Clinical management of nausea and vomiting in pregnancy and hyperemesis gravidarum across primary and secondary care: a population-based study

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.

Patterns of antiemetic medication use during pregnancy: A multi-country retrospective cohort study

OBJECTIVE

To compare patterns in use of different antiemetics during pregnancy in Canada, the United Kingdom, and the United States, between 2002 and 2014.

METHODS

We constructed population-based cohorts of pregnant women using administrative healthcare data from five Canadian provinces (Alberta, British Columbia, Manitoba, Ontario, and Saskatchewan), the Clinical Practice Research Datalink from the United Kingdom, and the IBM MarketScan Research Databases from the United States. We included pregnancies ending in live births, stillbirth, spontaneous abortion, or induced abortion. We determined maternal use of antiemetics from pharmacy claims in Canada and the United States and from prescriptions in the United Kingdom.

RESULTS

The most common outcome of 3 848 734 included pregnancies (started 2002-2014) was live birth (66.7% of all pregnancies) followed by spontaneous abortion (20.2%). Use of antiemetics during pregnancy increased over time in all three countries. Canada had the highest prevalence of use of prescription antiemetics during pregnancy (17.7% of pregnancies overall, 13.2% of pregnancies in 2002, and 18.9% in 2014), followed by the United States (14.0% overall, 8.9% in 2007, and 18.1% in 2014), and the United Kingdom (5.0% overall, 4.2% in 2002, and 6.5% in 2014). Besides use of antiemetic drugs being considerably lower in the United Kingdom, the increase in its use over time was more modest. The most commonly used antiemetic was combination doxylamine/pyridoxine in Canada (95.2% of pregnancies treated with antiemetics), ondansetron in the United States (72.2%), and prochlorperazine in the United Kingdom (63.5%).

CONCLUSIONS

In this large cohort study, we observed an overall increase in antiemetic use during pregnancy, and patterns of use varied across jurisdictions. Continued monitoring of antiemetic use and further research are warranted to better understand the reasons for differences in use of these medications and to assess their benefit-risk profile in this population.

Risk of abnormal pregnancy outcomes after using ondansetron during pregnancy: A systematic review and meta-analysis

Background: Hyperemesis gravidarum is a serious pregnancy complication that affects approximately 1% of pregnancies worldwide.

Objective: To determine whether the use of ondansetron during pregnancy is associated with abnormal pregnancy outcomes.

Search strategy: PubMed, Cochrane Library, CINAHL, Embase, CNKI, CBM, WANFANG, and ClinicalTrials.gov were searched for citations published in any language from inception to 15 December 2021.

Selection criteria: Eligible studies included any observational study.

Data collection and analysis: Odds ratio (OR) and 95% confidence interval (CI) were used as indicators to examine the association between ondansetron and abnormal pregnancy outcomes.

Main results: Twenty articles from 1,558 citations were included. Our preliminary analysis showed that compared with the unexposed group, the use of ondansetron during pregnancy may be associated with an increased incidence of cardiac defects (OR = 1.06, 95% CI: 1.01–1.10), neural tube defects (OR = 1.12, 95% CI: 1.05–1.18), and chest cleft (OR = 1.21, 95% CI: 1.07–1.37). Further sensitivity analysis showed no significant association between ondansetron and cardiac defects (OR = 1.15,95% CI: 0.94–1.40) or neural tube defects (OR = 0.87,95% CI: 0.46–1.66). When controversial studies were eliminated, the results for the chest defects disappeared. Simultaneously, we found that the use of ondansetron was associated with a reduced incidence of miscarriage (OR = 0.53, 95% CI: 0.31–0.89). Ondansetron was not associated with orofacial clefts (OR = 1.09,95% CI: 0.95–1.25), spinal limb defects (OR = 1.14,95% CI: 0.89–1.46), urinary tract deformities (OR = 1.06,95% CI: 0.97–1.15), any congenital malformations (OR = 1.03,95% CI: 0.98–1.09), stillbirth (OR = 0.97,95% CI: 0.83–1.15), preterm birth (OR = 1.22,95% CI: 0.80–1.85), neonatal asphyxia (OR = 1.05,95% CI: 0.72–1.54), or neonatal development (OR = 1.18,95% CI: 0.96–1.44) in our primary analysis.

