Hyperemesis gravidarum and eating disorders before and after pregnancy: A register-based study.

OBJECTIVE: Hyperemesis gravidarum (HG) is a severe form of excessive vomiting during pregnancy. The connection between psychiatric morbidity and HG has been debated, but only a few studies have focused on eating disorders (EDs). The objective of this study was to evaluate the association between HG and both pre-pregnancy and new post-pregnancy EDs. METHODS: A register-based controlled study. HG diagnoses were retrieved from healthcare registers between 2005 and 2017. Women with HG in their first pregnancy resulting in delivery were chosen as cases (n = 4265; the HG group) and women with no HG as controls (n = 302,663; the non-HG group). The associations between EDs and HG were analyzed by binary logistic regression, adjusted with age, body mass index, smoking, socioeconomic status, and pre-pregnancy psychiatric diagnoses. RESULTS: In the HG group, 1.6% and in the non-HG group, 0.2% had a pre-pregnancy ED. Women with ED were more likely to have HG in their first pregnancy compared with women with no history of EDs (adjusted odds ratio [AOR] 9.4, 95% CI 6.52-13.66, p < .0001). Moreover, 0.4% of the women in the HG group and 0.1% of the women in the non-HG group had a new ED diagnosis after pregnancy, and thus the women in the HG group were more likely to have an ED diagnosis after pregnancy (AOR I 3.5, 95% CI 1.71-7.15, p < .001, AOR II 2.7, 95% CI 1.30-5.69, p = .008). DISCUSSION: We found a bidirectional association between ED and HG, suggesting a shared etiology or risk factors between these disorders. This finding emphasizes the importance of collaboration across various specialties when treating these patients. PUBLIC SIGNIFICANCE: Our findings suggest a bidirectional association between HG and EDs before and after pregnancy. This finding provides essential information for healthcare professionals working with pregnant women. As both of these disorders are known to have far-reaching effects on the lives of both the mother and her offspring, our results help clinicians to target special attention and interventions to the patients suffering from these disorders.

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 statementWhat 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.

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.

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

BACKGROUND: Nausea and vomiting of pregnancy (NVP) deteriorates many aspects of daily lives of women. However, little is known about associations between NVP and sleep quality. METHODS: Women 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 30 years, mean gestational week 16.6, mean BMI 24.4 kg/m2, 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 3 months 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. RESULTS: According 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 . CONCLUSIONS: More 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.

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

INTRODUCTION: Hyperemesis 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 with non-hyperemetic pregnancies both in different women and in the same women's different pregnancies. MATERIAL AND METHODS: Data about all pregnancies resulting in delivery in Finland in 2005-2017 were retrieved from healthcare registers. Women who had a diagnosis of hyperemesis gravidarum 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. The 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. RESULTS: 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. The 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. The incidence of hyperemesis gravidarum in Finland was comparable to that in other countries.

Nausea and vomiting of pregnancy: associations with personal history of nausea and affected relatives.

PURPOSE: To examine whether personal history of nausea or history of nausea and vomiting of pregnancy (NVP) in relatives are risk factors for a woman to suffer from NVP. Further, to evaluate if these factors are associated with the severity of NVP. METHODS: Cohort study of 2411 pregnant women recruited from maternity health care clinics. The severity of NVP was categorized according to Pregnancy-Unique Quantification of Emesis (PUQE) questionnaire into no/mild/moderate/severe NVP. History of nausea was assessed in connection with motion sickness, seasickness, migraine or other kinds of headache, after anesthesia, related to the use of contraceptives, and other kinds of nausea. History of NVP in relatives was categorized into first-degree (mother/sister) and second-degree relatives (more distant). RESULTS: In multivariable analysis including previous personal history of nausea, motion sickness (OR 3.17, 95% CI 1.81-5.56, p < 0.0001) and nausea in migraine (OR 3.18, 95% CI 1.86-5.45, p < 0.0001) were associated with severe NVP. History of nausea in other kinds of headache was associated with moderate NVP (OR 1.91, 95% CI 1.34-2.72, p = 0.001). Women with affected first-degree relatives had higher odds for moderate (OR 3.84, 95% CI 2.72-5.40) and severe (OR 3.19, 95% CI 1.92-5.28) NVP (p < 0.0001). All these results remained significant after adjusting for parity, body mass index, smoking, employment and age. CONCLUSION: Women with personal history of nausea or family history of NVP have an increased susceptibility of NVP. This information is useful in pre-pregnancy counselling.

Recurrence patterns of hyperemesis gravidarum.

