Day-case management of hyperemesis gravidarum: Feasibility and clinical efficacy

Outpatient management of hyperemesis gravidarum and the impact on inpatient admissions; A retrospective observational study

OBJECTIVES

The objectives of this study were to investigate the impact of the Ambulatory Hyperemesis Unit at an inner-city teaching hospital since its establishment in 2012, on both the inpatient admission rate and length of stay for hyperemesis gravidarum, and to provide an estimate of the financial impact this service has on the hospital trust.

STUDY DESIGN

A retrospective observational analysis was undertaken at King's College Hospital, London, spanning a 12 year period. Data were collected from the admissions database, both before and after the unit opened. The number of inpatient spells per year, inpatient nights per year and length of stay were analysed (unpaired t-test). The estimated cost of inpatient care for hyperemesis gravidarum prior and subsequent to the unit opening was also compared.

RESULTS

The average number of inpatient spells per year before and after the unit opened was 243.25 and 254.13 spells respectively (p = 0.6128). The average number of inpatient nights per year was 424.5 vs. 227.38 nights respectively (p < 0.0001). The average length of inpatient stay per spell was 1.74 vs. 0.89 nights respectively (p < 0.0001). The estimated average cost of inpatient stays per year was £199,535 versus £106,866 respectively (p < 0.0001).

CONCLUSIONS

Although the total number of inpatient admissions did not appear to alter after outpatient services were established, the length of stay per patient admission and total number of inpatient nights per year were significantly reduced. This benefit is sustained over many years, and is likely due to the focused and accessible aftercare the ambulatory hyperemesis unit provides. As a consequence, there was a substantial estimated cost-saving to the hospital trust, of almost £100,000 per year.

Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy: a systematic review and economic assessment

BACKGROUND

Nausea and vomiting in pregnancy (NVP) affects up to 85% of all women during pregnancy, but for the majority self-management suffices. For the remainder, symptoms are more severe and the most severe form of NVP - hyperemesis gravidarum (HG) - affects 0.3-1.0% of pregnant women. There is no widely accepted point at which NVP becomes HG.

OBJECTIVES

This study aimed to determine the relative clinical effectiveness and cost-effectiveness of treatments for NVP and HG.

DATA SOURCES

MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, PsycINFO, Commonwealth Agricultural Bureaux (CAB) Abstracts, Latin American and Caribbean Health Sciences Literature, Allied and Complementary Medicine Database, British Nursing Index, Science Citation Index, Social Sciences Citation Index, Scopus, Conference Proceedings Index, NHS Economic Evaluation Database, Health Economic Evaluations Database, China National Knowledge Infrastructure, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects were searched from inception to September 2014. References from studies and literature reviews identified were also examined. Obstetric Medicine was hand-searched, as were websites of relevant organisations. Costs came from NHS sources.

REVIEW METHODS

A systematic review of randomised and non-randomised controlled trials (RCTs) for effectiveness, and population-based case series for adverse events and fetal outcomes. Treatments: vitamins B6 and B12, ginger, acupressure/acupuncture, hypnotherapy, antiemetics, dopamine antagonists, 5-hydroxytryptamine receptor antagonists, intravenous (i.v.) fluids, corticosteroids, enteral and parenteral feeding or other novel treatment. Two reviewers extracted data and quality assessed studies. Results were narratively synthesised; planned meta-analysis was not possible due to heterogeneity and incomplete reporting. A simple economic evaluation considered the implied values of treatments.

RESULTS

Seventy-three studies (75 reports) met the inclusion criteria. For RCTs, 33 and 11 studies had a low and high risk of bias respectively. For the remainder (n = 20) it was unclear. The non-randomised studies (n = 9) were low quality. There were 33 separate comparators. The most common were acupressure versus placebo (n = 12); steroid versus usual treatment (n = 7); ginger versus placebo (n = 6); ginger versus vitamin B6 (n = 6); and vitamin B6 versus placebo (n = 4). There was evidence that ginger, antihistamines, metoclopramide (mild disease) and vitamin B6 (mild to severe disease) are better than placebo. Diclectin^® [Duchesnay Inc.; doxylamine succinate (10 mg) plus pyridoxine hydrochloride (10 mg) slow release tablet] is more effective than placebo and ondansetron is more effective at reducing nausea than pyridoxine plus doxylamine. Diclectin before symptoms of NVP begin for women at high risk of severe NVP recurrence reduces risk of moderate/severe NVP compared with taking Diclectin once symptoms begin. Promethazine is as, and ondansetron is more, effective than metoclopramide for severe NVP/HG. I.v. fluids help correct dehydration and improve symptoms. Dextrose saline may be more effective at reducing nausea than normal saline. Transdermal clonidine patches may be effective for severe HG. Enteral feeding is effective but extreme method treatment for very severe symptoms. Day case management for moderate/severe symptoms is feasible, acceptable and as effective as inpatient care. For all other interventions and comparisons, evidence is unclear. The economic analysis was limited by lack of effectiveness data, but comparison of costs between treatments highlights the implications of different choices.

