Maternal serum cytokine levels in women with hyperemesis gravidarum in the first trimester of pregnancy

Determination of the relationships between hyperemesis gravidarum and systemic inflammation markers: a case‒control study

BACKGROUND

We conducted our study to investigate the relationships between hyperemesis gravidarum (HEG) and inflammatory markers such as the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR).

MATERIALS AND METHODS

A total of 150 pregnant women diagnosed with HEG and 150 controls were included in our study. The data analysed included demographic variables, complete blood count results, and urinary ketonuria levels.

RESULTS

We found that the NLR, PLR and MLR were significantly greater in HEG patients than in controls (p < 0.05), indicating a potential role of systemic inflammation in the pathophysiology of HEG. Receiver operating characteristic (ROC) analysis revealed that these markers had moderate discriminative power, suggesting their utility as adjunctive diagnostic tools in clinical settings. However, no correlation was found between inflammatory markers and the severity of ketonuria.

CONCLUSIONS

The NLR, PLR and MLR can be used as indicators of HEG as a result of the inflammatory process in pregnant women with HEG.

Blood-Based Clinical Biomarkers of Inflammation and Nutrition in Hyperemesis Gravidarum

Background: In this study, the aim was to investigate blood-based clinical biomarkers of inflammation and nutrition indices in hyperemesis gravidarum (HG). Methods: This retrospective case-control study was conducted at a tertiary hospital between 2018 and 2022. A total of 820 pregnant women were enrolled in this study; 410 pregnant women were diagnosed with HG (HG group) at 6-14 weeks of gestation, and 410 pregnant women were healthy controls (control group) in the same gestational weeks. Patients' demographic and clinical characteristics and laboratory parameters were recorded. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score, the modified-HALP (m-HALP) score, and the prognostic nutritional index (PNI) were calculated. Results: The HALP score (32.6 (IQR: 24.9-41.5) vs. 39.2 (IQR: 30.8-49.2), p < 0.001) and the PNI score (50 (IQR: 46.3-53.6) vs. 51.3 (IQR: 48.6-53.8), p < 0.001) were significantly lower in the HG group, whereas the m-HALP score was similar between the groups. The HALP score had an AUC of 0.625 (95% CI: 0.586-0.664), with the optimal cut-off value set at 35.8, resulting in a sensitivity of 59.7% and a specificity of 59.5% (p < 0.001). Similarly, the PNI score showed an AUC of 0.580 (95% CI: 0.541-0.619), and the optimal cut-off value was set at 50.6, resulting in a sensitivity of 54.9% and a specificity of 54.9% (p < 0.001). In regression analysis, lower HALP scores (OR: 0.906, 95% CI: 0.833-0.984, p = 0.019) and lower PNI scores (OR: 0.941, 95% CI: 0.891-0.995, p = 0.033) were significantly associated with HG, highlighting their potential as diagnostic markers. Additionally, a negative statistically significant correlation was observed between PNI scores and ketonuria (r = -0.073, p = 0.036). Conclusions: This study demonstrated a decrease in the HALP score and PNI score in cases of HG. However, the m-HALP score was similar in the HG and control groups.

Thematic analysis of X (Twitter) users' experiences of Hyperemesis Gravidarum (HG)

Hyperemesis Gravidarum (HG) is a debilitating condition characterized by severe nausea and vomiting during pregnancy, yet its severity is often misunderstood or underestimated by both the public and healthcare providers. This lack of understanding can lead to misdiagnosis, inadequate treatment, and undue suffering for individuals experiencing HG. This study explores the online discourse surrounding HG to identify key themes related to patient experiences and perceptions. Using the Twint0 application, we collected 5,856 relevant posts from the X social networking site over a 12-month period. A thematic analysis revealed four major themes: (1) misconceptions about severity of symptoms, (2) emotional and psychological toll of HG, (3) experiences with healthcare and treatment, and (4) impact on pregnancy and maternal health. The findings highlight the urgent need for greater awareness and understanding of HG, particularly within healthcare settings, to improve diagnosis and treatment. Additionally, the study emphasizes the importance of patient-centered care and mental health support to address the emotional challenges faced by women with HG.

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.

