Hyperemesis Gravidarum in the context of migration: when the absence of cultural meaning gives rise to "blaming the victim".

BACKGROUND: Hyperemesis gravidarum (HG) is a rare complication of pregnancy that involves persistent nausea and extreme vomiting to an intensity that differentiates HG from nausea and vomiting commonly experienced during pregnancy. Research has suggested potential biological and psychological etiological pathways for HG, but the augmented prevalence in immigrant populations, which is 4.5 times higher, remains unclear. Studies show that in order to better address the psychosocial needs of immigrant patients with HG, we must first improve our understanding of how they experience their illness. The objective of this study was to understand the meaning and experience of HG among immigrant women in Canada. METHODS: Our "qualitative comparative analysis design" involved a sample of 15 pregnant mothers following their hospitalization for HG, including 11 immigrant women and 4 Canadian-born women recruited for comparison purposes. We used the Edinburgh Perinatal Depression Scale to assess distress, and the McGill Illness Narrative Interview Schedule to explore how pregnant women understood and experienced their HG and the health services that they received. RESULTS: With the exception of a few women whose mothers suffered from HG, immigrant women and their loved ones did not have cultural knowledge to attribute meaning to HG symptoms. This left them vulnerable to criticism from family, as well as feelings of self-doubt, stress, and anxiety. We interpret this phenomenon as 'victim blaming'. Immigrant women's experience of HG was also characterised by high levels of depressive symptoms (40%) which they linked to the severity of their symptoms, high levels of stress associated with adapting to their new country, social isolation, and loss of female family members. Furthermore, in contrast to Canadian-born women, immigrant women frequently reported feeling that their symptoms were minimized by hospital emergency room medical staff, which led to delays in obtaining appropriate health care. However, once admitted to hospital, they perceived the care provided by dieticians and nurses as helpful in managing their symptoms. CONCLUSIONS: Wider awareness of the impact of HG may improve the quality of family support for immigrant women. There is a need to improve the delays and appropriateness of clinical care.

Helicobacter pylori infection amongst Arab Israeli women with hyperemesis gravidarum--a prospective, controlled study.

OBJECTIVE: Helicobacter pylori has been associated with hyperemesis gravidarum in some geographical regions. The prevalence of H. pylori in Arab Israeli women in the Upper Galilee and its association with hyperemesis gravidarum has not been studied previously. We aimed to examine if hyperemesis gravidarum is associated with H. pylori in this population. METHODS: Subjects with hyperemesis gravidarum carrying a singleton fetus were recruited prospectively. Women with an uncomplicated pregnancy served as controls. All patients underwent (13)C-urea breath testing to assess for H. pylori infection. RESULTS: A total of 72 subjects, including 24 patients with hyperemesis gravidarum and 48 controls, aged 28.8±5.3 years, were included. H. pylori infection was identified in 75.0% (18/24) of cases and 60.4% (29/48) of controls (p=not significant). H. pylori infection did not correlate with age, fetal sex, or the number of previous pregnancies (p=not significant). CONCLUSION: H. pylori does not seem to increase the likelihood of hyperemesis gravidarum in Arab Israeli women. However, given the high background prevalence of H. pylori in this population, a larger study is required to corroborate these findings. (MOH20110066).

Helicobacter pylori infection and severe hyperemesis gravidarum among immigrant women in Norway: a case-control study.