LIMITATIONS

The main limitations were the quantity and quality of the data available.

CONCLUSION

There was evidence of some improvement in symptoms for some treatments, but these data may not be transferable across disease severities. Methodologically sound and larger trials of the main therapies considered within the UK NHS are needed.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013006642.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Day care versus inpatient management of nausea and vomiting of pregnancy: cost utility analysis of a randomised controlled trial

OBJECTIVE

To assess the comparative cost effectiveness of day care over inpatient management of nausea and vomiting of pregnancy (NVP).

STUDY DESIGN

A cost utility analysis was performed using a decision analytical model in which a Markov model was constructed. The Markov model was primarily populated with data from a recently published randomised controlled trial. Which included pregnant women presenting to Cork University Maternity Hospital, a tertiary referral maternity hospital, seeking treatment for NVP. Costs and outcomes were estimated from the perspective of the Irish health service (HSE) and patients. A probabilistic sensitivity analysis, using a Monte Carlo simulation, was also performed. A Bayesian Value of Information analysis was used to estimate the value of collecting additional information.

RESULTS

When both the healthcare provider and patient's perspective was considered, day care management of NVP remained less costly (mean €985; 95% C.I. 705-1456 vs. €3837 (2124-8466)) and more effective (9.42; 4.19-12.25 vs. 9.49; 4.32-12.39 quality adjusted life years) compared with inpatient management. The Cost Effectiveness Acceptability Curve indicates the probability that day care management is 70% more cost effective compared to inpatient management at a ceiling ratio of €45,000 per QALY, indicating little decision uncertainty. The Bayesian Value of Information analysis indicates there is value in collecting further information; the Expected Value of Perfect Information (EVPI) is estimated to be €5.4 million.

CONCLUSION

Day care management of NVP is cost effective compared to inpatient management.

Hyperemesis gravidarum: current perspectives

Hyperemesis gravidarum is a complex condition with a multifactorial etiology characterized by severe intractable nausea and vomiting. Despite a high prevalence, studies exploring underlying etiology and treatments are limited. We performed a literature review, focusing on articles published over the last 10 years, to examine current perspectives and recent developments in hyperemesis gravidarum.

A novel approach to hyperemesis gravidarum: evaluation by a visual analogue scale score and treatment with transdermal clonidine

OBJECTIVE

A preliminary report on the symptomatic effect of clonidine in severe hyperemesis gravidarum (HG).

DESIGN

Observational.

SETTTING

Hospital based: Ospedale Sant'Anna, Torino, Italy.

POPULATION

Twelve pregnant women, 8-16 weeks, affected by severe, refractory HG.

METHODS

Assessment by two clinical score indexes: Pregnancy Unique Quantification of Emesis (PUQE) score and a Visual Analogue Scale (VAS) 5-item questionnaire, filled out daily, to detect subjective improvement or worsening of symptoms.

MAIN OUTCOME MEASURES

PUQE score and VAS score before and after transdermal clonidine treatment.

RESULTS

We found substantial improvement of symptoms and severity score indexes after four and 14 days. The comparison of pretreatment and post-treatment scores shows a significant statistical difference P < 0.0001.

CONCLUSION

Transdermal clonidine may be considered as a treatment for resistant severe HG.

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.

Psychosomatic approaches to obstetrics, gynaecology and andrology--a review

This review aims to clarify the scope and clinical importance of psychosomatic approaches to obstetrics, gynaecology and andrology. This gradually expanding sub-specialty covers a wide domain of complex disease conditions that can be managed more effectively if the various biological, psychological and social aspects are recognised at the start and concurrent treatment initiated. The current need to practise biopsychosocial management of disease conditions is highlighted along with a description of what this would involve. The nine-field psychosomatic approach, which can be applied to everyday clinical encounters, has been illustrated. Clinical applications of the psychosomatic approach are discussed for various conditions including chronic pelvic pain, eating disorders, tokophobia, post-traumatic stress disorder, depression, menstrual disorders, infertility, bereavement and testicular cancer. Cultural considerations and the need for further research are also briefly discussed.

Management strategies for hyperemesis

Nausea and vomiting occur in up to 80% of normal pregnancies. Hyperemesis gravidarum, resulting in dehydration and ketonuria, is a more severe, disabling and potentially life threatening condition affecting up to 1.5% of pregnancies. Treatment is supportive with intravenous rehydration, antiemetics and correction of vitamin deficiency to minimize complications. There are good safety data to support the use of antihistamines, phenothiazines and metoclopromide in hyperemesis gravidarum, though trials of efficacy are lacking and there is little evidence on which to chose the optimum therapy. This review discusses the diagnosis and management of hyperemesis gravidarum and the prevention, recognition and treatment of the serious complications of Wernicke encephalopathy, osmotic demyelination syndrome and thromboembolism.