A Narrative Review of Oxidative Stress and Liver Disease in Pregnancy: The Role of Antioxidants

Pregnancy brings numerous physiological changes to the body of the pregnant woman. Liver diseases in pregnancy contribute to increased oxidative stress, disrupting the delicate balance between reactive oxygen species and antioxidant defence. Antioxidant supplementation may have potential benefits in addressing pregnancy-related liver disorders, such as HELLP (haemolysis, elevated liver enzymes, low platelet count) and preeclampsia-associated liver dysfunction in pregnancy. The purpose of this narrative review is to review the evidence regarding oxidative stress in liver disorders during pregnancy and the role of antioxidants in alleviating oxidative stress and its effect on maternal and foetal outcomes. A narrative review study design involved a comprehensive search across three scientific databases: PubMed, Embase, and MEDLINE, published in the last 20 years. The searches were performed up to January 2024. Thirty-two studies were included in the narrative review. The most studied antioxidants were vitamins (vitamin C and E) for their role in clinical treatment, prophylaxis, and clearing surrogate oxidative stress markers. The majority of studies were on preeclampsia. Though the existing literature is not robust, available evidence suggests that antioxidant supplementation may have potential benefits in addressing pregnancy-related liver disorders, such as HELLP and preeclampsia-associated liver dysfunction in pregnancy. However, there is a need to establish consistent protocols, ethical standards, and well-designed clinical trials to clarify the timing and dosage of antioxidants in pregnancy. Antioxidants may alleviate the oxidative stress in various liver disorders during pregnancy, which still needs to be studied further for their clinical relevance.

The predictive value of HALP score and systemic immune inflammation (SII) index in hyperemesis gravidarum

AIM

Hyperemesis gravidarum (HG) is one of the most common serious diseases in early pregnancy. This study aimed to investigate the clinical significance of hemoglobin, albumin, lymphocyte, and platelet (HALP) score and systemic immune inflammation (SII) index in the presence and severity of HG.

METHODS

This retrospective case-control study was conducted in a training and educational university hospital between January 2019 and July 2022. A total of 521 pregnant women, of whom 360 were diagnosed with HG at 6-14 weeks of gestation and 161 were low-risk pregnancies, were included in the study. Patients' demographic characteristics and laboratory parameters were recorded. Patients with HG were divided into three categories: mild (n = 160), moderate (n = 116), and severe (n = 84), according to disease severity. The modified PUQE scoring was used to determine the severity of HG.

RESULTS

The mean age of the patients was 27.6 (16-40) years. We divided the pregnant women into the control group and HG group. The HALP score was significantly lower in the HG group (average, 2.8 ± 1.3), whereas the SII index was found to be significantly higher (average, 895.8 ± 458.1). A negative correlation was found between the increase in the severity of HG and HALP score. The HALP score was the lower in severe HG (mean, 2.16 ± 0.81) and was significantly different from other HG categories (p < 0.01). Moreover, a positive correlation was noted between increased HG severity and SII index levels. The SII index was higher in the severe HG group and was significantly different from the others (1001.2 ± 437.2) (p < 0.01).

CONCLUSIONS

The HALP score and SII index can be useful, cost-effective, and easily accessible objective biomarkers to predict the presence and severity of HG.

The Role Of Systemic Immune-Inflammation Index In The Severity Of Hyperemesis Gravidarum

BACKGROUND

Hyperemesis gravidarum(HEG) is one of the severe health problems in early pregnancy. Obstetricians should be aware of systemic inflammation in HEG patients to provide better preventive strategies.

AIM

Hyperemesis gravidarum(HEG) is one of the most common causes of hospitalization in early pregnancy. Complete blood count parameters can be used as inflammatory markers in patients with HEG. We aimed to investigate the Systemic Immune-Inflammation Index (SII)in predicting the severity of HEG.

METHODS

This cross-sectional study was performed with 469 pregnant women diagnosed and hospitalized with HEG. The study parameters were calculated from complete blood count tests and urine analysis. Demographic characteristics, the Pregnancy Unique Quantification of Emesis (PUQE) scale values, and ketonuria levels at hospital admission were recorded. The neutrophil‑to‑lymphocyte ratio (NLR), platelet‑to‑lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and SII, calculated by the formula (neutrophil × platelet/lymphocyte), were evaluated for predicting the severity of HEG.

RESULTS

There was a positive correlation between the increased degree of ketonuria and SII. The cut-off value of SII for predicting the severity of HEG was 1071.8 (AUC 0.637, 95% CI (0.582-0.693), p<.001), and sensitivity and specificity were 59% and 59%, respectively. The cut-off value of SII to predict the length of hospitalization was 1073.6(AUC: 0.565, 95% CI: (0.501-0.628), p= 0.039); sensitivity and specificity were 56.3% and 55.5%, respectively CONCLUSIONS: : The clinical utility of SII in predicting HEG severity is limited due to relatively low sensitivity and specificity. Further research is needed to determine the importance of inflammatory indices in HEG patients.