BACKGROUND: Hyperemesis 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 15-81%, depending on study settings. Factors affecting recurrence of hyperemesis gravidarum are as yet insufficiently studied. OBJECTIVE: We sought to 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 DESIGN: Out of all pregnancies ending in delivery in Finland from 2004 through 2011, data of women who had at least 1 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 that followed the index pregnancy to the total number of pregnancies that followed the index pregnancy. Recurrence patterns 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, prepregnancy body mass index, smoking, marital and socioeconomic status, domicile, month of delivery, assisted reproductive technology, sex, and number of fetuses were analyzed in both the index pregnancies and in pregnancies following the index pregnancy. RESULTS: There 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 >1 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 2 than parity of 1 (adjusted odds ratio, 1.33, P = .046). Overweight women (adjusted odds ratio, 0.58, P = .036) or women who smoked after the first trimester (adjusted odds ratio, 0.27, P < .001) had lower recurrence of hyperemesis. In the comparison of the subsequent pregnancies, quitting smoking in the first trimester (adjusted odds ratio, 0.32, P = .010) and smoking continued after the first trimester (adjusted odds ratio, 0.38, P = .002) were associated with lower odds of recurring hyperemesis. Female sex of the fetus was associated with higher odds of recurring hyperemesis (adjusted odds ratio, 1.29, P = .012). CONCLUSION: In 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 1 pregnancy with hyperemesis, the following pregnancy may be different.

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 (p<0.0001). At admission, women rating worse physical QoL (first admission adjusted OR (AOR) 1.09; 95% CI 1.03 to 1.16; readmissions AOR 1.13; 95% CI 1.02 to 1.25) and women with ketonuria of +++ (first admission AOR 16.00; 95% CI 1.44 to 177.82) fell into higher PUQE score category. On discharge day, women with better physical QoL had lower PUQE score category (first admission AOR 0.94; 95% CI 0.91 to 0.98; readmissions AOR 0.93; 95% CI 0.90 to 0.97). The results between physical QoL and continuous PUQE scores were similar. Concerning readmissions, better mental QoL was associated with lower PUQE score category at discharge (AOR 0.93; 95% CI 0.89 to 0.97). As for continuous PUQE score, worse mental QoL was associated with higher score at admission (readmissions, p=0.007) and better mental QoL with lower score at discharge (readmissions, p=0.007). CONCLUSIONS: 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.

Nausea and vomiting of pregnancy: A study with pregnancy-unique quantification of emesis questionnaire.

OBJECTIVES: Nausea and vomiting of pregnancy (NVP) is frequent, affecting up to 70-85% of pregnant women. However, severity of NVP especially in clinical practice is often uncertainly assessed and thus both under- and overdiagnosing is probable. Furthermore, risk factors for NVP, although recognized, are not well established. The aim of our study was to evaluate the severity of NVP with a structured questionnaire and evaluate associative risk factors. STUDY DESIGN: Sample of 2411 women were recruited from maternity health care clinics. Severity of NVP was assessed with pregnancy-unique quantification of emesis (PUQE) questionnaire. Age, previous pregnancies, previous deliveries, previous miscarriages including ectopic pregnancies, previous pregnancy terminations, nationality, pre-pregnancy body mass index, smoking, marital status and employment were used as explanatory factors. RESULTS: Altogether 88.0% of the women reported some level of NVP, of which 6.4% was severe, 52.2% moderate and 29.4% mild. Daily duration of NVP was ≥ four hours in 12 h in 45.0%. Further, 18.8% of the women had vomiting episodes ≥ three times and 37.4% retching episodes ≥ three times in 12 h. Women with ≥ two previous pregnancies had increased risk for more severe NVP (OR 2.17, 95%CI; 1.34-3.51, p < 0.0001). Older women had increased daily duration of nausea (OR 1.03, 95%CI; 1.00-1.06, p = 0.004) but lower number of vomits (OR 0.93, 95%CI; 0.93-0.97, p < 0.0001) and lower number of retching (OR 0.93, 95%CI; 0.90-0.96, p < 0.0001). Smokers had shorter daily duration of nausea (OR 0.49, 95%CI; 0.33-0.73, p < 0.0001), but higher number of vomiting episodes compared to non-smokers (OR 1.83, 95%CI; 1.26-2.66, p = 0.021). CONCLUSIONS: Women suffered from NVP very frequently. The daily duration of NVP was moderately long, in nearly half of the women four hours or more. In addition, retching was more frequent than vomiting. From studied risk factors, few associations with different aspects of NVP emerged, but only multiparity was associated with the severity of NVP. As NVP affects several women during pregnancy, in future, the impact of NVP on quality of life, future family planning and health costs should be evaluated.