The windsor definition for hyperemesis gravidarum: A multistakeholder international consensus definition

Association between exposure to perfluoroalkyl substances (PFASs) and risk of hyperemesis gravidarum

The fluctuation of endocrine hormones during early pregnancy plays an important role in the pathogenesis of hyperemesis gravidarum (HG). As an endocrine disrupting chemical (EDC), perfluoroalkyl substances (PFASs) exert an impact on pregnancy-related complications by altering hormone balances throughout gestation. Despite this potential impact, the relationship between serum PFAS levels in early pregnancy and the risk of HG has not been previously investigated. A total of 98 HG cases and 495 controls were included in this study from the Xi'an Birth Cohort Study. In total, serum levels of 10 PFASs were measured using High Performance Liquid Chromatography with tandem Mass Spectrometry (HPLC-MS/MS) during early pregnancy. Binary logistic models were applied to evaluate the associations between individual PFAS levels and HG. Weighted quantile sum (WQS) regression models and Bayesian kernel machine regression (BKMR) models were performed to test the overall effect of the PFAS mixture on HG. After adjusting for confounding variables, the highest tertile concentrations of perfluoroundecanoic acid (PFUnDA) (OR: 3.49, 95 %CI: 1.31-9.29), and perfluorododecanoic acid (PFDoA) (OR: 3.13, 95 % CI: 1.40-6.98) were significantly associated with a higher risk of HG, while highest tertile of perfluorohexanoic acid (PFHxA) (OR: 0.34; 95 % CI: 0.16-0.73), and PFOS (OR: 0.35; 95 % CI: 0.13-0.97) were inversely associated with HG. The WQS index showed a positive correlation with HG risk (β = 0.80; 95 % CI: 0.02, 1.57), with notable contributions from PFDoA (0.952), PFUnDA (0.159), and perfluorobutanoic acid (PFBA) (0.146). In addition, the joint effect of the PFAS mixture was positively associated with HG, with PFDoA (posterior inclusion probability (PIP) = 0.78) and PFUnDA (PIP = 0.75) being identified as the primary contributors. Our findings indicate that exposure to PFAS mixture during early pregnancy was associated with an increased risk of HG, with PFDoA and PFUnDA being the major contributors.

Understanding the support needs of women with hyperemesis gravidarum

PROBLEM

Hyperemesis Gravidarum (HG) is a severe condition, but little is known about how best to psychologically support those going through this experience.

BACKGROUND

HG, a severe form of nausea and vomiting affects 0.3-3.4 % of pregnancies. It can have significant psychological impacts on sufferers, with increased rates of anxiety, depression and post-traumatic stress. There is a need for interventions tailored to this group that could ameliorate these impacts.

AIM

To explore what women with HG found useful for their mental health, what could and should be targeted in an intervention and optimal features of an intervention.

METHODS

A series of focus groups were run with 22 survivors of HG, analysed using reflexive thematic analysis.

FINDINGS

Four overarching themes were identified: the individual journey of HG; recognition and validation by healthcare professionals; impact on family roles and systems; flexible personalised support. The need for cultural competence in understanding and developing support ran through the themes.

DISCUSSION

HG involves both physical and psychological impacts, some of which are exacerbated by invalidating interactions and lack of knowledge in the healthcare system. Those with HG are simultaneously physically and mentally depleted, leading to multiple impacts on woman and family. A tailored intervention including elements of information, recording and active psychological intervention could support women's physical and mental health during HG, with the potential to prevent or ameliorate negative psychological consequences.

CONCLUSION

Psychological support for women with HG is a current gap. A tailored intervention has promise to mitigate negative impacts of this condition.

"Deprived of my autonomy." Women's experiences and self-concepts of Hyperemesis Gravidarum - A qualitative study

OBJECTIVE

Hyperemesis Gravidarum affects women's health on a physical, psychological, and socioeconomic level, and they express a need for acknowledgement from family and healthcare providers. Historically associated with hysteria, Hyperemesis Gravidarum may still be stigmatised due to lingering perceptions of it as a psychological issue. To enhance understanding of the disease's impact on women's health, this study aimed to explore women's experiences and self-concepts of Hyperemesis Gravidarum.

METHODS

Participants were recruited from a social media platform with the following criteria: i) women in Sweden with Hyperemesis Gravidarum who debuted before week 22 of pregnancy, ii) who gave birth within the last four years, and iii) who received intravenous fluid therapy during their illness. Data were gathered through 15 digital, individual, semi-structured, in-depth interviews and were analysed with Reflexive Thematic Analysis.

RESULTS

The mean age of participants was 32. The majority experienced HG within 12-36 months before the interview and were living with a partner. The overarching theme, "Deprived of my Autonomy", depicts the woman's transition from being responsible, reliable and hard-working to becoming a woman who perceived herself as disempowered, unprioritised and dependent.

CONCLUSION

The women experienced a new perception of themselves as unable to meet their own and others' expectations in managing pregnancy, family, and work and as individuals disbelieved by the healthcare system. Healthcare professionals' neglectful attitudes may contribute to self-stigma with isolation, and low social support as a result. Healthcare professionals must recognise the impact of dismissive behaviour and implement validating and empowering support structures.

School performance in offspring born to mothers with hyperemesis gravidarum

BACKGROUND

Hyperemesis gravidarum is characterized by severe nausea, vomiting, and potentially undernutrition during pregnancy. Despite affecting up to 3% of all pregnancies, little is known about the impact of hyperemesis gravidarum on the cognitive development of the child.

OBJECTIVE

We aimed to compare the school performance of offspring exposed to hyperemesis gravidarum during pregnancy with their nonexposed counterparts and siblings.

STUDY DESIGN

We conducted a population-based cohort study including all liveborn children, born in Denmark between January 1, 1986, and December 31, 2005. We included 1,162,249 offspring, of which 12,720 (1.1%) had been exposed in utero to a maternal diagnosis of hyperemesis gravidarum. The 2 coprimary outcomes were mean grade point average in the final year of elementary school (ninth grade, 15-16 years) and a composite outcome of low school performance, defined as a mean grade point average below 4 or no registered mean grade point average. The difference in mean grade point average was evaluated using uni- and multivariable linear mixed models and differences in proportions of the binary outcomes were compared using uni- and multivariable logistic regression models.

RESULTS

Of the exposed offspring, 29.3% had low school performance compared to 25.7% of the nonexposed group. After adjustment for confounders (birth year, maternal age, multiple pregnancies, parity, maternal education, maternal smoking, and sex), we found that exposed offspring had increased odds of low school performance (odds ratio 1.19, 95% confidence interval 1.14-1.24). Furthermore, the exposed group had a lower mean grade point average of 6.55 compared with 6.78 in the nonexposed group, yielding an adjusted mean difference of -0.18 (-0.22 to -0.14). However, within-sibling analyses, comparing exposed offspring with their unexposed siblings (same mother), revealed no increased odds of low school performance (adjusted odds ratio 0.98 [0.92-1.04]) or difference in mean grade point average (-0.02 [-0.08 to 0.05]).

CONCLUSION

We found a small association between in utero exposure to hyperemesis gravidarum and low school performance. However, no difference in school performance was observed between exposed and unexposed siblings, indicating that the association could be attributed to genetics or other familial factors rather than hyperemesis gravidarum.

Association of Antioxidant Diet with Risk of Hyperemesis Gravidarum Among Chinese Pregnant Women: A Population-Based Cross-Sectional Study

(1) Background: Oxidative stress plays a pivotal role in the pathophysiologic of hyperemesis gravidarum (HG). Epidemiological studies have explored the associations of specific antioxidant foods and nutrients with HG. However, evidence regarding the relationship between an antioxidant-rich diet and the risk of HG remains limited. The objective of this research was to explore the relationship between antioxidant-rich diet and HG. (2) Methods: This was a population-based cross-sectional study. A total of 2980 pregnant women were included in our population. A composite dietary antioxidant index (CDAI) was calculated by summing the standardized intakes of vitamins A, C, and E, selenium, zinc, and total carotene. A dietary antioxidant potential score (DAPS) was derived using reduced rank regression. Binary logistic regression models were employed to analyze the associations of CDAI and DAPS with risk of HG. (3) Results: In total, 241 (8.09%) cases of HG were identified in this study. After adjusting for potential confounders, including age, socioeconomic status, ethnicity, physical activity, current smoking status, current alcohol consumption, pre-pregnancy body mass index, nutritional supplement usage, total energy intake, gestational week, menstruation regularity, family history of HG, primigravida status, and quality of life during pregnancy, ORs (95% CIs) of HG in the highest tertiles were 0.31 (0.21-0.47) for CDAI and 0.41 (0.28-0.57) for DAPS when comparing lowest tertiles (all p-trend < 0.001). Such associations remained robust across multiple sensitivity analyses and subgroup analyses. (4) Conclusions: Higher CDAI and DAPS, indicative of greater adherence to an antioxidant-rich diet, were associated with a lower risk of HG. This finding underscores the crucial role of consuming antioxidant-rich foods in the prevention of HG.