Conclusion: In our analysis, using ondansetron during pregnancy was not associated with abnormal pregnancy outcomes. Although our study did not find sufficient evidence of ondansetron and adverse pregnancy outcomes, future studies including the exposure period and dose of ondansetron, as well as controlling for disease status, may be useful to truly elucidate the potential risks and benefits of ondansetron.

Emesis in pregnancy - a qualitative study on trial recruitment failure from the EMPOWER internal pilot

BACKGROUND

As part of the internal pilot of the EMPOWER trial investigating the second-line antiemetic therapies in severe emesis in pregnancy ( https://www.isrctn.com/ISRCTN16924692 ), a qualitative study of women's views was carried out, to improve our understanding of why women did, or did not, consent to participation in the trial. Interviews were also conducted with site research staff, to broaden our analysis and explore other factors affecting recruitment.

METHODS

The sample comprised women who accepted or declined trial participation (n=21) and site research staff (n=22). A structured topic guide was used, in four email interviews and 17 telephone interviews with women, and semi-structured telephone interviews were carried out with staff. Of the women interviewed, seven had declined trial participation, and of the staff interviewed, 16 were research midwives/research nurses and six were principal investigators. All transcripts were checked for accuracy, anonymised and entered into NVIVO12 for indexing and retrieval. Data was analysed using a reflexive thematic analytic approach. In total, 72 codes were generated from the thematic analysis, and 36 from each sample group.

RESULTS

Three key themes based on all the interviews were (a) the diversity of recruitment pathways and boundaries of care, (b) the impact of trial complexity on recruitment and staff morale and (c) the ethics of caring for a patient with emesis. Ethical issues discussed included the use of double dummy and time to treat, particularly those suffering severely from the effects of nausea and vomiting. To illustrate these themes, staff perspectives are given more prominence.

CONCLUSIONS

The main reason the trial was stopped related to the high proportion of women ineligible for recruitment due to prior treatment with study drug(s) because of unanticipated changes in clinical practice. The qualitative results also demonstrate the impact of the trial on women and staff and highlight how the diversity of referral pathways, boundaries of care and the complexity of the trial and protocol resulted in additional barriers to successful trial recruitment. Qualitative work in pilot and feasibility studies of a clinical trial is recommended, to evaluate whether recruitment strategies remain viable in unanticipated contexts.

TRIAL REGISTRATION

Trial registration number ISRCTN16924692 . Date: 08/01/2018.

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.

Readmissions due to hyperemesis gravidarum: a nation-wide Finnish register study

Purpose

To evaluate the burden of illness caused by hyperemesis gravidarum (HG) and association of readmissions due to HG with maternal, environmental and pregnancy-related factors, and different pregnancy outcomes.

Methods

Data of women with HG diagnosis in Finland, 2005–2017, were retrieved from health-care registers. Associations between readmissions due to HG and age, gravidity, parity, pre-pregnancy body mass index (BMI), smoking, marital status, socioeconomic status, municipality population, assisted reproductive technology (ART), and number and sex of fetuses were analyzed in pregnancies resulting in delivery. Admissions and readmissions due to HG in deliveries, gestational trophoblastic disease, ectopic pregnancies, miscarriages and pregnancy terminations were calculated.

Results

10,381 pregnancies with HG diagnosis were identified: 9518 live births, 31 stillbirths, 8 cases of gestational trophoblastic disease, 16 ectopic pregnancies, 299 miscarriages, and 509 pregnancy terminations. Both outpatients and inpatients were included. Readmission occurred in 60% of pregnancies, inpatient readmission in 17%. Parity of ≥ 5, multiple gestation and female sex of fetus were associated with higher odds of readmission, maternal age 36–40 years, BMI ≥ 35 kg/m², smoking and ART with lower odds of readmission. Of the 9549 pregnancies resulting in delivery, 33% involved at least one outpatient visit or inpatient episode after the first trimester, and 8% in the third trimester.