OBJECTIVE: To study associations between Helicobacter pylori exposure and severe hyperemesis gravidarum (HG) among immigrant women in Norway by exploring IgG seropositivity and H. pylori antigens in faeces. Additionally, we investigated whether cytotoxin-associated gene A product (CagA) and vacuolating cytotoxin A (VacA) seropositivity modulated this association. STUDY DESIGN: An institution-based case-control study among immigrant women in Norway was performed at Ullevål and Akershus University Hospitals in September 2005-December 2007. Blood samples were used to explore IgG, CagA and VacA seropositivity, and faecal samples were used to explore the presence of antigens. Multiple logistic regressions were used to study associations between HG and H. pylori exposure. RESULTS: The sample comprised 170 women: 62 cases and 108 controls. The observed proportion of IgG seropositive women did not differ between cases and controls. Neither IgG seropositivity nor CagA and VacA seropositivity were significantly associated with HG. For IgG positive and CagA and VacA negative women, the crude OR was 1.26 (95% CI: 0.57-2.82). For those being IgG positive and CagA and VacA positive, the crude OR was 0.82 (0.40-1.68). Adjustment for confounding factors, such as maternal age, body mass index and earlier HG, did not change the results. Additional adjustment for faecal antigens did not change the conclusions regarding these associations. Likewise, the crude OR for H. pylori antigens was not statistically significant. Adjustment for confounders and IgG seropositivity did not change this result. CONCLUSIONS: This study did not find H. pylori exposure to be significantly associated with severe HG among immigrant women in Norway. This was regardless of whether H. pylori exposure was investigated by IgG seropositivity, CagA and VacA seropositivity or by the presence of H. pylori antigens in faeces. These results may indicate that the association between H. pylori and HG is weaker than previously expected, particularly in populations with high prevalence of H. pylori infection.

Do immigration and acculturation have an impact on hyperemesis gravidarum? Results of a study in Berlin/Germany.

QUESTION: How large is the number of immigrant women being treated for hyperemesis gravidarum (HG) among the in-patients in a University hospital in Germany? Does migration have an impact on the psychosocial state of HG patients? Does acculturation have an impact on psychosocial distress in HG patients? METHODS: The following methods were used: retrospective evaluation of all in-patients with HG from 1/1997 to 11/2009, inquiry of a consecutively surveyed group (from 2007 to 2009) of HG in-patients with a questionnaire set: socio-demographic data, questionnaire on psychic distress (SCL-90-R) questionnaire on migration/acculturation, and comparison of German patients and patients with immigration backgrounds as well as among immigrant groups. RESULTS: During the 13-year study period, there were 4.5 times more immigrants treated for HG than native German patients. Compared to the age standardized resident population, the number of women with immigration backgrounds is over-proportionally high. The HG patients scored high in the SCL-90-R scale "somatization" without showing a higher level of psychic distress than the native patients. CONCLUSIONS: Experience of migration is an etiological cofactor for HG. The grade of acculturation does not have a significant influence on the psychic well-being of HG patients.

Change in paternity and recurrence of hyperemesis gravidarum.

OBJECTIVE: To determine whether change in paternity changes recurrence risk of hyperemesis gravidarum (HG). STUDY DESIGN: Survey data on recurrence of HG was compared between cases who had a paternity change between pregnancies and cases who did not. RESULTS: The percentage of HG pregnancies in women with the same partner for all pregnancies was not significantly different from the percentage of HG pregnancies in women who changed partners for at least one pregnancy (78% vs 71%, p > 0.05). Participants who did and did not change partners between their first and second pregnancies, were asked to rate their first and second pregnancy in regards to symptoms of HG. Neither the ratings nor the change in rating between pregnancies was significantly different between the two groups. CONCLUSION: Women reported HG in over 70% of their pregnancies regardless of a paternity change. Paternal genes expressed through the fetus do not have a significant effect on incidence or recurrence of HG. This study supports a strong maternal genetic factor involved in HG. However, because the recurrence risk is not 100%, other factors play a role. Identification of the predisposing gene(s) and other factors will determine the cause of this poorly understood complication of pregnancy.

Maternal characteristics largely explain poor pregnancy outcome after hyperemesis gravidarum.

