Emergency department burden of hyperemesis gravidarum in the United States from 2006 to 2014

Pregnancy Burden: An Integrative Review and Dimensional Analysis of Pregnancy's Hidden Challenges

INTRODUCTION

Outcomes surrounding childbirth have focused on survival, leaving gaps in understanding the comprehensive experience of pregnancy for the pregnant individual. Anecdotally, pregnancy and the opportunity to reproduce is often received with a celebratory response. Yet whether planned or unplanned, a wide array of burdens may exist throughout pregnancy ranging from minor inconveniences to dangerous contributions to morbidity and mortality. The experience of pregnancy is superimposed onto the physical, mental, and social reality that already exists as an individual's life and consistently accentuates aspects of stress that can lead to increased physical, mental, emotional, financial, or other burden that many health and social systems globally lack resources to support. To address this gap, this analysis sought to explore the concept of pregnancy burden.

METHODS

A formal search of 5 databases was conducted using integrative review methodology, with a total of 37 articles meeting inclusion criteria. To better conceptualize pregnancy burden, a dimensional analysis was then undertaken posing the research question, "What is pregnancy burden?"

RESULTS

The current social construction of pregnancy burden revealed multidimensional contributors to burden that were identified as both intrinsic and extrinsic, with no current definition available. Five dimensions of pregnancy burden were discovered: health, education, financial or cost, inequity, and social support. Three distinct perspectives were identified that included the pregnant person; their partners, family, or friends; and health systems or care providers. To best answer the research question and focus on the personal experience, the scope of this analysis was limited to the perspective of the pregnant individual.

DISCUSSION

The term burden is discussed and well-developed in chronic disease literature but has not been inclusive of pregnancy. This review revealed that pregnancy burden exists but remains unclassified and understudied, supporting the need for further exploration. Better understanding and valuing of the total experience of pregnancy, inclusive of burden, has the potential to improve the pregnancy experience.

Endocrine-Disrupting Chemicals and Persistent Nausea among Pregnant Women Enrolled in the Illinois Kids Development Study (I-KIDS)

BACKGROUND

Pregnant women are exposed to numerous endocrine-disrupting chemicals (EDCs). Pregnancy-related nausea likely has hormonal etiology and may persist beyond the first trimester.

OBJECTIVES

Therefore, we aimed to determine the relationship between EDC biomarkers and pregnancy nausea characteristics.

METHODS

Illinois Kids Development Study (I-KIDS) pregnant women (n = 467 ) reported nausea symptoms monthly from conception to delivery. We categorized women as never having nausea (9%) or as having typical (ends by 17 wk gestation; 42%), persistent (ends after 17 wk gestation; 25%), or irregular (24%) nausea. Women provided five urine samples across pregnancy, which we pooled and analyzed for phthalate/replacement, phenol, and triclocarban biomarkers. Using covariate-adjusted logistic regression, we evaluated relationships of EDCs with nausea and used quantile-based g-computation (QGComp) and Bayesian kernel machine regression (BKMR) to evaluate joint associations of EDCs with nausea symptoms. We also considered differences in associations by fetal sex.

RESULTS

Only the sum of urinary biomarkers of di(isononyl) cyclohexane-1,2-dicarboxylate (Σ DiNCH ) was associated with higher risk of persistent nausea compared to typical nausea [odds ratio (OR) = 1.18 ; 95% CI: 1.01, 1.37] in all women. However, using QGComp, a 10% higher concentration of the EDC mixture was associated with 14% higher risk of persistent nausea [relative risk (RR) = 1.14 ; 95% CI: 1.01, 1.30], due to Σ DiNCH , ethylparaben, and the sum of di-2-ethylhexyl phthalate (Σ DEHP ) metabolites. Similarly, using BMKR, the EDC mixture was associated with greater odds of persistent nausea in all women. In women carrying male offspring, ethylparaben was associated with persistent nausea, and a 10% higher concentration of the QGComp mixture was associated with 26% higher risk of persistent nausea (RR = 1.26 ; 95% CI:1.13, 1.41), driven by ethylparaben and Σ DiNCH . Consistently, using BKMR, EDCs were positively associated with persistent nausea in women carrying males. We did not identify associations between EDC biomarkers and persistent nausea in women carrying females or between EDC biomarkers and other nausea patterns.

DISCUSSION

Nonpersistent EDCs, modeled as a mixture, are associated with persistent nausea in pregnancy, primarily in women carrying males. Future work should explore possible mechanisms, clinical implications, and interventions to reduce exposures and symptoms. https://doi.org/10.1289/EHP15547.

Exploring midwifery role and scope in acute early pregnancy care: a survey of midwives and midwifery students in Australia

BACKGROUND

The scope of practice of the contemporary midwife encompasses a range of sexual and reproductive healthcare, including care throughout pregnancy. Midwives are experts in pregnancy care, but many do not provide care for women with unexpected (acute) complications in early pregnancy (< 20 weeks) in Australia. Women experiencing acute pregnancy complications < 20 weeks usually attend an emergency department rather than a maternity unit. These settings do not typically employ midwives and may not meet women's need for timely and informed physical care and psychosocial support. A gap in evidence exists in relation to the role and scope of practice of the midwife in acute early pregnancy care provision in Australia.

METHODS

Midwives and midwifery students in Australia were purposively sampled and invited to complete an online cross-sectional survey exploring midwifery practice in acute early pregnancy care. Data were collected from July 1st to September 30th, 2024. Quantitative data were analysed using descriptive and inferential statistics. Free-text responses were analysed using inductive content analysis.