Conclusion

The majority of women suffering from HG needed repeated medical care, often persisting after the first trimester. Our results provide practical information allowing clinicians to prepare for symptom duration beyond the first trimester and emphasize the importance of planning for eventual long-term treatment.

Hyperemesis gravidarum in the primary care setting: cross-sectional study of GPs

BACKGROUND

Hyperemesis gravidarum (HG), if untreated, can lead to malnutrition, dehydration, and Wernicke's encephalopathy. Foetal complications include low birth weight and neurodevelopmental delay. Recent evidence supports increased rates of termination of pregnancy and suicidal ideation. Drivers included difficulty in accessing medications, which thus contributed to poor perception of care.

AIM

To identify factors that may influence prescribers' confidence and knowledge regarding pharmacological therapy for HG.

DESIGN & SETTING

Cross-sectional study of qualified GPs and GP trainees in Wales.

METHOD

Distribution of a 22-item online survey. Statistical analysis was carried out using SPSS.

RESULTS

In total, 241 responses were received, with 216 included in the analysis (59% qualified GPs, 41% GP trainees). In total, 93% of responders correctly identified cyclizine as being safe in pregnancy, but no other drug recommended in the Royal College of Obstetrics and Gynaecology guidance was considered safe by more than 58%. Those reporting higher confidence levels in managing HG were more likely to correctly report guideline-recommended drugs as safe in pregnancy (P = 0.04). Additional qualifications related to obstetrics and gynaecology (O&G) and/or prior clinical experience increased confidence levels (P = 0.0001 and P = 0.0002, respectively). Only 19% of participants routinely screened for signs of mental health complications, and prior experience or education did not increase likelihood of this happening. The majority of participants (87%) would like additional education and/or access to evidence-based resources.

CONCLUSION

This study demonstrates a demand for improved dissemination of evidence-based education on HG to support those working in primary care. The extent to which HG is covered in pre-existing educational programmes should also be revisited.

Ondansetron and metoclopramide as second-line antiemetics in women with nausea and vomiting in pregnancy: the EMPOWER pilot factorial RCT

BACKGROUND

Around one-third of pregnant women suffer from moderate to severe nausea and vomiting, causing physical and emotional distress and reducing their quality of life. There is no cure for nausea and vomiting in pregnancy. Management focuses on relieving symptoms and preventing morbidity, and often requires antiemetic therapy. National guidelines make recommendations about first-, second- and third-line antiemetic therapies, although care varies in different hospitals and women report feeling unsupported, dissatisfied and depressed.

OBJECTIVES

To determine whether or not, in addition to intravenous rehydration, ondansetron compared with no ondansetron and metoclopramide compared with no metoclopramide reduced the rate of treatment failure up to 10 days after drug initiation; improved symptom severity at 2, 5 and 10 days after drug initiation; improved quality of life at 10 days after drug initiation; and had an acceptable side effect and safety profile. To estimate the incremental cost per treatment failure avoided and the net monetary benefits from the perspectives of the NHS and women.

DESIGN

This was a multicentre, double-dummy, randomised, double-blinded, dummy-controlled 2 × 2 factorial trial (with an internal pilot phase), with qualitative and health economic evaluations.

PARTICIPANTS

Thirty-three patients (who were < 17 weeks pregnant and who attended hospital with nausea and vomiting after little or no improvement with first-line antiemetic medication) who attended 12 secondary care NHS trusts in England, 22 health-care professionals and 21 women participated in the qualitative evaluation.

INTERVENTIONS

Participants were randomly allocated to one of four treatment groups (1 : 1 : 1: 1 ratio): (1) metoclopramide and dummy ondansetron; (2) ondansetron and dummy metoclopramide; (3) metoclopramide and ondansetron; or (4) double dummy. Trial medication was initially given intravenously and then continued orally once women were able to tolerate oral fluids for a maximum of 10 days of treatment.