Gastrointestinal symptoms and disorders of gut-brain interaction in pregnancy

Gastrointestinal (GI) symptoms occur frequently in pregnant women, resulting in poor quality of life. These patients frequently require co-management with the obstetrician and a physician/GI specialist. The causation is complex and multifactorial. It is a result of a combination of maternal changes in pregnancy and feto-placental hormonal effects on the GI tract (the feto-placental-gut axis). Additional factors such as the gut-brain interaction, genetics, immune response and effects of maternal supplements during pregnancy also contribute to the causation of symptoms. The most common of these symptoms include nausea and vomiting followed by heartburn. The common lower GI symptoms include constipation and hemorrhoids. Irritable bowel syndrome (IBS) is also common in a pregnant patient. But there is a paucity of literature and high-quality studies concerning the management of IBS. This review addresses the pathophysiology and clinical and laboratory evaluation of the common upper GI and lower GI symptoms and their management. A majority of symptoms are mild and lifestyle modifications with non-pharmacological measures should be the first-line management, whereas drugs should be used judiciously in case of non-response or severe symptoms. The nutritional status of the mother and the fetus needs close monitoring. Drugs that are routinely used in pregnancy are discussed with regard to the safety of the mother and the fetus. GI endoscopy may be needed in select patients and the indications for endoscopy and colonoscopy in pregnancy along with special pregnancy-related precautions are discussed. Most symptoms improve to pre-pregnancy state after delivery.

Effect of Olanzapine on Hyperemesis Gravidarum in Individuals With Mood Disorders: A Case Series

This case series examines the effect of olanzapine on symptoms of hyperemesis gravidarum in individuals with mood disorders. Patient charts from 2022 to 2024 were reviewed, focusing on those with hyperemesis gravidarum who were treated with olanzapine alone or with other psychotropic drugs for their mood disorder. Of 6 patients with hyperemesis gravidarum, 3 had bipolar II disorder, and the others had major depressive disorder. Olanzapine was used alone in 3 cases. A daily dose of 2.5-5 mg was well tolerated and effective in all patients who had failed trials of conventional antiemetics. Thus, olanzapine may be a viable treatment for hyperemesis gravidarum in mood disorder patients unresponsive to standard antiemetics.

Cannabinoid hyperemesis syndrome in pregnancy: a case series and review

Background

Cannabinoid hyperemesis syndrome (CHS) is a syndrome of cyclic nausea and vomiting in the setting of chronic cannabis use. To date, only 11 cases of CHS in pregnancy have been reported.

Case presentation

We describe two cases of uncontrolled vomiting in pregnancy due to CHS. Case 1 represents a 30-year-old Caucasian woman presenting in the 5th week of gestation with nausea, vomiting and abdominal pain intermittently of 1 week duration. Physical work-up was normal, and symptoms resolved with supportive treatment within 3 days, only to occur again at the 14th week of gestation, and again at the 30th week of gestation. Link between symptom relief and hot bathing led to suspicion for CHS, confirmed with positive cannabis urine toxicology screening. Nausea, vomiting and pain subsided with cannabis cessation, and baby was born healthy at 38 + 5 weeks gestation. Case 2 describes a 28-year-old Caucasian woman presenting in the 16th week of gestation with nausea, vomiting and abdominal pain. Physical examination was normal, and symptoms self-resolved. Two weeks later, in the 18th week of gestation, the patient re-presented to the emergency room with sudden re-occurrence of nausea, vomiting and abdominal pain. Once again, a link between symptom relief and hot bathing was noted on admission. The patient was educated on possible links of chronic cannabis use with CHS symptoms and subsequently relayed extensive (>14 years) cannabis use history. Symptoms resolved with cannabis cessation. Baby was born at 37 weeks gestation, with low birth weight of 2180 g requiring 5 days neonatal intensive care unit (NICU) treatment. Regular follow-up up to 5 months post-partum confirmed no CHS relapse with cannabis cessation.

Conclusion

CHS in pregnancy is likely under-reported, reflective possibly of limited physician and patient awareness of this condition, as well as patient concealment of cannabis use in pregnancy. In cases of severe, cyclic nausea and vomiting in pregnancy unresponsive to typical anti-emetic treatment, comprehensive social history including cannabis use should be sought, and associated hot bathing for symptomatic relief out-ruled.

Investigation of serum spexin concentrations in pregnant women diagnosed with hyperemesis gravidarum

OBJECTIVE

We aimed to investigate the serum concentration of the spexin, which has been shown to have an anorexic effect in animal models, in pregnant women with hyperemesis gravidarum (HG).

METHODS

This case-control study was conducted with 80 pregnant women who applied to the Umraniye Training and Research Hospital Gynecology and Obstetrics Clinic between April 2022 and September 2022. The HG group consisted of 40 pregnant women who were diagnosed with HG in the first 14 weeks of pregnancy, and the control group consisted of 40 healthy pregnant women matched with the HG group in terms of age, BMI, and gestational week.

RESULTS

Both groups were similar in terms of demographic characteristics and gestational age at blood sampling for spexin (p > 0.05). While maternal serum spexin concentration was 342.4 pg/ml in the HG group, it was 272.8 pg/ml in the control group (p = 0.003). ROC analysis was performed to determine the value of maternal serum spexin concentration in terms of predicting HG. AUC analysis of maternal serum spexin for HG estimation was 0.693 (p = 0.003, 95% CI =0.577 - 0.809). The optimal cutoff value for maternal serum spexin concentration was determined as 305.90 pg/ml with 65% sensitivity and 65% specificity.

CONCLUSIONS

High serum spexin concentration is thought to play a role in the etiopathogenesis of HG, and this should be supported by demonstrating changes in serum spexin concentrations in pregnant women with HG whose symptoms alleviated and weight regain started after treatment.

Hidden Rhythms: A Complex Case of Hyperemesis Gravidarum-Induced Arrhythmias

Hyperemesis gravidarum (HG) is a severe condition marked by intense nausea and vomiting during pregnancy, which is different from typical morning sickness. It is marked by weight loss exceeding 5% of pre-pregnancy weight, ketonuria, dehydration, electrolyte imbalances, and in some cases, arrhythmias - primarily linked to electrolyte disturbances. Treatment typically involves conservative measures such as small, bland meals, medications like metoclopramide and ondansetron, and correction of electrolyte abnormalities. This case study presents a 29-year-old female, G5P2022, who arrived at the ED with severe nausea, vomiting, intermittent chest pain, and palpitations lasting five days. She was confirmed to be seven weeks and five days pregnant. Her medical history included preeclampsia with severe features and HG in prior pregnancies. Initial evaluations, including CBC, complete metabolic panel, and troponin levels, were unremarkable, with normal electrolytes. However, an ECG revealed multiple arrhythmias. Cardiology and electrophysiology consultations recommended outpatient follow-up. This case highlights the serious risks HG poses to both maternal and fetal health. Although arrhythmias are a recognized complication of HG, this case is notable for their occurrence despite normal electrolyte levels, emphasizing the complex interplay between HG and cardiac function.

Risk Factors for Infusions, Emergency Room Visits and Hospitalizations for Hyperemesis Gravidarum: New Data and Literature Review

Purpose

Few factors have been identified that increase the risk of visits (hospital emergency room or inpatient stays) due to hyperemesis gravidarum (HG). The purpose of this study is to understand trends in HG management and identify variables increasing visit frequency so that strategies may be developed to reduce hospital utilization.

Study Design

An online survey was posted on the Hyperemesis Education and Research Foundation website and social media between June 2022 and May 2023. Participants had previous or current severe pregnancy nausea and vomiting. Respondents were asked about themselves and their HG experience, including weight loss, medications, infusion care, and visit frequency. Odds ratios, p-values, and 95% confidence intervals were calculated via MedCalc to analyze the significance of each factor, and Spearman rank correlations were analyzed via SPSS for associations of ondansetron usage with visits and weight loss. Microsoft Excel and SPSS were used to calculate treatment and visit frequencies.

Results

Survey data from 1220 respondents who reported a current or prior pregnancy with HG were included in this study. Respondents were primarily White, from the US, and had at least one visit due to HG. Participants with a visit were significantly more likely to be a person of color (POC), unable to work, have no children, and lose over 15 pounds (6.8 kg). Those who took medications as prescribed had fewer visits. No medication combination or dose was found to be significantly more effective in preventing weight loss or repeat hospital visits.