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.

Liver diseases in pregnancy

Liver disease in pregnancy can be related to a pre-existing condition (such as autoimmune liver disease) or arise as a consequence of pregnancy. In women with pre-existing disease, pre-pregnancy counselling is important to discuss the potential complications that may occur during pregnancy and how best to manage these. Acute fatty liver of pregnancy and HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome are pregnancy-related liver diseases and are considered obstetric emergencies. Women with liver dysfunction need appropriate investigations, including blood tests and imaging. They should be managed as part of a multidisciplinary team with obstetricians, obstetric anaesthetists, specialist midwives, gastroenterologists and obstetric physicians.

Associations between maternal obesity, gestational cytokine levels and child obesity in the NEST cohort

BACKGROUND

Although maternal systemic inflammation is hypothesized to link maternal pre-pregnancy obesity to offspring metabolic dysfunction, patient empirical data are limited.

OBJECTIVES

In this study, we hypothesized that pre-pregnancy obesity alters systemic chemo/cytokines concentrations in pregnancy, and this alteration contributes to obesity in children.

METHODS

In a multi-ethnic cohort of 361 mother-child pairs, we measured prenatal concentrations of plasma TNF-α, IL-6, IL-8, IL-1β, IL-4, IFN-γ, IL-12 p70 subunit, and IL-17A using a multiplex ELISA and examined associations of pre-pregnancy obesity on maternal chemo/cytokine levels, and associations of these cytokine levels with offspring body mass index z score (BMI-z) at age 2-6 years using linear regression.

RESULTS

After adjusting for maternal smoking, ethnicity, age, and education, pre-pregnancy obesity was associated with increased concentrations of TNF-α (P = .026) and IFN-γ (P = .06). While we found no evidence for associations between TNF-α concentrations and offspring BMI-z, increased IFN-γ concentrations were associated with decreased BMI-z (P = .0002), primarily in Whites (P = .0011). In addition, increased maternal IL-17A concentrations were associated with increased BMI-z in offspring (P = .0005) with stronger associations in African Americans (P = .0042) than Whites (P = .24).

CONCLUSIONS

Data from this study are consistent with maternal obesity-related inflammation during pregnancy, increasing the risk of childhood obesity in an ethnic-specific manner.

Hyperemesis Gravidarum: Strategies to Improve Outcomes

Hyperemesis gravidarum (HG) is a debilitating and potentially life-threatening pregnancy disease marked by weight loss, malnutrition, and dehydration attributed to unrelenting nausea and/or vomiting; HG increases the risk of adverse outcomes for the mother and child(ren). The complexity of HG affects every aspect of a woman's life during and after pregnancy. Without methodical intervention by knowledgeable and proactive clinicians, life-threatening complications may develop. Effectively managing HG requires an understanding of both physical and psychosocial stressors, recognition of potential risks and complications, and proactive assessment and treatment strategies using innovative clinical tools.

Study of Liver Dysfunction in Hyperemesis Gravidarum

Introduction Hyperemesis gravidarum (HG) is said to occur when early pregnancy is complicated by excessive vomiting that leads to electrolyte imbalance, ketosis or loss of more than 5% of the bodyweight. It can be accompanied by deranged liver function tests (LFT), and most patients recover uneventfully with no fetal harm. Methods A retrospective study was conducted by evaluating records of 135 patients who were admitted or underwent day care for HG at our center over a period of 30 months. After excluding patients who were not investigated and those with another pre-existing or newly diagnosed liver disease, 63 patients were enrolled in the study. Their LFT were analyzed with the software Graphpad Prism version 8.4 (GraphPad Software, San Diego, California). The values were expressed as mean ± standard deviation and statistical analysis was done using unpaired t test and simple linear regression. Results The mean age of the study population was 26.59 ± 5.15 years and the mean period of gestation was 13.27 ± 2.48 weeks. 60.3% (38/63) of the patients had some form of abnormality on the LFT. The mean total serum bilirubin (TSB) was 1.56 ± 0.84 mg/dL, mean aspartate transaminase (AST) was 46.63 ± 30.89 U/L and mean alanine transaminase (ALT) was 51.35 ± 42.86 U/L. ALT was higher than AST with statistical significance (p<0.0001). There was no statistically significant difference in the LFT of primigravida and multigravida women. The study population included three diabetic and two hypertensive women, and two women had multiple pregnancy. All the patients were treated with anti-emetics. One patient required corticosteroid administration, and none required termination of pregnancy. Conclusion Mild liver dysfunction in HG can occur in over 50% of the patients. When diagnosis is not in doubt, no further intervention is required with regard to the LFT.