OBJECTIVE: To describe the characteristics of women who suffer from hyperemesis gravidarum, and explore the independent effect of hyperemesis gravidarum on pregnancy outcome. STUDY DESIGN: In The Netherlands Perinatal Registry, we used all data on singleton pregnancies of at least 24 weeks and 500 g without congenital anomalies in the years 2000-2006. We examined the characteristics of women who suffered from hyperemesis gravidarum and their children. RESULTS: Women who suffered from hyperemesis gravidarum were slightly younger; more often primiparous, of lower socio-economic status, of non-Western descent and substance abusers; had more often conceived through assisted reproduction techniques and more often had pre-existing hypertension, diabetes mellitus and psychiatric diseases than women who did not suffer from hyperemesis gravidarum. Also, their pregnancies were more often complicated by hypertension and diabetes and they more often carried a female fetus. Pregnancies complicated by hyperemesis gravidarum significantly more often had an adverse outcome (prematurity or birth weight below the 10th percentile). The increased risk of adverse pregnancy outcomes after hyperemesis gravidarum was largely explained by the differences in maternal characteristics (crude OR 1.22 (95% CI 1.10-1.36), adjusted OR was 1.07 (95% CI 0.95-1.19)). CONCLUSION: Hyperemesis gravidarum is associated with adverse pregnancy outcomes. This is largely explained by differences in maternal characteristics. Given the impact of the early environment on later health (which is independent of size at birth), studies that aim to assess the long-term consequences of hyperemesis gravidarum need to be given high priority.

Evidence against a link between hyperemesis gravidarum and personality characteristics from an ethnically diverse sample of pregnant women: a pilot study.

BACKGROUND: Hyperemesis gravidarum (HG), a pregnancy-related condition marked by extreme nausea and vomiting, has been considered a psychosomatic illness associated with long-standing personality characteristics (e.g., hysteria). In this pilot study, we examined personality, somatic, and psychological variables with ethnically diverse samples of women with HG and women with typical levels of nausea and vomiting of pregnancy (NVP). METHODS: Personality (Minnesota Multiphasic Personality Index-2 [MMPI-2] and MMPI-2RF), somatic (MMPI-2RF), and psychological (Beck Depression Inventory-II [BDI-II] and NVP-related quality of life) variables collected during the first trimester of pregnancy were compared between 15 women with HG and 15 women with normal levels of NVP matched for age, education, marital status, insurance source, and race/ethnicity. A secondary analysis was performed comparing these variables among a group of 9 asymptomatic pregnant women to the HG and NVP groups. RESULTS: No significant differences were found between the HG and NVP groups on any personality, somatic, or psychological variables. Both groups had clinically significant elevations on the MMPI-2 hypochondriasis scale, which incorporates somatic symptoms. The NVP group had a clinically significant elevation on the MMPI-2RF gastrointestinal complaints scale. Both groups had significantly higher means on the MMPI-2 and MMPI-2RF scales than the asymptomatic group. Predominantly Spanish speakers appeared particularly vulnerable to psychological distress associated with somatic complaints. CONCLUSIONS: The results of this pilot study suggest that research with HG patients is feasible and that psychological distress expressed by women with HG and NVP may reflect reactions to somatic symptoms. No evidence was found to support an association between HG and personality characteristics. Recommendations for future research are provided, such as examining the potential benefits of translation services for Spanish-speaking HG patients.

Variations in prevalence of hyperemesis gravidarum by country of birth: a study of 900,074 pregnancies in Norway, 1967-2005.

OBJECTIVE: To estimate the prevalence of hyperemesis gravidarum (HG) in women living in Norway by their country of birth, and explore whether the variations in the occurrence of HG could be explained by the differences in maternal sociodemographic factors. DESIGN: This was a cross-sectional study. METHODS: All primiparous women registered in the Medical Birth Registry of Norway (MBRN) from 1967 through June 2005 (N=900,074) comprised the sample. Data on HG, age, plurality and sex of the fetus were obtained from the MBRN and linked to the data on country of birth and maternal education obtained from Statistics Norway. Independent associations between country of birth and HG were studied by multiple logistic regression with and without adjustment for potential confounders. RESULTS: The overall prevalence of HG in primiparous women in Norway during the study period was 0.89% (95% confidence interval (CI) 0.88-0.92). Women born in Western Europe had the lowest prevalence of HG (0.8%), whereas those born in India and Sri Lanka had the highest (3.2%). Women born in Africa (except North Africa) and India or Sri Lanka were 3.4 (95% CI 2.7- 3.5) and 3.3 (95% CI 2.6-3.4) times more likely to develop HG than women born in Norway, after adjustment for potential confounders. CONCLUSIONS: Substantial variations in the prevalence of HG in Norway by country of birth cannot be explained by the differences in maternal sociodemographic factors.