Conclusion

Risk factors predicting visits included POC, not having children, being too sick to work, and having extreme weight loss. Utilization of medication and nutritional therapies is inconsistent and inadequate in this population, which may increase visit frequency.

AGA Clinical Practice Update on Pregnancy-Related Gastrointestinal and Liver Disease: Expert Review

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with pregnancy-related gastrointestinal and liver disease.

METHODS

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Gastroenterology. This article provides practical advice for the management of pregnant patients with gastrointestinal and liver disease based on the best available published evidence. The Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because formal systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: To optimize gastrointestinal and liver disease before pregnancy, preconception and contraceptive care counseling by a multidisciplinary team should be encouraged for reproductive-aged persons who desire to become pregnant. BEST PRACTICE ADVICE 2: Procedures, medications, and other interventions to optimize maternal health should not be withheld solely because a patient is pregnant and should be individualized after an assessment of the risks and benefits. BEST PRACTICE ADVICE 3: Coordination of birth for a pregnant patient with complex inflammatory bowel disease, advanced cirrhosis, or a liver transplant should be managed by a multidisciplinary team, preferably in a tertiary care center. BEST PRACTICE ADVICE 4: Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum. In addition to standard diet and lifestyle measures, stepwise treatment consists of symptom control with vitamin B6 and doxylamine, hydration, and adequate nutrition; ondansetron, metoclopramide, promethazine, and intravenous glucocorticoids may be required in moderate to severe cases. BEST PRACTICE ADVICE 5: Constipation in pregnant persons may result from hormonal, medication-related, and physiological changes. Treatment options include dietary fiber, lactulose, and polyethylene glycol-based laxatives. BEST PRACTICE ADVICE 6: Elective endoscopic procedures should be deferred until the postpartum period, whereas nonemergent but necessary procedures should ideally be performed in the second trimester. Pregnant patients with cirrhosis should undergo evaluation for, and treatment of, esophageal varices; upper endoscopy is suggested in the second trimester (if not performed within 1 year before conception) to guide consideration of nonselective β-blocker therapy or endoscopic variceal ligation. BEST PRACTICE ADVICE 7: In patients with inflammatory bowel disease, clinical remission before conception, during pregnancy, and in the postpartum period is essential for improving outcomes of pregnancy. Biologic agents should be continued throughout pregnancy and the postpartum period; use of methotrexate, thalidomide, and ozanimod must be stopped at least 6 months before conception. BEST PRACTICE ADVICE 8: Endoscopic retrograde cholangiopancreatography during pregnancy may be performed for urgent indications, such as choledocholithiasis, cholangitis, and some cases of gallstone pancreatitis. Ideally, endoscopic retrograde cholangiopancreatography should be performed during the second trimester, but if deferring the procedure may be detrimental to the health of the patient and fetus, a multidisciplinary team should be convened to decide on the advisability of endoscopic retrograde cholangiopancreatography. BEST PRACTICE ADVICE 9: Cholecystectomy is safe during pregnancy; a laparoscopic approach is the standard of care regardless of trimester, but ideally in the second trimester. BEST PRACTICE ADVICE 10: The diagnosis of intrahepatic cholestasis of pregnancy is based on a serum bile acid level >10 μmol/L in the setting of pruritus, typically during the second or third trimester. Treatment should be offered with oral ursodeoxycholic acid in a total daily dose of 10-15 mg/kg. BEST PRACTICE ADVICE 11: Management of liver diseases unique to pregnancy, such as pre-eclampsia; hemolysis, elevated liver enzymes, and low platelets syndrome; and acute fatty liver of pregnancy requires planning for delivery and timely evaluation for possible liver transplantation. Daily aspirin prophylaxis for patients at risk for pre-eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome is advised beginning at week 12 of gestation. BEST PRACTICE ADVICE 12: In patients with chronic hepatitis B virus infection, serum hepatitis B virus DNA and liver biochemical test levels should be ordered. Patients not on treatment but with a serum hepatitis B virus DNA level >200,000 IU/mL during the third trimester of pregnancy should be considered for treatment with tenofovir disoproxil fumarate. BEST PRACTICE ADVICE 13: In patients on immunosuppressive therapy for chronic liver diseases or after liver transplantation, therapy should be continued at the lowest effective dose during pregnancy. Mycophenolate mofetil should not be administered during pregnancy.

Evaluation of Fasting Bile Acid Levels in Pregnant Women Diagnosed with Hyperemesis Gravidarum

Background: Hyperemesis gravidarum is a common cause of nausea and vomiting during the early gestational week. At the same time, it can also lead to an increase in liver enzyme values in patients due to or independently of underlying liver disease. This study aimed to evaluate fasting bile acid (FBA) levels, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total and direct bilirubin, and urine ketone levels in pregnant women diagnosed with hyperemesis gravidarum (HG). Additionally, the study sought to investigate the relationship between HG and FBA levels. The diagnosis of HG remains primarily clinical, and identifying markers for disease severity is crucial. Methods: This retrospective cohort study obtained blood samples from 50 women diagnosed with HG and 25 healthy pregnant women. Serum levels of AST, ALT, total bilirubin (TBS), direct bilirubin, urine ketones, and FBA were measured. Statistical analysis was performed using the SPSS software version 28.0. Results: FBA levels were significantly higher in pregnant women diagnosed with HG compared to the healthy control group. Additionally, FBA levels increased simultaneously with ketonuria in the patient group. Our findings suggest that FBA levels can serve as a biomarker for diagnosing HG and indicating early-stage liver damage. Unlike previous studies, our research focused on the relationship between FBA levels and HG, providing valuable insights for future studies. Conclusions: FBA levels show promise as an objective biomarker for diagnosing HG and indicating early-stage liver damage. Further research with larger cohorts is necessary to validate these findings.

Risk factors and recurrence of hyperemesis gravidarum: A population-based record linkage cohort study

INTRODUCTION

There are limited contemporary population-based studies on the risk factors for hyperemesis gravidarum (HG), a severe type of nausea and vomiting in pregnancy. This study aimed to determine the prevalence and trend of HG over time, identify risk factors for any and multiple HG health service visits during pregnancy, and investigate HG recurrence across pregnancies.

MATERIAL AND METHODS

This population-based record linkage cohort study featured births in New South Wales, Australia from 2010 to 2019. Hospital and emergency data collections were used to identify health service visits for HG using relevant diagnosis codes and were linked to the corresponding pregnancy on the birth data set. Outcomes included any HG and multiple HG visits during pregnancy, and HG recurrence across pregnancies. Annual HG prevalence was calculated, and negative binomial regression was used to examine standardized prevalence trends. Risk factors for any HG and multiple HG visits within a pregnancy were examined using Robust Poisson models with generalized estimating equations and Prentice-Williams-Peterson Gap Time models, respectively. Rates and risk of recurrence were calculated for women with a second and third pregnancy.

RESULTS

Of the 955 107 pregnancies, 21 702 (2.3%) were classified as HG. There was an average annual increase of 6.8% (95% CI 5.3-8.3) in HG prevalence. Younger maternal age, multiple pregnancies, and selected preexisting conditions were associated with an increased risk of HG, with the strongest factor being HG in any previous pregnancy (risk ratio 8.92, 99% CI 8.43-9.44). Hyperemesis gravidarum recurrence at the second (28.9%) and third (54.7%) pregnancies was high.

CONCLUSIONS

Hyperemesis gravidarum history is the strongest risk factor for HG, which has implications for counseling and care that women receive around pregnancy.

Association between Dietary Inflammatory Index and Hyperemesis Gravidarum

(1) Background: Diet holds a pivotal position in exacerbating or ameliorating chronic inflammation, which has been implicated in the pathogenesis of hyperemesis gravidarum (HG). However, no study has explored the association between dietary inflammatory potential and HG. This study aimed to investigate the potential correlation between following a pro-inflammatory diet and the likelihood of developing HG. (2) Methods: A total of 2033 Chinese pregnant women (mean age: 31.3 ± 3.4 years) were included in this cross-sectional study from April 2021 to September 2022 as part of the China Birth Cohort Study (CBCS). Dietary inflammatory index (DII) scores with 23 food components were constructed through dietary intakes collected via a reliable 108-item semi-quantitative food frequency questionnaire. HG was defined as a pregnancy-unique quantification of emesis (PUQE) score ≥13 points, severe nausea and vomiting leading to weight loss ≥5%, or being hospitalized for treatment due to the disease. The relationship between DII and HG was conducted utilizing binary logistic regression and restricted cubic spline regression. (3) Results: Overall, 8.2% (n = 167) of study participants had HG. The DII scores ranged from -4.04 to 3.82. After adjusting for potential confounders, individuals with the highest tertile of DII score had a higher risk of HG (OR = 1.65, 95% CI: 1.04, 2.62, Ptrend = 0.032). Such an association was stronger in those with pre-pregnancy overweight/obesity (Pinteraction = 0.018). (4) Conclusions: A higher DII score, which serves as a marker for a diet promoting inflammation, is correlated with an elevated risk of developing HG. This finding suggests that dietary recommendations for HG should focus on minimizing the DII through incorporating foods abundant in anti-inflammatory components.