Liver Disease in Pregnancy: What's New

Liver disease in pregnancy may present as a disorder that is unique to pregnancy or as an acute or chronic liver disease occurring coincidentally in pregnancy. Hepatic diseases that are unique to pregnancy include hyperemesis gravidarum; preeclampsia/eclampsia; the syndrome of hemolysis, elevated liver enzymes, and low platelets; intrahepatic cholestasis of pregnancy; and acute fatty liver of pregnancy. Acute and chronic forms of primary hepatic disorders that are seen in pregnancy include viral hepatitis, autoimmune hepatitis, nonalcoholic fatty liver disease, and cirrhosis. Because of the need to consider both maternal and fetal health, there are special considerations for the implementation of diagnostic strategies and pharmacologic therapies for liver disease that occurs in pregnancy. An understanding of the pathogenesis and expression of liver diseases in pregnancy has been evolving, and various diagnostic and prognostic tools have been studied in order to determine noninvasive approaches to identifying and staging of such diseases. Investigations have also been underway to evaluate the safety and utility of existing and new therapeutic agents that previously were thought to not be compatible with pregnancy. This review will explore updates in the epidemiology, diagnosis, and management of various liver diseases seen in pregnancy.

Comparison of Serum Ykl-40 and Ischemia Modified Albulmin Levels Between Pregnant Women with Hyperemesis Gravidarum and Normal Pregnant Women

INTRODUCTION

The etiopathogenesis of HG is still unclear.

AIM

The aim of this study was to investigate the levels of YKL-40 protein as an inflammatory marker and evaluate the levels of IMA as an oxidative marker in hyperemesis gravidarum women.

MATERIALS AND METHODS

Totally 35 patients with hyperemesis gravidarum and 35 healthy pregnants were included in the study. Singleton pregnancies between 6+0 week and 13+6 weeks of gestation, with normal fetal anatomy were included in the study. Complete blood count, complete urine analyze, biochemical tests and thyroid function tests were done.

RESULTS

There was no significant difference between groups for demographical features (age, gravidity, gestational age, body mass index). Also, there was no statistically significant difference between groups for IMA levels (p>0.05). The median level of YKL-40 was higher in pregnants with hyperemesis gravidarum than normal pregnants but the difference was not statistically significance (p>0.05).

CONCLUSION

Further comprehensive studies with more number of patients are needed to show the efficacy of YKL-40 and IMA levels for predicting hyperemesis gravidarum and even monitoring of the treatment.

Nausea and vomiting of pregnancy - What's new?

Nausea and vomiting of pregnancy (NVP) is one of the most common disorders of pregnancy. The symptoms occur predominantly during the first trimester, although in a subgroup of patients they can continue throughout the entire pregnancy and can affect the woman's quality of life. A small percentage of women develop a severe form of NVP called hyperemesis gravidarum (HG) that if left untreated may lead to significant maternal morbidity and adverse birth outcomes. Overall, the morbidity in pregnant women with NVP is significant, although it tends to be underestimated. The pathogenesis of NVP remains unclear, but there is consensus that the disorder is multifactorial and that various genetic, endocrine and infectious factors may be involved. The treatment of NVP can be challenging as the optimal targets for therapy are not known. Currently, the therapy used depends on the severity of the disorder and it is focused on improving the symptoms while minimizing risks to mother and fetus. Therapies range from dietary changes, pharmacologic treatment or hospitalization with intravenous fluid replacement and nutrition therapy. The aims of this review are 1) to provide an overview of NVP, 2) to present possible links between the most important factors associated with the pathogenesis of NVP and 3) to discuss the effectiveness and safety of the pharmacologic and non-pharmacologic options available to treat this disorder.

Immunology of hepatic diseases during pregnancy

The mother's immune system has to adapt to pregnancy accepting the semi-allograft fetus and preventing harmful effects to the developing child. Aberrations in feto-maternal immune adaptation may result in disease of the mother, such as liver injury. Five pregnancy-associated liver disorders have been described so far, however, little is known concerning immune alterations promoting the respective disease. These liver disorders are pre-eclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP), acute fatty liver, hyperemesis gravidarum, and intrahepatic cholestasis of pregnancy. On the other hand, pre-existing autoimmune liver injury of the mother can be affected by pregnancy. This review intends to summarize current knowledge linking feto-maternal immunology and liver inflammation with a special emphasis on novel potential biomarkers.