MAIN OUTCOME MEASURES

The primary end point was the number of participants who experienced treatment failure, which was defined as the need for further treatment because symptoms had worsened between 12 hours and 10 days post treatment. The main economic outcomes were incremental cost per additional successful treatment and incremental net benefit.

RESULTS

Of the 592 patients screened, 122 were considered eligible and 33 were recruited into the internal pilot (metoclopramide and dummy ondansetron, n = 8; ondansetron and dummy metoclopramide, n = 8; metoclopramide and ondansetron, n = 8; double dummy, n = 9). Owing to slow recruitment, the trial did not progress beyond the pilot. Fifteen out of 30 evaluable participants experienced treatment failure. No statistical analyses were performed. The main reason for ineligibility was prior treatment with trial drugs, reflecting an unpredicted change in prescribing practice at several points along the care pathway. The qualitative evaluation identified the requirements of the study protocol, in relation to guidelines on anti-sickness drugs, and the diversity of pathways to care as key hurdles to recruitment while the role of research staff was a key enabler. No important adverse events or side effects were reported.

LIMITATIONS

The pilot trial failed to achieve the recruitment target owing to unforeseen changes in the provision of care.

CONCLUSIONS

The trial was unable to provide evidence to support clinician decisions about the best choice of second-line antiemetic for nausea and vomiting in pregnancy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN16924692 and EudraCT 2017-001651-31.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 63. See the NIHR Journals Library website for further project information.

Weight loss among pregnant women hospitalized because of hyperemesis gravidarum: Is there a lack of nutrition intervention?

BACKGROUND

Nutrition therapy is a key component in the management of hyperemesis gravidarum (HG). The aim of this study was to describe sociodemographic, anthropometric, and nutrition aspects of pregnant women hospitalized because of HG and raise a discussion about the nutrition care provided.

MATERIALS AND METHODS

This is a retrospective descriptive study that includes 26 pregnant women with confirmed diagnosis of HG who were hospitalized because of this condition in a tertiary hospital. Data of interest were collected from official medical records and analyzed to obtain measures of central tendency and dispersion, as well as frequencies.

RESULTS

The studied individuals had a mean age of 25.7 years and a low level of education, and 65% of them were single mothers. They registered a low weight gain (2.8 kg) during pregnancy and in the course of their hospitalization, during which they lost an average of 1.7 kg, showing a decline in nutrition status during this period. Although the average intake of oral diet (OD) was 55% during hospital stay and only 5% of the studied population met caloric needs through OD, the prescription of complementary medical nutrition therapy (oral supplements, enteral or parenteral nutrition) was scarcely observed in this sample.

CONCLUSION

Despite the negative impact that HG can impose on the mother's nutrition status and the known benefits that complementary nutrition therapies can provide, few nutrition interventions have been carried out to improve this situation. That indicates an urgent need for implementation or reviewing of nutrition assistance protocols for HG patients.

State of the Art in Hepatic Dysfunction in Pregnancy

Hepatic dysfunction in pregnant women is always challenging for the obstetrician, as the spectrum of hepatic abnormalities can be very large and have various implications, both for mother and fetus. There is a diagnostic and therapeutic polymorphism of hepatic dysfunction in pregnancy and insufficient knowledge related to the etiopathogenesis and epidemiology of this disease. The clinical forms of hepatic dysfunction encountered in pregnancy can vary from liver diseases related to pregnancy (e.g., HELLP syndrome, intrahepatic cholestasis, hyperemesis gravidarum, or acute fatty liver of pregnancy) to de novo ones occurring in pregnancy, and pre-existing liver disease (cholelithiasis, Budd-Chiari syndrome, and cirrhosis). We performed a systematic literature search over 10 years. The review protocol assumed a search of two databases (PubMed®/MEDLINE and Web of Science Core Collection). The strategy regarding the management of these diseases involves multidisciplinary teams composed of different specialists (obstetricians, gastroenterologists and anesthetists) from specialized tertiary centers. Despite the improving prognosis of pregnant women with liver diseases, the risk of maternal-fetal complications remains very high. Therefore, it is necessary to ensure careful monitoring by a multidisciplinary team and to inform the patients of the potential risks.