Oral rehydration therapy versus intravenous rehydration therapy in the first 12 h following hospitalization for hyperemesis gravidarum: A randomized controlled trial

OBJECTIVE

To evaluate oral rehydration therapy (ORT) compared with intravenous rehydration therapy (IVT) in the early inpatient management of hyperemesis gravidarum (HG).

METHODS

A total of 124 women hospitalized for HG from February 10, 2021 till January 6, 2023 were randomized to ORT (n = 61) or IVT (n = 63) for an initial 12 h. Inclusion criteria includes women older than 18 years, with a viable intrauterine pregnancy less than 14 weeks at their first hospitalization for HG with ketonuria of at least 2+. Primary outcomes were (1) satisfaction score with allocated intervention, (2) weight change, and (3) ketonuria change at 12 h. Secondary outcomes included vomiting frequency, nausea score, serial vital signs, hematocrit and electrolyte levels at 12 h, deviation from treatment protocol (cross-over therapy), participant recommendation of allocated treatment to a friend, and length of hospital stay.

RESULTS

Primary outcomes of (1) participant satisfaction score (on a 0-10 visual numerical rating scale) was 7 (interquartile range [IQR] 5-8) versus 9 (IQR 8-10), P < 0.001; (2) weight gain was 293 ± 780 g versus 948 ± 758 g, P < 0.001; and (3) ketonuria improvement was 50/61 (82.0%) versus 49/63 (77.8%) (relative risk [RR] 1.05, 95% confidence interval [CI] 0.88-1.26, P = 0.561) for ORT versus IVT, respectively. For secondary outcomes, vomiting frequency was 2.6 ± 2.7 versus 1.1 ± 1.4 episodes (P < 0.001), participant cross-over rate to opposing treatment 20/61 (32.8%) versus 0/63 (0%) (P < 0.001) (in the 12-h study period) and participant recommendation of allocated treatment to a friend rate 24/61 (39.3%) versus 61/63 (96.8%) (RR 0.41, 95% CI 0.30-0.56, P < 0.001) for ORT versus IVT, respectively. By hospital discharge, 31/61 (50.8%) of women allocated to ORT had required IVT. Other secondary outcomes of serial assessments of nausea score and vital signs, hematocrit and electrolyte levels, and length of hospital stay were not different.

CONCLUSIONS

ORT was inferior to IVT in two primary outcomes and three secondary outcomes. Cross-over rate to intravenous therapy from oral therapy was 50.8% by hospital discharge. Intravenous rehydration therapy should remain as first-line rehydration therapy in the early inpatient treatment of HG.

CLINICAL TRIAL REGISTRATION

The present study was registered in ISRCTN registry on December 6, 2020 with trial identification number: ISRCTN 40152556 (https://doi.org/10.1186/ISRCTN40152556). The first participant was recruited on February 10, 2021.

The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69)

An objective and validated index of nausea and vomiting such as the Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can be used to classify the severity of NVP and HG. [Grade C] Ketonuria is not an indicator of dehydration and should not be used to assess severity. [Grade A] There are safety and efficacy data for first line antiemetics such as anti (H1) histamines, phenothiazines and doxylamine/pyridoxine (Xonvea®) and they should be prescribed initially when required for NVP and HG (Appendix III). [Grade A] There is evidence that ondansetron is safe and effective. Its use as a second line antiemetic should not be discouraged if first line antiemetics are ineffective. Women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed HG. [Grade B] Metoclopramide is safe and effective and can be used alone or in combination with other antiemetics. [Grade B] Because of the risk of extrapyramidal effects metoclopramide should be used as second-line therapy. Intravenous doses should be administered by slow bolus injection over at least 3 minutes to help minimise these. [Grade C] Women should be asked about previous adverse reactions to antiemetic therapies. If adverse reactions occur, there should be prompt cessation of the medications. [GPP] Normal saline (0.9% NaCl) with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, is the most appropriate intravenous hydration. [Grade C] Combinations of different drugs should be used in women who do not respond to a single antiemetic. Suggested antiemetics for UK use are given in Appendix III. [GPP] Thiamine supplementation (either oral 100 mg tds or intravenous as part of vitamin B complex (Pabrinex®)) should be given to all women admitted with vomiting, or severely reduced dietary intake, especially before administration of dextrose or parenteral nutrition. [Grade D] All therapeutic measures should have been tried before considering termination of pregnancy. [Grade C].

Inpatient Management of Hyperemesis Gravidarum

Hyperemesis gravidarum has a reported incidence of approximately 0.3-3% of pregnancies. Without treatment, refractory hyperemesis gravidarum can result in dehydration, electrolyte deficiencies, and severe nutritional deficiencies, resulting in significant maternal morbidity. The overall goals of inpatient management of refractory hyperemesis gravidarum are the resumption of oral intake to an adequate level to maintain hydration and nutrition, including the ability to tolerate oral pharmacotherapy. Patients initially are stabilized with rehydration and electrolyte repletion. There are numerous pharmacotherapeutics available that can be administered intravenously to control symptoms when oral intake is not an option. However, despite maximizing typical antiemetics, there will be cases refractory to these medications, and alternative pharmacotherapeutics and nutrition-support modalities must be considered. Mirtazapine, olanzapine, corticosteroids, and gabapentin are examples of alternative pharmacotherapeutics, and enteral and parenteral nutrition are alternative therapies that can be used when oral intake is not tolerated for prolonged time periods with ongoing weight loss. In refractory cases of hyperemesis gravidarum, the risks and benefits of these alternative forms of management must be considered, along with the risks of undertreated hyperemesis gravidarum and the overall effect of hyperemesis gravidarum on patients' quality of life.

Hyperemesis gravidarum theories dispelled by recent research: a paradigm change for better care and outcomes

Nausea and vomiting (NVP) affect most pregnant women. At the severe end of the clinical spectrum, hyperemesis gravidarum (HG) can be life-threatening. The condition is fraught with misconceptions that have slowed progress and left women undertreated. Herein, recent scientific advances are presented that dispel common myths associated with HG related to maternal/offspring outcomes, etiology, and evolution. There is now strong evidence that (i) HG is associated with poor outcomes, (ii) a common cause of NVP and HG has been identified, and (iii) NVP is likely a protective evolutionary mechanism that occurs throughout the animal kingdom but is no longer necessary for human survival. Therefore, it is encouraging that we are finally on the cusp of testing treatments that may put an end to unnecessary suffering.

"Navigating in a maze without a map". Partners' experiences of hyperemesis gravidarum- a qualitative study

OBJECTIVE

A supportive environment for women with Hyperemesis Gravidarum is crucial but not always provided. There is a lack of research regarding Hyperemesis Gravidarum, its impact on the family, and the partner's perception of supporting their spouse. Thus, this study aims to explore partners' experiences of Hyperemesis Gravidarum during their spousés pregnancy.

METHODS

Data were gathered through 13 individual, semi-structured, in-depth, digital interviews with partners of women who had experienced Hyperemesis Gravidarum and analysed with Qualitative Content Analysis. The partners were recruited through advertisement on a social media platform and were exclusively males, representing 8 of 21 Swedish regions. The mean age was 34, and they had, on average, 1 previous child. The mean time from the experience to the interview was 12 months.

FINDINGS

The main theme, "Navigating in a maze without a map", explains partners' situation as stressful and demanding when their spouse suffers from Hyperemesis Gravidarum, with insufficient support and guidance from healthcare providers. The analysis resulted in three themes: "Standing alone with a demanding responsibility", "Being in a lottery when facing healthcare", and "Climbing the mountain together." The themes display challenges within everyday life and healthcare, as well as strained relations within the family.

CONCLUSION

Partners experience a need to support their spouse in every aspect of daily life and advocate for adequate healthcare. Healthcare professionals must support and acknowledge the partners' struggles during the demanding situation with Hyperemesis Gravidarum.

Efficacy and safety of acupressure in nausea and vomiting during pregnancy: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this study was to evaluate the efficacy and safety of acupressure on nausea and vomiting during pregnancy.

METHODS

PubMed, Embase, Springer, Web of Science, and the Cochrane Library were searched for all randomized controlled trials (RCT) of treating nausea and vomiting during pregnancy by acupressure from the inception date of database to July 31st, 2023. Study selection, data extraction, and risk of bias assessment were conducted independently by researchers. The methodological quality of included studies was evaluated by the Cochrane Collaboration's bias risk assessment tool, meta-analysis by Stata 17.0 software, and publication bias by Begg's test.