Is there any relationship between serum sirtuin-1 level and neutrophil-lymphocyte ratio in hyperemesis gravidarum?

AIM

The aim of this study was to evaluate the relationship between serum sirtuin-1 (SIRT1) level and neutrophil-lymphocyte ratio (NLR) with hyperemesis gravidarum (HG).

METHODS

Overall, 90 patients who presented with pregnancy between August 2013 and November 2014 were included in the study. The patients were divided into two groups: patients with HG (n=45) and patients without HG (control group [C]; n=45). The patients with comorbid conditions other than pregnancy (disease or medication) were excluded. In all patients, demographic data including age, body mass index (BMI), gestational week, and smoking status were recorded. Blood samples were drawn for complete blood count and measurements of blood lipid, liver enzymes, serum SIRT1, and insulin levels. NLR was calculated from CBC.

RESULTS

No significant differences were detected in age, BMI, or GA between groups (P>0.05). Serum SIRT1 and NLR were found to be significantly higher in patients with HG compared with those in the control group (P=0.001 and 0.006, respectively).

CONCLUSION

In HG, both SIRT1 level and NLR increased. In HG, this occurred as a response to metabolic alterations and potential inflammation.

Evaluation of hearing and cochlear function by audiometric testing in patients with hyperemesis gravidarum

Introduction

The aim of this study was to investigate cochlear functions in patients with hyperemesis gravidarum (HG).

Methods

Twenty-nine HG patients (58 ears) and 31 healthy control subjects (62 ears) were included. Audiometry testings at 250 and 500 Hz and 1, 2, 4, 8, 10, 12, 14, 16 kHz were performed to the patients and controls.

Results

Mean age of patients with HG was 26,5 ± 4,4 years and the mean age of control group was 28,0 ± 4,2 years. At the time of the tests mean gestational age of the HG group and controls were 9 and 11 weeks respectively. No differences were observed between the groups in tympanic membrane status, orother otolaringological evaluations. No significant differences were observed in audiometric tests at any frequencies between the groups (p values for all > 0.05).

Conclusion

There was not a difference between pregnant cases with HG and cases with normal pregnancy in terms of audimetric tests. Cochlear functions are not affectedremarkably in women with HG.

Hepatobiliary diseases during pregnancy and their management: An update

Liver diseases in pregnancy although rare but they can seriously affect mother and fetus. Signs and symptoms are often not specific and consist of jaundice, nausea, vomiting, and abdominal pain. Although any type of liver disease can develop during pregnancy or pregnancy may occur in a patient already having chronic liver disease. All liver diseases with pregnancy can lead to increased maternal and fetal morbidity and mortality. It is difficult to identify features of liver disease in pregnant women because of physiological changes. Physiological changes of normal pregnancy can be confounding with that of sign and symptoms of liver diseases. Telangiectasia or spider angiomas, palmar erythema, increased alkaline phosphatase due to placental secretion, hypoalbuminemia due to hemodilution. These normal alterations mimic physiological changes in patients with decompensated chronic liver disease. Besides all these pathological changes however, blood flow to the liver remains constant and the liver usually remains impalpable during pregnancy. The diagnosis of liver disease in pregnancy is challenging and relies on laboratory investigations. The underlying disorder can have a significant effect on morbidity and mortality in both mother and fetus, and a diagnostic workup should be initiated promptly. If we see the spectrum of liver disease in pregnancy, in mild form there occur increase in liver enzymes to severe form, where liver failure affecting the entire system or maternal mortality and morbidity. It can not only complicate mother's life but also poses burden of life of fetus to growth restriction. Most of the times termination is only answer to save life of mother but sometimes early detection of diseases, preventive measures and available active treatment is helpful for both of the life. Extreme vigilance in recognizing physical and laboratory abnormalities in pregnancy is a prerequisite for an accurate diagnosis. This could lead to a timely intervention and successful outcome.

Risk factors, treatments, and outcomes associated with prolonged hyperemesis gravidarum

OBJECTIVE

To identify factors associated with prolonged Hyperemesis Gravidarum (HG).

STUDY DESIGN

About 395 women completed a survey regarding pre-existing conditions, treatments and outcomes. Responses were compared using two-sided t-tests or the F-test.

