskauspahoinvoinnin lievittämiseksi, ja yli puolet odottajista sai niistä riittävästi apua. Runsas kolmannes vastanneista olisi toivonut saavansa neuvolasta enemmän apua tai tietoa. Interventiossa tietoa tuotiin odottaville äideille ensisijassa neuvoloiden kautta ja loppukartoituksessa selvitettiin, miten tehostettu tiedon anto vaikuttaa odottajien kokemuksiin raskauspahoinvoinnista. Loppukartoituksen tulosten perusteella projektin mitattava vaikutus on toistaiseksi ollut vähäinen, mutta sanallisen palautteen perusteella projektista on ollut hyötyä sekä neuvoloiden työntekijöille että niille odottajille, jotka ovat saaneet sivustolta apua pahoinvointiin.The project Please stop! was carried out as a part of a project called Kymppi-hanke, organised by the Turku University of Applied Sciences. Other organisations involved were the Hospital District of Southwest Finland, Social and Health Care Services of the City of Turku and third sector organisations. The vision of the project was to eradicate nausea and vomiting of pregnancy (NVP) from the world. The concrete aim was to find ways to treat NVP at home, bring the information to expecting mothers and thus lighten the suffering caused by NVP. NVP affects up to 80 % of pregnant women especially in the beginning of pregnancy. NVP is not dangerous to the mother or fetus, but it may lead to hospitalisation and prevent the mother from enjoying the pregnancy. Effective and safe ways for treating NVP exist but are not well known by expecting mothers. As a part of the project, an intervention study was carried out: in the initial survey, NVP care in the maternity care services in Turku was explored from both the expecting mothers’ and personnel point of view using a structured questionnaire. The intervention consisted of bringing together information about NVP in a web page in the address lopujo.fi, as well as organising various brief seminars. The final survey determined what kind of effect the project has had on the treatment and the information given to mothers suffering from NVP. According to the results of the surveys, the majority of pregnant women seek help and information about treating NVP elsewhere than maternity care services, especially from the Internet and from friends. Maternity care services provide pregnant women with guidance about resting and eating to relieve NVP symptoms, and more than half of those who answered the questionnaires got sufficient help from the guidance. More than third of the expecting mothers would have liked to get more help or information from the maternity care services. The intervention provided the women with information primarily through the maternity care services and the final survey examined how the information affects expecting mothers’ experiences about NVP. According to the results of the final survey, the measurable impact of the project was negligible, but verbal feedback suggests that the project has benefited both the maternity care workers and those mothers who have received help for NVP from the web pages.Lopu jo! -internetsivut osoitteessa http://lopujo.fi Käytettävissä ainakin vuoteen 2015 saakka

Recalling the severity of nausea and vomiting of pregnancy – a study using Pregnancy-Unique Quantification of Emesis Questionnaire

The accuracy of the recall of the severity of nausea and vomiting of pregnancy (NVP) with Pregnancy-Unique Quantification of Emesis (PUQE) questionnaire has been questioned. We aimed to compare PUQE scores of women recalling the worst episode of NVP of their current pregnancy in different gestational weeks (gwks). Total of 2343 pregnant women (gwks 7–40) were recruited. Four groups were formed according to the gwks at reply: ≤16 gwks (n = 554), ≤20 gwks (n = 1209), >20 gwks (n = 1134) and ≥24 gwks (n = 495). PUQE scores were similar between the groups. Consequently, consistency of PUQE scores across the groups endorses the useability of the PUQE questionnaire in retrospective assessment of the overall severity of NVP in different gwks, regardless of passing of the peak NVP symptoms.Impact statement What is already known on this subject? Retrospective evaluation of the severity of nausea and vomiting of pregnancy (NVP) has been argued to be disposed to recall bias. Structured Pregnancy-Unique Quantification of Emesis (PUQE) questionnaire is a validated tool for assessing the severity of NVP. What do the results of this study add? When the women recalled the most severe NVP symptoms of their current pregnancy, no differences in the PUQE scores were found despite different gestational weeks at reply. Of distinct PUQE questions, women answering in early pregnancy reported longer duration of nausea than women answering in late pregnancy, but other questions were rated similarly. What the implications are of these findings for clinical practice and/or further research? Our aim was to compare the PUQE scores between the women who filled in the PUQE questionnaire in early or in late pregnancy, instructed to recall their worst symptoms in their current pregnancy. As there were no differences between the groups in total PUQE scores, our results support the application of PUQE questionnaire to assess the severity of NVP during pregnancy not only concurrent to the peak symptoms but also retrospectively