RESULTS

A total of 11 RCTs involving 1378 pregnant women were included in this review, which was assessed to be moderate quality. 10 RCTs involving 1298 pregnant women were assessed for the meta-analysis. The results revealed that acupressure showed significant difference on improvement in symptom score compared with sham acupressure (pooled MD, - 1.33; 95%CI [- 2.06, - 0.61]; P < 0.001) or control group (pooled MD, - 0.73; 95%CI [- 1.08, - 0.39]; P < 0.001), and incidence of effective rate compared with sham acupressure group (pooled RR, 1.78; 95%CI [1.03, 3.07]; P = 0.039). However, no statistical significance was found between acupressure and control group (pooled RR, 4.53; 95%CI [0.67, 30.48]; P = 0.120) on effective rate. On comparing acupressure with sham acupressure, there was no beneficial effect on preventing nausea and vomiting during pregnancy (pooled RR, 0.83; 95%CI [0.50, 1.38]; P = 0.476), shortening the duration of hospital stay (pooled MD, - 0.78; 95%CI [- 1.98, 0.41]; P = 0.199) and improving patient satisfaction (pooled RR, 1.36; 95%CI [0.47, 3.91]; P = 0.570). Begg's test did not reveal any publication bias. Only one RCT reported minimal acupressure-related adverse events.

CONCLUSION

Acupressure may have potential favorable or encouraging effect on treating nausea and vomiting during pregnancy, but strong supportive data are not yet available. Well-designed and large-scale RCTs should be conducted for assessing and confirming the efficacy and safety of acupressure in nausea and vomiting during pregnancy.

The timing, duration, and severity of nausea and vomiting of pregnancy and adverse birth outcomes among controls without birth defects in the National Birth Defects Prevention Study

BACKGROUND

Nausea and vomiting of pregnancy (NVP) occurs in approximately 70% of pregnant people, with varying severity and duration. Treatments include pharmacologic and herbal/natural medications. The associations between NVP and birth outcomes, including preterm birth, small for gestational age (SGA), and low birth weight are inconclusive.

OBJECTIVE

To determine whether NVP and reported medications are associated with adverse birth outcomes.

METHODS

We used data from the population-based, multisite National Birth Defects Prevention Study (1997-2011) to evaluate whether self-reported NVP according to timing, duration, and severity or its specific treatments were associated with preterm birth, SGA, and low birth weight among controls without birth defects. Odds ratios (aOR) and 95% confidence intervals (CI) were adjusted for sociodemographic, reproductive, and medical factors. For any NVP, duration, treatment use, and severity score analyses, the comparison group was participants with no reported NVP. For timing analyses, the comparison group was women with no reported NVP in the same trimester of pregnancy.

RESULTS

Among 6018 participants, 4339 (72.1%) reported any NVP. Among those with NVP, moderate or severe symptoms were more common than mild symptoms. Any versus no NVP was not associated with any of the outcomes of interest. NVP in months 4-6 (aOR 1.21, 95% CI: 1.00, 1.47) and 7-9 (aOR 1.57, 95% CI: 1.22, 2.01) of pregnancy were associated with an increase in the risk of preterm birth. NVP lasting one trimester in duration was associated with decrease in risk of SGA (aOR: 0.74, 95% CI: 0.58, 0.95), and NVP present in every trimester of pregnancy had a 50% increase in risk of preterm birth (aOR: 1.50, 95% CI: 1.11, 2.05). For NVP in months 7-9 and preterm birth, ORs were elevated for moderate (aOR: 1.82, 95% CI: 1.26, 2.63), and severe (aOR: 1.53, 95% CI: 1.06, 2.19) symptoms. NVP was not significantly associated with low birth weight. Our analyses of medications were limited by small numbers, but none suggested increased risk of adverse outcomes associated with use of the medication.

CONCLUSION

Mild NVP and NVP limited to early pregnancy appear to have no effect or a small protective effect on birth outcomes. Long-lasting NVP, severe NVP, and NVP later in pregnancy may increase risk of preterm birth and SGA.

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.

Treatments for hyperemesis gravidarum: A systematic review

INTRODUCTION

Hyperemesis gravidarum affects 0.3%-3% of pregnant women each year and is the leading cause of hospitalization in early pregnancy. Previous systematic reviews of available treatments have found a lack of consistent evidence, and few studies of high quality. Since 2016, no systematic review has been conducted and an up-to date review is requested. In a recent James Lind Alliance collaboration, it was clear that research on effective treatments is a high priority for both patients and clinicians.

MATERIAL AND METHODS

Searches without time limits were performed in the AMED, CINAHL, Cochrane Library, EMBASE, Medline, PsycINFO, and Scopus databases until June 26, 2023. Studies published before October 1, 2014 were identified from the review by O'Donnell et al., 2016. Selection criteria were randomized clinical trials and non-randomized studies of interventions comparing treatment of hyperemesis gravidarum with another treatment or placebo. Outcome variables included were: degree of nausea; vomiting; inability to tolerate oral fluids or food; hospital treatment; health-related quality of life, small-for-gestational-age infant; and preterm birth. Abstracts and full texts were screened, and risk of bias of the studies was assessed independently by two authors. Synthesis without meta-analysis was performed, and certainty of evidence was assessed using the GRADE approach. PROSPERO (CRD42022303150).

RESULTS

Twenty treatments were included in 25 studies with low or moderate risk of bias. The certainty of evidence was very low for all treatments except for acupressure in addition to standard care, which showed a possible moderate decrease in nausea and vomiting, with low certainty of evidence.

CONCLUSIONS

Several scientific knowledge gaps were identified. Studies on treatments for hyperemesis gravidarum are few, and the certainty of evidence for different treatments is either low or very low. To establish more robust evidence, it is essential to use validated scoring systems, the recently established diagnostic criteria, clear descriptions and measurements of core outcomes and to perform larger studies.

Survivors' Experiences of Hyperemesis Gravidarum

Hyperemesis gravidarum can result in life-threatening physical and psychological maternal morbidity, including severe dehydration, weight loss, electrolyte imbalance, depression, and suicidal ideation. The reported prevalence of hyperemesis gravidarum ranges from 0.3% to 3.6%. The purpose of this qualitative study was to investigate what blogs can tell us about women's experiences of hyperemesis gravidarum. Thirty-three blogs written by hyperemesis gravidarum survivors posted on Hyperemesis Australia's website were analyzed using Krippendorff's qualitative content analysis method. Clustering was used and yielded 6 themes: (1) debilitating physical and mental health problems: digging deep to persevere, (2) heartbreaking choices, (3) lack of understanding and dismissed, (4) so much guilt surrounding their unborn infant, (5) it takes a village to support women with hyperemesis gravidarum, and (6) warriors and survivors: giving back. Infusion nurses are in a perfect position to provide support and compassionate care for women who are repeatedly coming to the hospital for rehydration treatment. Infusion nurses can validate women's physical and emotional struggles with hyperemesis gravidarum and help to no longer make women feel stigmatized.

Women's experiences of Hyperemesis Gravidarum (HG) and of attending a dedicated multi-disciplinary hydration clinic

PROBLEM

Hyperemesis Gravidarum (HG) is a severe form of nausea and vomiting in pregnancy that affects 1-3 % of women and has profound nutritional, physical and psychological consequences. Previous research identified that women with HG report inadequate infrastructure for day case management.

INTRODUCTION

A multi-disciplinary HG day case service (IRIS Hydration Clinic) was launched and provides routine care for women with HG in a dedicated unit. The multi-disciplinary team involves midwives, dietitians, obstetricians and perinatal mental health.

AIMS

To explore women's experiences of HG and of attending the dedicated clinic.

METHODS

Ten interviews were conducted with women who attended the clinic. Data were transcribed and analysed using Reflexive Thematic Analysis.

FINDINGS

The physical and psychological impact of HG was captured. The appreciation for the dedicated clinic was a common theme, regarding having somewhere specific for treatment rather than ad-hoc treatment. 'Relationships' was a significant theme - women described the benefits of continuity of care and the positive impact of peer support. Areas for improvement were explored, such as expansion and extra sensitivity around some women's issues around weight gain/loss.

DISCUSSION

HG causes significant ill-health and its impact remains undervalued. Women had highly positive experiences of attending the dedicated HG clinic. The impact of continuity and individualized care in a day-case setting improved women's experiences of this condition.

CONCLUSION

The dedicated HG clinic was highly valued by women experiencing the condition. The IRIS clinic provides much-needed validation for a medical condition with little understanding from the general public or many healthcare professionals.