RESULTS

Participants with prolonged HG are slightly younger and weigh more. Pre-existing factors associated with prolonged HG include allergies and a restrictive diet. Prolonged HG is associated with hematemesis, dizziness, fainting and antiemetic treatment. Following pregnancy, those with prolonged HG reported more posttraumatic stress, motion sickness, muscle weakness and infants with irritability, severe colic and growth restriction.

CONCLUSION

Multiple pre-existing conditions and poor maternal and infant outcomes were associated with prolonged HG. The most significant condition prior to pregnancy was allergies suggesting a possible autoimmune component affecting duration of HG. In addition, the most significant lifestyle choice linked to prolonged HG was a restrictive diet. Future research is needed to determine whether a change in diet prior to pregnancy may lead to a shorter duration of HG and its associated outcomes.

Liver disease in pregnancy

Changes in the liver biochemical profile are normal in pregnancy. However, up to 3% to 5% of all pregnancies are complicated by liver dysfunction. It is important that liver disease during pregnancy is recognized because early diagnosis may improve maternal and fetal outcomes, with resultant decreased morbidity and mortality. Liver diseases that occur in pregnancy can be divided into 3 different groups: liver diseases that are unique to pregnancy, liver diseases that are not unique to pregnancy but can be revealed or exacerbated by pregnancy, and liver diseases that are unrelated to but occur coincidentally during pregnancy.

The clinical management of hyperemesis gravidarum

Hyperemesis gravidarum is a severe and disabling condition with potentially life-threatening complications. It is likely to have a multifactorial etiology which contributes to the difficulty in treatment. Treatment is supportive with correction of dehydration and electrolyte disturbance, antiemetic therapy, prevention and treatment of complications like Wernicke's encephalopathy, osmotic demyelination syndrome, thromboembolism, and good psychological support. There are abundant data on the safety of antihistamines, phenothiazines, and metoclopromide in early pregnancy and treatment should therefore not be withheld on the basis of teratogenicity concerns. Thiamine replacement is indicated in hyperemesis gravidarum to prevent development of Wernicke's encephalopathy.

Nausea and vomiting of pregnancy

Nausea and vomiting are common experiences in pregnancy, affecting 70% to 80% of all pregnant women. Various metabolic and neuromuscular factors have been implicated in the pathogenesis of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum (HG), an entity distinct from NVP. However, their exact cause is unknown. Consequently, treatment of NVP and HG can be difficult, as neither the optimal targets for treatment nor the full effects of potential treatments on the developing fetus are known. This article reviews the epidemiology, pathology, diagnosis, outcomes, and treatment of NVP and HG.

Pregnancy-related liver diseases

Liver diseases related to pregnancy may be associated with preeclampsia (liver dysfunction related to preeclampsia; hemolysis, elevated liver enzymes, and low platelets with or without preeclampsia [HELLP syndrome]; and acute fatty liver of pregnancy) or may not involve preeclampsia (hyperemesis gravidarum and intrahepatic cholestasis of pregnancy). Liver diseases associated with pregnancy have unique presentations, but it can be difficult differentiating these from liver diseases that occur coincidentally with pregnancy. Recently, advances have been made in the disease mechanism and intervention of pregnancy-related liver diseases. Early diagnosis and delivery remains the key element in managing the liver diseases associated with preeclampsia, but emerging data suggest that incorporating advance supportive management into current strategies can improve both maternal and fetal outcomes.

Liver disease in pregnancy

Liver diseases in pregnancy may be categorized into liver disorders that occur only in the setting of pregnancy and liver diseases that occur coincidentally with pregnancy. Hyperemesis gravidarum, preeclampsia/eclampsia, syndrome of hemolysis, elevated liver tests and low platelets (HELLP), acute fatty liver of pregnancy, and intrahepatic cholestasis of pregnancy are pregnancy-specific disorders that may cause elevations in liver tests and hepatic dysfunction. Chronic liver diseases, including cholestatic liver disease, autoimmune hepatitis, Wilson disease, and viral hepatitis may also be seen in pregnancy. Management of liver disease in pregnancy requires collaboration between obstetricians and gastroenterologists/hepatologists. Treatment of pregnancy-specific liver disorders usually involves delivery of the fetus and supportive care, whereas management of chronic liver disease in pregnancy is directed toward optimizing control of the liver disorder. Cirrhosis in the setting of pregnancy is less commonly observed but offers unique challenges for patients and practitioners. This article reviews the epidemiology, pathophysiology, diagnosis, and management of liver diseases seen in pregnancy.