Use of metoclopramide in the first trimester and risk of major congenital malformations: A systematic review and meta-analysis

Background

Nausea and vomiting of pregnancy affects up to 80% of pregnant women, it typically occurs during the first trimester which is the most sensitive time for environmental exposures given organogenesis. Metoclopramide is an antiemetic drug used widely during NVP, but the findings of studies evaluating its safety of use in pregnancy is inconsistent. Therefore, we conducted a systematic review and meta-analysis to assess whether metoclopramide use during first trimester of pregnancy is associated with the risk of major congenital malformations.

Methods

The systematic search using database included Pubmed, Embase, Web of science, and Cochrane library. Studies written in English, comprising with an exposed group and a control group, reporting major congenital malformation as an outcome were included.

Results

Six studies assessing a total number of 33374 metoclopramide-exposed and 373498 controls infants were included in this meta-analysis. No significant increase in the rate of major congenital malformation was detected following metoclopramide use during first trimester (OR, 1.14; 95% CI, 0.93–1.38).

Conclusions

Metoclopramide use during first trimester of pregnancy was not associated with the risk of major congenital malformations.

The Prevalence and Risk Factors of Hypokalemia in Pregnancy-Related Hospitalizations: A Nationwide Population Study

Background

There are no nationwide population studies conducted to analyze the prevalence and risk factors associated with hypokalemia during pregnancy in the U.S.

Method

We retrieved data from the Nationwide Inpatient Sample (NIS) and the National Inpatient Sample of Healthcare Cost and Utilization Project (HCUP) for pregnant patients with hypokalemia from 2012 to 2014. We used a chi-squared test to analyze categorical variables and an adjusted Wald test to compare quantitative variables. We applied logistic regression models to calculate adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) to identify the risk factors for hypokalemia. We used a p value <0.05 as the cutoff for statistical significance.

Result

Among 12,431,909 pregnancy-related discharges, females of younger age (mean age 27.0 ± 6.2 vs. 28.1 ± 6.0, p < 0.001), of African American race, using government-paid insurance, with an income level in the first quartile, and of a higher Charlson Comorbidity Index score (≥1) were found to have a higher likelihood of hypokalemia during pregnancy (p < 0.001). Gestational hypertension (GH) (including pre-eclampsia and eclampsia, aOR 2.03, 95% CI 1.94-2.12, p < 0.001), hyperemesis gravidarum (aOR 33.18, 95% CI 31.61-34.83, p < 0.001), and post-partum hemorrhage (aOR 1.42, 95% CI 1.31-1.53, p < 0.001) were found to be independently associated with a higher rate of hypokalemia during pregnancy.

Conclusion

The prevalence of hypokalemia during pregnancy was less than 1% in this large, nationwide population-based study. There were significant differences between those patients who developed hypokalemia during pregnancy. Notably, those who had hypokalemia were younger, of African American race, and of a low-income level. Congestive heart failure, coronary artery disease, Cushing's syndrome, GH, and hyperemesis gravidarum were found to be associated with hypokalemia during pregnancy.

The Contribution of Registered Dietitians in the Management of Hyperemesis Gravidarum in the United Kingdom

Hyperemesis Gravidarum (HG) is a condition at the extreme end of the pregnancy sickness spectrum, which can cause poor oral intake, malnutrition, dehydration and weight loss. The aim of this study is to explore the role of Registered Dietitians (RD) in the management of HG in the United Kingdom (UK). A survey was designed and distributed electronically to members of the British Dietetic Association. There were 45 respondents, 76% (n = 34) worked in secondary care hospitals, 11% (n = 5) were in maternal health specialist roles. The most commonly used referral criteria was the Malnutrition Universal Screening Tool (40%, n = 18), followed by second admission (36%, n = 16). However 36% (n = 16) reported no specific referral criteria. About 87% (n = 37) of respondents did not have specific clinical guidelines to follow. Oral nutrition supplements were used by 73% (n = 33) either ‘sometimes’ or ‘most of the time’. Enteral and parenteral nutrition were less commonly used. There was an inconsistent use of referral criteria to dietetic services and a lack of specific clinical guidelines and patient resources. Further training for all clinicians and earlier recognition of malnutrition, alongside investment in the role of dietitians were recommended to improve the nutritional care of those with HG.