The Nutritional Online sUrvey for pRegnancy Induced Sickness & Hyperemesis (NOURISH) study: results from the first trimester

BACKGROUND

Hyperemesis gravidarum (HG) is severe pregnancy sickness, often leading to dehydration, weight loss and electrolyte disturbances. Little is known about nutritional intake and its consequences in those affected. The aim of this study was to explore the first trimester nutritional intake and clinical characteristics in those with severe sickness.

METHOD

Recruitment was via the social media accounts of national pregnancy charities. The eligibility criteria were as follows: between 6 and 11 weeks pregnant, age ≥18 years and residing in the UK. Participants completed a self-report online questionnaire including the Pregnancy Unique Quantification of Emesis 24 (PUQE24) score and a 3-day online diet diary. Groups were compared by PUQE24 categories. Nutritional intakes were compared to dietary reference values.

RESULTS

One hundred sixty-six participants took part in the study: 36 categorised with mild, 109 with moderate and 21 with severe symptoms at a median gestation of 8.1 (interquartile range [IQR] 3) weeks. Those in the severe category had significantly higher weight loss (3.0 kg, IQR 3.5) than the mild category (0.0 kg, IQR 0.9). In those who completed the diet diary (n = 70), intakes of energy, carbohydrate, protein, fat, fibre, calcium, iron, zinc, thiamine, riboflavin, folate and vitamin C were all significantly lower in the severe category (p < 0.05). The severe group consumed only 39.5% and 41.6% of energy and protein needs, respectively, and were more likely to stop taking micronutrient supplements (p < 0.05).

CONCLUSION

Nutritional and supplement intake in those with severe pregnancy sickness was poor; however, intake across all participants was suboptimal. Future research should investigate how to improve nutritional intake across all categories of pregnancy sickness.

Investigation of Serum Phoenixin-14 Concentration in Pregnant Women Diagnosed with Hyperemesis Gravidarum

OBJECTIVE

We aimed to investigate the relationship between the hyperemesis gravidarum (HG) and maternal serum phoenixin-14 (PNX-14) concentrations.

MATERIALS AND METHODS

This cross-sectional study was conducted with 88 pregnant women who applied to the Umraniye Training and Research Hospital Gynecology and Obstetrics Clinic between February 2022 and October 2022. The HG group consisted of 44 pregnant women diagnosed with HG between the 7th and 14th gestational weeks, and the control group consisted of 44 healthy pregnant women matched with the HG group in terms of age, BMI, and gestational week. Demographic characteristics, ultrasound findings, and laboratory outcomes were noted. The two groups were compared in terms of maternal serum PNX-14 concentrations.

RESULTS

Gestational age at blood sampling for PNX-14 was similar in both groups (p=1.000). While maternal serum PNX-14 concentration was 85.5 pg/ml in the HG group, it was 71.3 pg/ml in the control group (p=0.012). ROC analysis was performed to determine the value of maternal serum PNX-14 concentration in terms of predicting HG. AUC analysis of maternal serum PNX-14 for HG estimation was 0.656 (p=0.012, 95% CI=0.54-0.77). The optimal cutoff value for maternal serum PNX-14 concentration was determined as 79.81 pg/ml with 59% sensitivity and 59% specificity.

CONCLUSION

In this study, maternal serum PNX-14 concentration was found to be higher in pregnant women with HG, which indicates that high serum PNX-14 concentrations may have an anorexigenic effect on food intake in pregnancy. Concentrations of other PNX isoforms in HG and changes in PNX concentrations in pregnant women with HG who regained weight after treatment remain to be investigated.

Hyperemesis gravidarum: Associations with personal and family history of nausea

INTRODUCTION

The pathogenesis and risk factors for hyperemesis gravidarum, excessive nausea and vomiting of pregnancy, are not adequately recognized. In our previous study, we found that women with a personal history of nausea in different situations and a family history of nausea and vomiting of pregnancy (NVP) were more likely to have severe NVP. The present study focuses on these themes in association with hyperemesis gravidarum in a hospital setting.

MATERIAL AND METHODS

Women with hyperemesis gravidarum (n = 102) were recruited from among patients hospitalized due to hyperemesis gravidarum in Turku University Hospital, Finland. Our control group (Non-NVP group, n = 138) consisted of pregnant women with no NVP. Personal history of nausea in different situations was inquired about in relation to "motion sickness", "seasickness", "migraine", "other kind of headache", "after anesthesia", "during the use of contraception", and "other kinds of nausea". Relatives with NVP were divided into first-degree (mother and sisters) and second-degree (more distant) relatives.

RESULTS

In univariate analysis, a personal history of motion sickness, seasickness, nausea related to migraine, nausea with other headache and nausea in other situations were associated with hyperemesis gravidarum. After adjusting for age, parity, pre-pregnancy body mass index, marital status, and smoking, motion sickness (adjusted odds ratio [aOR] 5.24, 95% confidence interval [CI] 2.67-10.31, p < 0.0001), seasickness (aOR 4.82, 95% CI 2.32-10.03, p < 0.0001), nausea related to migraine (aOR 3.00, 95% CI 1.58-5.70, p < 0.001), and nausea in other situations (aOR 2.65, 95% CI 1.13-6.20, p = 0.025) remained significant. In multivariable analysis with all history of nausea variables, motion sickness (OR 2.76, 95% CI 1.29-5.89, p = 0.009) and nausea related to migraine (OR 3.10, 95% CI 1.40-6.86, p = 0.005) were associated with hyperemesis gravidarum. Having any affected relative (OR 3.51, 95%CI 1.84-6.73, p = 0.0002), especially a first-degree relative (OR 3.06, 95% CI 1.62-5.79, p = 0.0006), was also associated with hyperemesis gravidarum. Adjustment did not change the results.

CONCLUSIONS

Women with a personal history of nausea or a family history of NVP are more likely to suffer from hyperemesis gravidarum. These results are beneficial to better identify and help women at risk for hyperemesis gravidarum.

EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy

Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.

Reorganising and improving quality of care for hyperemesis gravidarum in a Danish hospital: a quality improvement project

BACKGROUND

Hyperemesis gravidarum (HG) is a pregnancy complication comprising severe nausea and vomiting in pregnancy. It is associated with adverse outcomes for both mother and child. Treatment consists primarily of antiemetics and intravenous fluids; however, support from healthcare professionals is also important.

LOCAL PROBLEM

At the department of obstetrics at Nordsjællands Hospital, an increasing workload caused challenges regarding patient care and organisation for patients with HG, and exploring possibilities of reorganising HG care to release midwife resources was warranted.

METHODS

Through input from staff and patients, possible improvements were identified. Plan-do-study-act cycles were conducted with staff and patients, resulting in adjustments in care and organisation and thus use of resources. The specific, measurable, attainable, realistic and timely aims included patient satisfaction and number of follow-ups conducted via phone.

INTERVENTIONS

HG care was relocated to the department of gynaecology, where it was managed primarily by nurses. Staff and patients were actively involved in the process.

RESULTS

HG care was successfully relocated without compromising patient satisfaction. Additionally, an option of patient-administered home treatment for selected patients was established.

CONCLUSION

This quality improvement project describes the relocation and set-up of hospital care provided to patients with HG, resulting in high patient satisfaction. This project might serve as an inspiration to other departments of obstetrics and gynaecology.

Watermelon and dietary advice compared to dietary advice alone following hospitalization for hyperemesis gravidarum: a randomized controlled trial

BACKGROUND

Hyperemesis gravidarum (HG) affects about 2% of pregnancies and is at the severe end of the spectrum of nausea and vomiting of pregnancy. HG causes severe maternal distress and results in adverse pregnancy outcomes long after the condition may have dissipated. Although dietary advice is a common tool in management, trial evidence to base the advice on is lacking.

METHODS

A randomized trial was conducted in a university hospital from May 2019 to December 2020. 128 women at their discharge following hospitalization for HG were randomized: 64 to watermelon and 64 to control arm. Women were randomized to consume watermelon and to heed the advice leaflet or to heed the dietary advice leaflet alone. A personal weighing scale and a weighing protocol were provided to all participants to take home. Primary outcomes were bodyweight change at the end of week 1 and week 2 compared to hospital discharge.

RESULTS

Weight change (kg) at end of week 1, median[interquartile range] -0.05[-0.775 to + 0.50] vs. -0.5[-1.4 to + 0.1] P = 0.014 and to the end of week 2, + 0.25[-0.65 to + 0.975] vs. -0.5[-1.3 to + 0.2] P = 0.001 for watermelon and control arms respectively. After two weeks, HG symptoms assessed by PUQE-24 (Pregnancy-Unique Quantification of Emesis and Nausea over 24 h), appetite assessed by SNAQ (Simplified Nutritional Appetite Questionnaire), wellbeing and satisfaction with allocated intervention NRS (0-10 numerical rating scale) scores, and recommendation of allocated intervention to a friend rate were all significantly better in the watermelon arm. However, rehospitalization for HG and antiemetic usage were not significantly different.