Length of residence and risk of developing hyperemesis gravidarum among first generation immigrants to Norway.

BACKGROUND: To estimate the risk of hyperemesis gravidarum (HG) among first generation immigrants to Norway by length of residence. DESIGN: A cross-sectional study. METHODS: The sample consisted of first generation immigrants with a prevalence of HG exceeding ethnic Norwegians by 50%, registered in the Medical Birth Registry of Norway (MBRN). The women were born in Turkey, Middle East, North Africa, Other Africa, Iran, Pakistan, India and Sri Lanka and Central and South America, the total sample size is 50,904. MBRN data on HG, age, parity, plurality and sex of the baby were linked to information on country of birth, maternal education and duration of stay obtained from Statistics Norway. Independent associations were studied for each immigrant group and adjusted for potential confounders. To account for dependencies in the sample, a generalized estimating equations (GEE) approach was used. RESULTS: For women from Central and South America, adjusted analysis showed a decrease in the risk of HG by longer residency (P for trend = 0.026). A similar but not significant trend was observed for women born in the Middle East (P for trend = 0.097). Women born in Turkey who had been living in Norway for 6-8 years had a higher risk of HG than newcomers, though no trend was observed (P for trend = 0.127). Women born in Iran and North Africa who lived longer in Norway tended to have a higher risk of developing HG than newcomers (P for trend = 0.083 and 0.118, respectively) CONCLUSION: Associations between HG and duration of residence in Norway did not show a universal pattern across immigrant groups. Women born in Central and South America had a lower risk of HG with increasing length of residence. Some evidence to the contrary was found for women born in Iran, North Africa and Turkey.

Helicobacter pylori infection and Hyperemesis gravidarum. An institution-based case-control study.

BACKGROUND: The etiology of Hyperemesis gravidarum (HG) is unclear. To test the hypothesis of an association between Helicobacter pylori infection and HG, an institution-based case-control study was performed at Aker University Hospital (AUH) during 1994-1999. MATERIAL AND METHOD: From the same source population, 244 incident cases of HG and 244 pregnant women free of the disease (controls) were consecutively identified. RESULTS: H. pylori were noted in 105 cases and 58 control subjects. The presence of H. pylori increased the risk of HG more than two fold (OR = 2.42, 95% CI: 1.64-3.57, P < 0.001). This association was much stronger in Africans as compared to non-Africans (OR = 5.26, 95% CI: 1.04-26.57 vs. OR = 1.67, 95% CI: 1.07-2.61) after controlling for the confounding effect of maternal age. A gradient effect of exposure to H. pylori, determined by presence of specific IgG antibody in serum, and increased frequency of HG was present in Africans (test for linear trend P = 0.05) and non-Africans (test for linear trend P = 0.004). CONCLUSION: These results indicate that H. pylori increase the risk of HG with a dose-response pattern and stronger in Africans.

[Migrants in obstetrics--psychosomatic aspects in the context of acculturation]. / Migrantinnen in der Geburtshilfe--psychosomatische Aspekte im Zusammenhang mit dem Akkulturationsprozess.

Psychosomatic aspects and processes of acculturation in migrants that indicate transcultural change can be observed in obstetrics. Such Turkish men increasingly accompany their partners during birth in the delivery room. The analysis of perinatal data shows a harmonization for important perinatal quality parameters like infant and maternal mortality and the rate of preterm delivery between migrant and German women. However differences in the utilization and in the quality of care have been observed internationally (e. g. for migrants: later utilization of pregnancy checkups, higher rate of anaemia, less planned and higher rates of in-patient treatment of hyperemesis gravidarum). Specific risks of migration and psychosocial as well as the potentials of transcultural change more consideration.