RESULTS

Responses from 294 midwives and 46 midwifery students (n = 340) were analysed. Participants recognised that midwives should provide acute care in early pregnancy, and many had knowledge, confidence or experience in this area. The most reported setting for acute early pregnancy care provision was the general emergency department; early pregnancy assessment service models were also common. Some settings prioritised the employment of registered nurses over midwives in acute early pregnancy services. Challenges to midwives providing acute early pregnancy care included inadequate clinical exposure as qualified midwives, and women being placed in non-maternity settings.

CONCLUSION

Participants supported midwives providing acute care in early pregnancy, confirming that midwives' professional scope should not be impacted by pregnancy gestation or outcome. However, current midwifery education programs may not be adequately preparing midwives to provide comprehensive care for women with acute early pregnancy complications. Those midwives who are providing care may not be fulfilling professional scope. Findings have utility in supporting policy, education and service review, and highlight further gaps in evidence for future research.

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.

Evaluation of controlling nutritional status (CONUT) score in the prognosis of hyperemesis gravidarum

OBJECTIVE

To investigate the predictive value of the Controlling Nutritional Status (CONUT) score on hyperemesis gravidarum (HG) severity, hospitalization, and length of stay.

MATERIALS AND METHODS

This retrospective cross-sectional study, conducted between December 2022 and June 2023, involved two groups. Group 1 comprised 52 pregnant women diagnosed with HG in the first trimester, receiving hospitalization and treatment. Group 2 included 105 pregnant women diagnosed with HG in the first trimester, managed and treated as outpatients. The CONUT score was calculated with the formula: Serum albumin score + total lymphocyte score + total cholesterol score. This score is calculated with a number of points between 0 and 12. The interpretation of the score involves four categories: normal (0-1), light (2-4), moderate (5-8), and severe (9-12).

RESULTS

The CONUT score differed significantly between the hospitalized (4, IQR: 2.25-5) and outpatient groups (2, IQR: 2-3) (p < 0.001). A CONUT score >3 was associated with the need for hospitalization, demonstrating a sensitivity of 60%, a specificity of 84% (p < 0.001). The CONUT score was the parameter with the highest odds ratio (OR) value among the parameters related to the need for hospitalization, and each unit increase in the CONUT score increased the need for hospitalization by 1.683 times [OR = 1.683 (95% CI: 1.042-2.718), p = 0.033]. A positive correlation was found between the CONUT score and the duration of hospital stay (r = 0.316, p = 0.023).

CONCLUSIONS

This study suggests CONUT score as a valuable tool for predicting HG severity, hospitalization need, and duration of hospital stay.

Use of Thiamine Supplementation in Pregnant Women Diagnosed With Hyperemesis Gravidarum and Wernicke Encephalopathy

Hyperemesis gravidarum is the most common condition requiring hospital care for women during the first 20 weeks of pregnancy and may lead to malnutrition, dehydration, and vitamin deficiencies. Depletion of vitamins such as thiamine may result in the development of Wernicke encephalopathy, a severe neurological disorder that can increase the risk for mortality and morbidity for the mother and fetus. A lack of awareness regarding the relationship of hyperemesis gravidarum and Wernicke encephalopathy may result in delayed treatment and disease management. Glucose administration in the presence of thiamine deficiency may induce Wernicke encephalopathy; protocols are needed to ensure dextrose is used for women with hyperemesis gravidarum in times of prolonged vomiting and poor oral intake only after first administering thiamine. This article includes a discussion of best practices for thiamine supplementation with hyperemesis gravidarum and Wernicke encephalopathy.

From Discomfort to Distress: A Critical Analysis of Hyperemesis Gravidarum in the Emergency Room

Hyperemesis gravidarum (HG) is a severe and debilitating condition characterized by persistent and excessive nausea and vomiting during pregnancy (NVP), often leading to significant maternal and fetal morbidity. This literature review aims to provide a scientifically comprehensive overview of HG within the context of the emergency room (ER) setting. This review aims to enhance understanding and improve the management of HG cases presented to the ER by synthesizing current knowledge and evidence-based practices. This literature review encompasses a systematic analysis of relevant scientific literature, encompassing original research studies, review articles, and clinical guidelines. An extensive search of electronic databases was conducted, covering the period from January 2003 to January 2023. Keywords related to HG, pregnancy-related complications, emergency medicine, and ER management were employed to identify pertinent publications. Through the literature review, we found the incidence of HG-related ER admission to be 0.8%. Although the etiology of HG remains to be unknown, a strong association was found between developing HG in pregnant females and a history of gastrointestinal (GI) disorders, use of cannabis, and pregnancies conceived through artificial reproductive technology (ART). Furthermore, overweight females were more likely to develop HG. Maternal smoking was found to be protective against HG. The symptoms of HG mainly include intractable nausea and vomiting occurring usually between four and nine weeks of gestational age with a significant aversion to food and loss of weight. Diagnosis is done through a strong clinical suspicion, a history of HG in previous pregnancies, and a basic metabolic panel. Treatment includes intravenous (IV) fluids, antiemetic therapy, corticoids, thiamine supplements, and laxatives. In our review, we highlight a few complications that can be seen in HG through a synopsis of unique case reports found during our literature search. In conclusion, through this review, we wish to highlight HG as an obstetrical emergency. We aim to improve understanding, enhance early recognition, and promote evidence-based management strategies for HG in the emergency room. We hope that the findings presented herein will serve as a valuable resource for healthcare professionals, researchers, and policymakers involved in the care of pregnant females experiencing HG in the ER.