CONCLUSION

Adding watermelon to the diet after hospital discharge for HG improves bodyweight, HG symptoms, appetite, wellbeing and satisfaction.

TRIAL REGISTRATION

This study was registered with the center's Medical Ethics Committee (on 21/05/2019; reference number 2019327-7262) and the ISRCTN on 24/05/2019 with trial identification number: ISRCTN96125404 . First participant was recruited on 31/05/ 2019.

Hyperemesis Gravidarum: Risk of Recurrence in Subsequent Pregnancies

This study aimed to examine whether the recurrence risk of hyperemesis gravidarum (HG) is modified by the timing of diagnosis, the severity of illness, and interpregnancy interval. The Kaiser Permanente Southern California 1998-2020 longitudinally linked medical records were used to examine the recurrence risk of HG in the first two (n = 93,444) and first three (n = 17,492) successive pregnancies. The timing of diagnosis- and the severity of illness-specific recurrence risks were examined by estimating the adjusted relative risks (aRR). The risks of HG in the second pregnancy among patients with and without previous HG were 23.8% and 3.4%, respectively (aRR: 8.20; 95% confidence interval [CI]: 7.52, 8.94). The recurrence risk persisted regardless of the trimester at diagnosis and the gestational age of delivery in the first pregnancy. The recurrence risk was greater for patients with metabolic disturbances requiring in-hospital treatment (30.0%) than those managed on an outpatient basis (18.6%) in the first pregnancy (aRR: 10.84 95% CI: 9.66, 12.16). Although Asian/Pacific Islander (RR = 12.9) and White (RR = 8.9) patients had higher HG recurrence risk regardless of the gestational age at delivery in the first pregnancy, all patients had significant recurrence risk only if their first pregnancy was delivered after 32 weeks of gestation. African American patients had the highest recurrence rate (34.4%). HG recurrence risk was unaffected by interpregnancy interval and correlated with the number of previous pregnancies complicated by HG. There is an increased recurrence risk of HG in subsequent pregnancies that is influenced by race/ethnicity and gestational age at delivery. The number of pregnancies complicated by HG synergistically adds to the recurrence risk.

Are serum delta neutrophil index and other inflammatory marker levels different in hyperemesis gravidarum?

AIM

Hyperemesis gravidarum (HEG) is a condition characterized by nausea and vomiting, fluid electrolyte and acid-base imbalance, dehydration, weight loss, and ketonuria in early pregnancy. The relationship of HEG with inflammation has been studied in many studies. This study aimed to investigate the role of serum delta neutrophil index (DNI), a new inflammatory marker, and other inflammatory markers in demonstrating the disease's presence and severity in HEG patients.

MATERIAL AND METHOD

This retrospective study was conducted by accessing the electronic data of 79 pregnant women diagnosed with HEG in a tertiary center between 2017 and 2022 and 100 healthy pregnant women. The demographic characteristics of the study and control groups, as well as the hematological parameters in the complete blood count and the levels of inflammatory markers, were recorded.

RESULTS

There was no significant difference between the groups regarding hematological parameters, DNI, platelet-lymphocyte ratio, monocyte-lymphocyte ratio, and systemic inflammation index (p > 0.05). Neutrophil count and neutrophil-lymphocyte ratio (NLR) were higher in the HEG group compared to the control group (p < 0.05).

CONCLUSION

This is the first study to determine the relationship between HEG and serum DNI, a new inflammatory marker. We found that serum DNI values in HEG patients were not different from normal pregnancies and did not reflect the presence and severity of the disease. We also found that inflammatory markers other than the NLR were not different from normal pregnancies in HEG patients.

Zinc Deficiency-Associated Dysgeusia Preventing the Improvement of Severe Hyperemesis Gravidarum

A 23-year-old primigravida visited the hospital frequently since the early phase of her pregnancy because of severe hyperemesis gravidarum. She was hospitalized for the same at 14 weeks and 1 day of pregnancy. After admission, peripheral intravenous nutrition was started; however, her symptoms did not improve. At 17 weeks and 1 day of gestation, a blood sample was collected to determine the presence of trace element deficiencies, and a zinc deficiency was revealed. We examined the patient's symptoms and found that she had developed dysgeusia. After receiving a zinc preparation, her taste disorder gradually improved, and her oral intake increased. Her hyperemesis gravidarum resolved, and she was discharged from the hospital at 18 weeks and 2 days of gestation. The findings from this case suggest that prolonged peripheral intravenous nutrition in patients with severe hyperemesis gravidarum can lead to zinc deficiency and impede the successful treatment of hyperemesis gravidarum.

Pregnant, miserable, and starving in 21st century America

Severe nausea and vomiting of pregnancy is too common and devastating to be trivialized any longer. Authors of recent studies observed that children exposed in utero to severe nausea and vomiting of pregnancy had an increased risk for autism spectrum disorder, a decreased brain cortical volume, and developmental deficits. Research on severe nausea and vomiting of pregnancy and hyperemesis gravidarum has been disturbingly slow. It was not until 2021 that an international consensus definition was published. Hyperemesis gravidarum starts before 16 weeks' gestation, is characterized by severe nausea with or without vomiting and an inability to eat and drink normally, and greatly limits daily activities. Maternal misery is caused by unrelenting nausea, intractable retching or vomiting, ptyalism, dehydration, reflux, malnutrition, and social isolation. Hyperemesis gravidarum is the second most common reason for hospitalization in pregnancy. Symptoms can persist until delivery in one-third of individuals who experience extreme weight loss. Significant associations have been identified between hyperemesis gravidarum and multiple adverse outcomes. Maternal deaths owing to hyperemesis gravidarum continue to be reported, and hyperemesis gravidarum is associated with high fetal loss and termination rates. These grim findings highlight the critical public health importance of treating severe nausea and vomiting of pregnancy early to mitigate serious complications that compromise maternal and offspring health during pregnancy and beyond. Despite suffering extreme debility, individuals with hyperemesis gravidarum report feeling that their experiences were dismissed by healthcare professionals, contributing to therapeutic termination, suicidal ideation, perinatal depression, and posttraumatic stress disorder. Hyperemesis gravidarum must be recognized early and treated aggressively with frequent monitoring. Although medications can be effective in reducing symptoms, many patients do not gain adequate relief, and new treatments are needed. A promising new avenue for treatment comes from genetic discoveries. The gene, growth differentiation factor-15, which codes for a nausea and vomiting hormone produced by the placenta, is the greatest genetic risk factor for hyperemesis gravidarum, and therapies are currently in clinical trials in cancer. However, until treatment is universally effective, abortion access must be available for refractory hyperemesis gravidarum. Herein, we emphasize data published since the most recent American College of Obstetrics and Gynecology report (2018), such as long-term neuropsychiatric consequences in offspring exposed to hyperemesis gravidarum and suggest interventions anticipated to prevent progression of early symptoms to hyperemesis gravidarum.

Systematic evidence map of evidence addressing the top 10 priority research questions for hyperemesis gravidarum

OBJECTIVE

Knowledge gaps regarding hyperemesis gravidarum (HG) are substantial. We aimed to systematically identify and map recent evidence addressing the top 10 priority questions for HG, as published in 2021 in a James Lind Alliance Priority Setting Partnership.

DESIGN

Systematic evidence map.

METHODS

We searched MEDLINE and EMBASE on 12 January 2021 and CINAHL on 22 February 2021 with search terms hyperemesis gravidarum, pernicious vomiting in pregnancy and their synonyms. Results were limited to 2009 onwards. Two reviewers independently screened titles and abstracts to assess whether the studies addressed a top 10 priority questions for HG. Differences were discussed until consensus was reached. Publications were allocated to one or more top 10 research questions. Study design was noted, as was patient or public involvement. Two reviewers extracted data synchronously and both cross-checked 10%. Extracted data were imported into EPPI-Reviewer software to create an evidence map.

OUTCOME MEASURES

The number and design of studies in the search yield, displayed per the published 10 priority questions.

RESULTS

Searches returned 4338 results for screening; 406 publications were included in the evidence map. 136 publications addressed multiple questions. Numerous studies address the immediate and long-term outcomes or possible markers for HG (question 8 and 9, respectively 164 and 82 studies). Very few studies seek a possible cure for HG (question 1, 8 studies), preventative treatment (question 4, 2 studies) or how to achieve nutritional requirements of pregnancy (question 10, 17 studies). Case reports/series were most numerous with 125 (30.7%) included. Few qualitative studies (9, 2.2%) were identified. 25 (6.1%) systematic reviews addressed eight questions, or aspects of them. 31 (7.6%) studies included patient involvement.