Consanguinity and the risk of hyperemesis gravidarum in Norway.

BACKGROUND: Hyperemesis gravidarum (HG) is a condition that occurs in the first half of pregnancy, and is manifested by severe vomiting, electrolyte disturbances and weight loss. Previous studies have suggested the potential role of genetic factors in the aetiology of HG. We hypothesise that consanguineous relations between parents increase the risk of HG due to the increased risk of homozygosity in HG-associated alleles in a fetus. Moreover, we examine whether ethnic variations in the occurrence of HG can be attributed to consanguinity. METHODS: All Norwegian, Pakistani and Turkish primiparous women with singleton pregnancies registered in the Norwegian Medical Birth Registry (MBRN) from 1967 to 2005 comprised the sample. Data on HG and potential confounders were obtained from MBRN. Multiple logistic regression was used to study associations between the degrees of relationship between women and their partners and the prevalence of HG. Crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) were calculated. RESULTS: The prevalence of HG was 0.9, 2.2 and 1.9% in Norwegian, Pakistani and Turkish women, respectively. Norwegian (OR =0.93; 95% CI: 0.42-2.09), Pakistani (OR =1.08; 95% CI: 0.68-1.74) and Turkish (OR =1.08; 95% CI: 0.44-2.67) women related to their partners as first cousins had similar risks of HG as non-related women after adjustment for potential confounders. CONCLUSIONS: Consanguinity was not associated with HG in this study. The differences in the occurrence of HG between Norwegian, Pakistani and Turkish women are not attributed to consanguinity.

Hyperemesis gravidarum in Eastern Asian population.

OBJECTIVE: To investigate the clinical features of hyperemesis gravidarum in Eastern Asian women. METHOD: Retrospective cohort study was conducted based on delivery records. Hyperemesis gravidarum was defined as a pregnancy with severe nausea and vomiting necessitating hospitalization with a body weight loss of over 5% from pre-pregnancy weight with ketonuria. The onset is at 10 weeks of gestation or less. Maternal and neonatal variables were compared. RESULT: There were 3,350 singleton deliveries in the study period. All subjects were Eastern Asian women. Hyperemesis gravidarum was observed in 119 cases (3.6%). Hyperemesis gravidarum subjects had a smaller pre-pregnancy body weight (50.5 +/- 0.64 kg vs. 51.8 +/- 0.16 kg, p = 0.046) and a smaller pre-pregnancy body mass index compared to non-hyperemetic subjects (20.2 +/- 0.21 kg/m2 vs. 20.8 +/- 0.06 kg/m2, p = 0.02). CONCLUSION: The Eastern Asian population had a significantly higher incidence of hyperemesis gravidarum. Small pre-pregnancy body habitus increased the risk of hyperemesis gravidarum.

The prevalence of Helicobacter pylori in the Hispanic population affected by hyperemesis gravidarum.

OBJECTIVE: The purpose of this study was to determine the prevalence of Helicobacter pylori seropositivity in pregnant Hispanics affected by hyperemesis gravidarum. STUDY DESIGN: This was a prospective cross-sectional study conducted over a 22-month period. Serum from pregnant Hispanics affected by hyperemesis gravidarum and unaffected Hispanics matched for age, gravidity, parity, and country of origin were tested for H pylori immunoglobulin G (IgG). IgG levels specific for H pylori were determined by enzyme-linked immunosorbent assay (ELISA). Assuming the background prevalence of H pylori serum positivity in the Hispanic population is approximately 60%, 38 patients in each group were needed to detect a 30% difference in affected patients versus controls with a power of 80% and P = .05. Statistical analysis was performed using Yate's chi-square, Student t test, Mann-Whitney U, and binary logistic regression. RESULTS: A total of 82 patients between the ages of 18 to 39 years were enrolled. Of 40 patients diagnosed with hyperemesis gravidarum, 26 (65%) were seropositive for H pylori compared with 28 of 42 (67%) unaffected controls (P = 1.0). There were no statistical differences in maternal age or countries of origin between the 2 groups. CONCLUSION: The overall prevalence of H pylori seropositivity in this patient population is 66%. In pregnant Hispanics affected by hyperemesis gravidarum, H pylori seropositivity is not increased compared with unaffected controls.