Maternal reproductive and demographic characteristics as risk factors for hypospadias

This study examined the association of hypospadias risk with several maternal reproductive and demographic characteristics: age, parity, body mass index (BMI), nausea and vomiting of pregnancy (NVP), multiple pregnancy, fertility treatments and procedures, education and race-ethnicity. The study included data on deliveries with estimated due dates from October 1997 to December 2000 that were part of the National Birth Defects Prevention Study, a multi-state case-control study of many birth defects. The analysis included 502 cases with second or third degree hypospadias (i.e. the urethra opened at the penile shaft, scrotum or perineum) and 1286 male, liveborn, non-malformed controls. Risks were estimated from a multivariable logistic regression model that included all exposures of interest. Results indicated particularly elevated risks among births to women who were primiparae, aged >or=35 years and had a BMI of >26, compared with women who were multiparae, aged <30 years and had a BMI of <or=26 [adjusted OR 12.5, 95% CI 5.1, 30.8]. NVP at least once per day during the second or third month of pregnancy vs. no NVP was associated with slightly reduced risk [OR 0.8, 95% CI 0.6, 1.1]. Multiple birth, fertility treatments and college education were associated with increased risks, and Hispanic race-ethnicity was associated with reduced risk. Although the potential contribution of underlying maternal endocrine parameters to the current findings are unknown, the results do provide clues regarding hypospadias aetiology that merit further investigation.

Relationship between adenosine and T-helper 1/T-helper 2 balance in hyperemesis gravidarum

BACKGROUND

Adenosine modulates the T-helper (Th) 1/T-helper (Th) 2 balance. We evaluated the relationship between changes in plasma adenosine and the T-helper (Th) 1/T-helper (Th) 2 balance in hyperemesis gravidarum.

METHODS

Plasma adenosine concentrations and the Th1/Th2 ratio were examined in the peripheral blood of 24 women with hyperemesis gravidarum and normal pregnancies. The proportion of CD4-positive cells that expressed intracellular cytokines (interferon gamma and interleukin 4) was analyzed by flow cytometry. The ratio of interferon-gamma-secreting cells to interleukin-4-secreting cells was taken as the Th1/Th2 ratio in vivo. The change induced by adenosine-receptor blocker 8-sulfophenyltheophylline was also measured in vitro to evaluate the possible role of adenosine in modifying the Th1/Th2 balance.

RESULTS

In hyperemesis gravidarum, plasma adenosine and the proportion of interleukin-4-secreting cells were increased significantly, and the Th1/Th2 ratio was significantly lower than in normal pregnancy (p<0.05). The decrease in the proportion of IL-4-secreting cells after adenosine receptor blockade in hyperemesis gravidarum significantly exceeded that of normal pregnancy (p<0.05).

CONCLUSIONS

Increased plasma adenosine may be involved in regulating the Th1/Th2 balance in hyperemesis gravidarum.

Tactile massage and severe nausea and vomiting during pregnancy - women's experiences

Nausea and vomiting during pregnancy is a condition with an obscure aetiology. The treatment is symptomatic but there is a lack of alternative treatments. Tactile massage is known to give relaxation and increased well-being in connection with different illnesses, but has never been studied on women with severe nausea and vomiting during pregnancy (SNVP). The aim of this study was to describe hospitalized women's experiences of SNVP and of tactile massage. A phenomenological method was used. Ten hospitalized women with SNVP were included. Each woman was given tactile massage on three separate occasions. After the final massage an open interview was used covering both the experience of severe nausea and vomiting, and of tactile massage. The findings revealed an essential meaning summarizing the experience: to obtain a relieving moment of rest and access to the whole body when nausea rules life. When nausea is experienced as controlling a woman's life, tactile massage is experienced as promoting relaxation and gives her an opportunity to regain access to her body. The findings suggest that tactile massage is a good alternative and complement to traditional treatment of SNVP.

Impaired fatty acid oxidation as a cause of liver disease associated with hyperemesis gravidarum

Hyperemesis gravidarum (HG) is the most severe form of illness within the spectrum of nausea and vomiting of pregnancy. Liver disease, usually consisting of mild serum transaminase elevation, occurs in almost 50% of patients with HG. While multiple risk factors have been proposed, the etiology and underlying mechanism of maternal liver disease associated with HG remains unclear. In this report, we hypothesize that impairment of mitochondrial fatty acid oxidation (FAO) plays a role in the pathogenesis of maternal liver disease associated with HG. We hypothesize that women heterozygous for FAO defects develop HG associated with liver disease while carrying fetuses with FAO defects due to accumulation of fatty acids in placenta and subsequent generation of reactive oxygen species. Alternatively, it is possible that starvation leading to peripheral lipolysis and increased load of fatty acids in maternal-fetal circulation, combined with reduced capacity of the mitochondria to oxidize fatty acids in mothers heterozygous for FAO defects, can also cause HG and liver injury while carrying non-affected fetuses. The rationale for this hypothesis is discussed.