CONCLUSIONS

There are significant gaps and overlap in the current HG literature addressing priority questions. Researchers and funders should direct their efforts at addressing the gaps in the top 10 questions.

Effect of Acupressure at P6 on Nausea and Vomiting in Women with Hyperemesis Gravidarum: A Randomized Controlled Trial

Hyperemesis gravidarum is characterized by severe nausea and vomiting. This study aims to illustrate the efficacy of acupressure at P6 in treating nausea and vomiting in hyperemesis gravidarum. This parallel randomized controlled trial was conducted from 2016-2017 in a tertiary hospital. Hospitalized women with ≤16 weeks of gestation and moderate to severe nausea and vomiting classified using a modified PUQE score were randomly assigned in a 1:1 ratio to either apply an acupressure wristband at the P6 point three times daily or to receive regular doses of intravenous antiemetics. The primary outcome was differences in modified PUQE scores among the groups. The secondary outcomes were differences in the rate of urine ketone clearance and the frequency of requiring rescue antiemetics. Ninety women were equally randomized into two groups, with no dropout. There was a statistically significant difference in the degrees of nausea and vomiting between the groups at 8, 16, and 24 hours post-admission (p8hours= 0.001, p16hours = 0.006, and p24hours = 0.001). The requirement of antiemetics and the rate of urine ketone clearance between the two groups were also statistically significant, at p = 0.001 and p = 0.02 respectively. There were no side effects in either group. The P6 acupressure was efficacious in alleviating nausea and vomiting among hyperemesis gravidarum women. The trial was retrospectively registered on ClinicalTrials.gov (NCT05175079).

Assessment of management approaches for hyperemesis gravidarum and nausea and vomiting of pregnancy: a retrospective questionnaire analysis

Background

Hyperemesis gravidarum is the most severe form of nausea and vomiting of pregnancy, or morning sickness. 2% of pregnancies in the United States are affected by hyperemesis gravidarum. The condition is characterized by severe vomiting in pregnant people, especially during the first trimester, often leading to hypovolemia and weight loss. The standard of care for hyperemesis and nausea and vomiting of pregnancy is commonly ineffective. We hypothesize that based on patient experience; the current treatment guidelines for hyperemesis are not clinically effective. Our objective was to identify the efficacy of the various management approaches that are currently in place for hyperemesis and nausea and vomiting of pregnancy.

Methods

A questionnaire was designed based on diagnostic criteria, standard demographic identifiers, and common medications for the treatment of hyperemesis gravidarum. This questionnaire was distributed online to through hyperemesis and nausea and vomiting of pregnancy support groups, personal social media, and institutional email.

Results

In our study, most participants diagnosed with hyperemesis gravidarum trialed at least three medications, most of which were ineffective and/or had severe side effects. The most used medication for treatment of hyperemesis gravidarum is ondansetron, a standard antiemetic, with fatigue and constipation being the most reported side effects. All data in the dataset was coded as categorical and analyzed using contingency tables using Mantel-Haenszel Chi square tests.

Conclusions

The data presented in this research provides insight into the suffering that patients with these diagnoses face day-to-day due to the lack of efficacious, well-tolerated treatment options. Establishing this gap in treatment can facilitate the development of effective treatments that will provide relief for thousands of patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04922-6.

Antiemetic treatment of hyperemesis gravidarum in 1,064 Norwegian women and the impact of European warning on metoclopramide: a retrospective cohort study 2002–2019

Background

Women suffering from severe nausea and vomiting during pregnancy, hyperemesis gravidarum, have poor quality of life and increased risk of potentially fatal maternal and fetal complications. There is increasing and reassuring knowledge about safety of antiemetics in pregnancy. In 2013, the European Medical Agency (EMA) issued a warning on metoclopramide limiting treatment to maximum five days. Metoclopramide was the most used antiemetic in pregnancy at the time the warning was implemented in the Norwegian hyperemesis guidelines (2014). We aimed at describing changes in the treatment of hyperemesis over time, including changes associated with the EMA warning.

Methods

Retrospective chart review of all women hospitalized for hyperemesis gravidarum with metabolic disturbances between 01/Jan/2002 and 31/Dec/2019 at a university hospital serving nearly 10% of the pregnant population in Norway. Time-series analysis described changes over time and interrupted time series analysis quantified changes in treatment and clinical outcomes related to the EMA warning.

Results

In total, 1,064 women (1.2% of the birthing population) were included. The use of meclizine, prochlorperazine, and ondansetron increased during 2002–2019. This led to a yearly increase in the percentage of women using any antiemetic of 1.5% (95%CI 0.6; 2.4) pre-hospital, 0.6% (95%CI 0.2; 1.1) during hospitalization, and 2.6% (95%CI 1.3; 3.8) at discharge. Overall, only 50% of the women received antiemetics pre-hospital. Following the EMA warning, prehospital use of metoclopramide dropped by 30% (95%CI 25; 36), while use of any antiemetic pre-hospital dropped by 20% (95%CI 5.7; 34). In timely association, we observed a decrease in gestational age (-3.8 days, 98.75%CI 0.6; 7.1) at first admission, as well as indication of increased rate of termination of pregnancy with an absolute increase of 4.8% (98.75%CI 0.9; 8.7) in 2014.

Conclusion

During 2002–2019, the overall use of antiemetics in treatment of hyperemesis increased. The EMA-warning on metoclopramide in 2013 temporarily limited pre-hospital antiemetic provision associated with hospitalization at lower gestational length and indication of an increase in termination of pregnancy.

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.

Lack of catch-up in weight gain may intermediate between pregnancies with hyperemesis gravidarum and reduced fetal growth: the Japan Environment and Children’s Study

Background

Women with nausea and vomiting of pregnancy (NVP) have higher birth weight infants, while those with hyperemesis gravidarum, a severe manifestation of NVP, have lower birth weight infants. We aimed to investigate the associations between maternal weight loss (a consequence of hyperemesis gravidarum), NVP, and infant birth weight.

Methods

This study was a secondary analysis of a nationwide birth cohort in Japan. Singleton pregnancies delivered at 28–41 weeks of gestation were included in the analysis. Women were categorized based on their weight change in the 1^st trimester (as a proportion to their pre-pregnancy weight: >  + 3%, > 0 to + 3%, > -3 to 0%, > -5 to -3%, ≤ -5%) and severity of NVP (no nausea, only nausea, vomiting but able to eat, vomiting and unable to eat). The effects of weight change and severity of NVP on infant birth weight and small for gestational age (SGA) were assessed using regression models. We further examined how these effects could be modified by maternal weight gain up to the 2^nd trimester.

Results

Among 91,313 women, 5,196 (5.7%) lost ≥ 5% of their pre-pregnancy weight and 9,983 (10.9%) experienced vomiting and were unable to eat in the 1^st trimester. Women with weight loss ≥ 5% in the 1^st trimester had infants 66 (95% CI: 53, 78) g lighter and higher odds of SGA (aOR: 1.29; 95% CI: 1.14, 1.47) than women who gained > 3% during the same period. However, when adjusting for weight gain up to the 2^nd trimester, women with weight loss ≥ 5% in the 1^st trimester had infants 150 (95% CI: 135, 165) g heavier and lower odds of SGA (aOR: 0.39; 95% CI: 0.33, 0.46) than those who gained > 3% during the same period. In contrast, women with more severe NVP tended to have infants with larger birth weight and lower odds of SGA compared to women without NVP. These trends were strengthened when adjusting for weight gain up to the 2^nd trimester.

Conclusions

Our study suggests the possibility that reduced fetal growth in pregnancies with hyperemesis gravidarum may be caused by the lack of catch-up in gestational weight gain up to the 2^nd trimester.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04542-0.

Emerging Progress in Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum: Challenges and Opportunities

Nausea and vomiting of pregnancy (NVP) is a common condition that affects up to 70% of pregnant women. Hyperemesis gravidarum (HG) is considered the serious form of NVP, which is reported in 0.3–10.8% of pregnant women. NVP has a relatively benign course, but HG can be linked with some poor maternal, fetal, and offspring outcomes. The exact causes of NVP and HG are unknown, but various factors have been hypothesized to be associated with pathogenesis. With the advance of precision medicine and molecular biology, some genetic factors such as growth/differentiation factor 15 (GDF15) have become therapeutic targets. In our review, we summarize the historical hypotheses of the pathogenesis of NVP and HG including hormonal factors, Helicobacter pylori, gastrointestinal dysmotility, placenta-related factors, psychosocial factors, and new factors identified by genetics. We also highlight some approaches to the management of NVP and HG, including pharmacological treatment, complementary treatment, and some supporting treatments. Looking to the future, progress in understanding NVP and HG may reduce the adverse outcomes and improve the maternal quality of life during pregnancy.