Rating of four different foods in women with hyperemesis gravidarum: a randomised controlled trial

OBJECTIVE

To evaluate four foods in women with hyperemesis gravidarum (HG) on their agreeability and tolerability.

DESIGN

Prospective, randomised, within-subject cross-over trial.

SETTING

Single-centre, tertiary, university hospital in Malaysia.

PARTICIPANTS

72 women within 24-hour of first admission for HG who were 18 years or above, with confirmed clinical pregnancy of less than 16 weeks' gestation were recruited and analysed. Women unable to consume food due to extreme symptoms, known taste or swallowing disorder were excluded.

INTERVENTIONS

Each participant chewed and swallowed a small piece of apple, watermelon, cream cracker and white bread in random order and was observed for 10 min after each tasting followed by a 2 min washout for mouth rinsing and data collection.

OUTCOME MEASURES

Primary outcome was food agreeability scored after 10 min using an 11-point 0-10 Visual Numerical Rating Scale (VNRS). Nausea was scored at baseline (prior to tasting) and 2 and 10 min using an 11-point VNRS. Intolerant responses of gagging, heaving and vomiting were recorded.

RESULTS

On agreeability scoring, apple (mean±SD 7.2±2.4) ranked highest followed by watermelon (7.0±2.7) and crackers (6.5±2.6), with white bread ranked lowest (6.0±2.7); Kruskal-Wallis H test, p=0.019. Apple had the lowest mean nausea score and mean rank score, while white bread had the highest at both 2 and 10 min; the Kruskal-Wallis H test showed a significant difference only at 10 min (p=0.019) but not at 2 min (p=0.29) in the ranking analyses. The intolerant (gagged, heaved or vomited) response rates within the 10 min study period were apple 3/72 (4%), watermelon 7/72 (10%), crackers 8/72 (11%) and white bread 12/72 (17%): χ² test for trend p=0.02.

CONCLUSION

Sweet apple had the highest agreeability score, the lowest nausea severity and intolerance-emesis response rate when tasted by women with HG. White bread consistently performed worst.

Antiemetic Prescription Fills in Pregnancy: A Drug Utilization Study Among 762,437 Pregnancies in Norway

Objective

To determine antiemetic prescription fill patterns during pregnancy in Norway, with special focus on the use of ondansetron and recurrent use in subsequent pregnancies.

Methods

We conducted a population-based registry study based on data from the Medical Birth Registry of Norway linked to the Norwegian Prescription Database for 762,437 pregnancies >12 gestational weeks ending in live or non-live births between 2005 and 2017. Prescription fills of medications used for nausea and vomiting of pregnancy were summarized in treatment pathways to determine drug utilization patterns. Logistic regression analyses were used to estimate associations between maternal and pregnancy characteristics and antiemetic prescription fills.

Results

The prescription fill rate for antiemetic medication during pregnancy was 7.6%. However, prescription fill rates were 35.5% in the second pregnancy after filling an antiemetic prescription in the first pregnancy and 53.5% for women who filled antiemetic prescriptions in the previous 2 pregnancies. Among pregnancies with antiemetic prescription fills, 62.2% were dispensed metoclopramide, 28.2% meclizine, and 17.2% promethazine. First-line treatment started with monotherapy in 97.4% of these pregnancies, which was the only treatment received in 78.7%. Prescriptions for ondansetron were filled in 0.3% of pregnancies, with 76.9% being initially filled in the first trimester. Ondansetron as first-line prescription medication and/or use in the first trimester was associated with proxies for more severe nausea and vomiting of pregnancy, including a diagnosis of hyperemesis gravidarum, multiple gestations, a higher obstetric comorbidity index, and concomitant use of medication for gastroesophageal reflux disease and nervous system medications. Women who filled an antiemetic prescription in their first pregnancy were less likely to have subsequent pregnancies than women who did not fill an antiemetic prescription in their first pregnancy (OR 0.93, 95% CI 0.90–0.96).