Transient hyperthyroidism of hyperemesis gravidarum.

OBJECTIVE: To characterise the clinical, biochemical and thyroid antibody profile in women with transient hyperthyroidism of hyperemesis gravidarum. DESIGN: Prospective observational study. SETTING: Hospital inpatient gynaecological ward. POPULATION: Women admitted with hyperemesis gravidarum and found to have hyperthyroidism. METHODS: Fifty-three women were admitted with hyperemesis gravidarum and were found to have hyperthyroidism. Each woman was examined for clinical signs of thyroid disease and underwent investigations including urea, creatinine, electrolytes, liver function test, thyroid antibody profile and serial thyroid function test until normalisation. MAIN OUTCOME MEASURES: Gestation at which thyroid function normalised, clinical and thyroid antibody profile and pregnancy outcome (birthweight, gestation at delivery and Apgar score at 5 minutes). RESULTS: Full data were available for 44 women. Free T4 levels normalised by 15 weeks of gestation in the 39 women with transient hyperthyroidism while TSH remained suppressed until 19 weeks of gestation. None of these women were clinically hyperthyroid. Thyroid antibodies were not found in most of them. Median birthweight in the infants of mothers who experienced weight loss of > 5% of their pre-pregnancy weight was lower compared with those of women who did not (P = 0.093). Five women were diagnosed with Graves' disease based on clinical features and thyroid antibody profile. CONCLUSIONS: In transient hyperthyroidism of hyperemesis gravidarum, thyroid function normalises by the middle of the second trimester without anti-thyroid treatment. Clinically overt hyperthyroidism and thyroid antibodies are usually absent. Apart from a non-significant trend towards lower birthweights in the infants of mothers who experienced significant weight loss, pregnancy outcome was generally good. Routine assessment of thyroid function is unnecessary for women with hyperemesis gravidarum in the absence of any clinical features of hyperthyroidism.

Hyperemesis gravidarum during Ramadan.

During Ramadan, adult Muslims fast from dawn to dusk. We frequently encounter young pregnant Muslim women with hyperemesis gravidarum who fast during this holy month. We have investigated whether there is an association between the prolonged fasting during Ramadan and excessive vomiting during pregnancy. Possible psychologic and physiologic explanations are presented and discussed.

The incidence of hyperemesis gravidarum is increased among Pacific Islanders living in Wellington.

AIMS: To compare the incidence of hyperemesis gravidarum among Pacific Islanders living in Wellington with nonPacific Islanders and to investigate some properties of the disorder. METHODS: Data were collected on all first time admissions to Wellington Women's Hospital for hyperemesis gravidarum over a 5-year period. Women were classified as having severe hyperemesis gravidarum if abnormalities of serum electrolytes and liver function tests results were present and as less severe if these abnormalities were absent. Almost all women had ketonuria. Mantel-Haenszel odds ratios, chi 2 analysis and Fisher's 2-tailed exact test were used for statistical analysis. RESULTS: The proportion of hyperemesis gravidarum patients who were Pacific Islanders was significantly increased when compared to their proportion in a control group (p < 0.01). The difference remained significant when the hyperemesis patients were divided into less and more severe. Abnormal thyroid function test results were more common among Pacific Island patients than among nonPacific Island patients. This difference was significant (p < 0.01) only in the less severe group. CONCLUSION: The incidence of hyperemesis gravidarum is significantly increased among Pacific Island women (especially Samoans) living in Wellington and is often associated with abnormalities of thyroid function test results.