Hyperemesis gravidarum, a literature review

Hyperemesis gravidarum (HG) is a condition causing severe nausea and vomiting in early pregnancy often resulting in hospital admission. The incidence of HG is approximately 0.5% of live births, said to be higher in multiple pregnancies, hydatidiform mole and other conditions associated with increased pregnancy hormone levels. Both the aetiology and pathogenesis of HG remain unknown. We conducted a literature review (1966-now) to summarize the current evidence on the aetiology and pathogenesis of HG. The potential role of pregnancy-related hormones such as progesterone, estrogen and HCG has been widely studied; however, various other hormones such as leptin, placental growth hormone, prolactin, thyroid and adrenal cortical hormones have been implicated in the aetiology of HG. In addition to endocrinological hypotheses, the rationale and evidence considering infectious, immunological, psychological, metabolic and anatomical causes for HG have been analysed here. Many studies suffer from the low number of patients included, the variable definition used for HG and varying assay methodology used in studies of hormone measurement. This review highlights the need for more extensive studies addressing the pathogenesis and aetiology of HG.

Plasma adenosine concentrations increase in women with hyperemesis gravidarum

BACKGROUND

Adenosine is an important metabolic modulator and its concentrations are affected by sympathetic nerve stimulation and cytokine production. Since hyperemesis gravidarum is characterized by overactivation of sympathetic nerves and enhanced production of tumor necrosis factor (TNF)-alpha, plasma adenosine concentrations may be altered. The present study evaluated plasma adenosine concentrations and their relation with norepinephrine and TNF-alpha concentrations in hyperemesis gravidarum.

METHODS

Plasma concentrations of adenosine, norepinephrine, and TNF-alpha were measured in 34 healthy nonpregnant women, and 34 women with hyperemesis gravidarum and normal pregnancies, matched for age, parity and gestational week. The relationships between plasma adenosine, and norepinephrine and TNF-alpha concentrations in hyperemesis gravidarum were evaluated.

RESULTS

Mean plasma adenosine, norepinephrine, and TNF-alpha concentrations were significantly increased in women with hyperemesis gravidarum compared to those in nonpregnant and normal pregnant women (p<0.05). The increase in plasma adenosine concentrations correlated with the increase of norepinephrine and TNF-alpha in hyperemesis gravidarum (r=0.50, p<0.05 and r=0.43, p<0.05, respectively).

CONCLUSIONS

Adenosine is an established suppressor of excessive sympathetic nerves activation and cytokine production, so the increase in plasma adenosine in hyperemesis gravidarum might serve to counteract further progression of hyperemesis gravidarum.

Plasma adenosine concentrations increase in women with hyperemesis gravidarum

BACKGROUND

Adenosine is an important metabolic modulator and adenosine concentrations are affected by sympathetic nerve stimulation and cytokine production. Since hyperemesis gravidarum is characterized by overactivation of sympathetic nerves and enhanced production of tumor necrosis factor (TNF)-alpha, plasma adenosine concentrations may be altered. The present study evaluated plasma adenosine concentrations and their relation with norepinephrine and TNF-alpha concentrations in hyperemesis gravidarum.

METHODS

Plasma concentrations of adenosine, norepinephrine, and TNF-alpha were measured in 34 healthy nonpregnant women, and 34 women with hyperemesis gravidarum and normal pregnancies, matched for age, parity and gestational week. The relationships between plasma adenosine, and norepinephrine and TNF-alpha concentrations in hyperemesis gravidarum were evaluated.

RESULTS

Mean plasma adenosine, norepinephrine, and TNF-alpha concentrations were significantly increased in women with hyperemesis gravidarum compared to those in nonpregnant and normal pregnant women (p<0.05). The increase in plasma adenosine concentrations correlated with the increase of norepinephrine and TNF-alpha in hyperemesis gravidarum (r=0.50, p<0.05 and r=0.43, p<0.05, respectively).

CONCLUSIONS

Adenosine is an established suppressor of excessive sympathetic nerves activation and cytokine production, so the increase in plasma adenosine in hyperemesis gravidarum might serve to counteract further progression of hyperemesis gravidarum.