Conclusion

Complex patterns of antiemetic prescription fills in pregnancy may mirror the challenge of optimal management of nausea and vomiting of pregnancy in clinical practice, especially for women with severe symptoms.

HyperEmesis Level Prediction (HELP Score) Identifies Patients with Indicators of Severe Disease: a Validation Study

Objective Hyperemesis gravidarum (HG) severity can be underestimated resulting in undertreatment and adverse outcomes. This study was conducted to validate a tool (HELP Score) designed to score HG severity.

Materials and Methods A survey link which included PUQE and HELP Score (HELP) tool questions was posted on websites related to HG. HELP scores were compared to PUQE scores for indicators of severe disease.

Results HELP classified 92% of women reporting “nothing goes or stays down” as severe, compared to 58% using PUQE. Women self-categorizing symptoms as severe were more likely categorized as severe using HELP. Women hospitalized for HG were more likely classified as severe using HELP. HELP performs better than PUQE in identifying patients with severe symptoms requiring intervention.

Conclusion This study provides a novel tool that should be implemented to determine the need for intervention for NVP that may be overlooked using PUQE or empirical assessment.

The onset of nausea and vomiting of pregnancy: a prospective cohort study

BACKGROUND

Nausea and vomiting are experienced by most women during pregnancy. The onset is usually related to Last Menstrual Period (LMP) the date of which is often unreliable. This study describes the time to onset of nausea and vomiting symptoms from date of ovulation and compares this to date of last menstrual period METHODS: Prospective cohort of women seeking to become pregnant, recruited from 12 May 2014 to 25 November 2016, in the United Kingdom. Daily diaries of nausea and vomiting were kept by 256 women who were trying to conceive. The main outcome measure is the number of days from last menstrual period (LMP) or luteinising hormone surge until onset of nausea or vomiting.

RESULTS

Almost all women (88%) had Human Chorionic Gonadotrophin rise within 8 to 10 days of ovulation; the equivalent interval from LMP was 20 to 30 days. Many (67%) women experience symptoms within 11 to 20 days of ovulation.

CONCLUSIONS

Onset of nausea and vomiting occurs earlier than previously reported and there is a narrow window for onset of symptoms. This indicates that its etiology is associated with a specific developmental stage at the foetal-maternal interface.

TRIAL REGISTRATION

NCT01577147 . Date of registration 13 April 2012.

Ondansetron in pregnancy revisited: Assessment and pregnancy labelling by the European Medicines Agency (EMA) & Pharmacovigilance Risk Assessment Committee (PRAC)

Ondansetron is an effective antiemetic that is being widely used as a second-line treatment option for severe nausea and vomiting of pregnancy in accordance with clinical guidelines. The safety of ondansetron during pregnancy has-following publication of controversial and seemingly contradictory results-been subject to considerable academic turmoil, specifically with respect to the risk of congenital cardiac malformations and oral cleft. In July 2019, the European Medicines Agency (EMA) Pharmacovigilance Risk Assessment Committee (PRAC) released an updated, comprehensive assessment report on the use of ondansetron in the first trimester. The ensuing Summary of Product Characteristics (SmPC) was updated in November 2019 with important changes to section on "Fertility, pregnancy and lactation." The SmPC now states that ondansetron should not be used in the first trimester of pregnancy. ENTIS, The European Network of Teratology Information Services, believes that the implementation of this regulatory step-which has important clinical consequences-is insufficiently substantiated and is not serving the interest of pregnant women with severe nausea and vomiting. Herein, we discuss the underlying evidence and argue the case against the EMA decision.

Risk Factors of Prolonged Nausea and Vomiting During Pregnancy

Background

Determination of the risk factors associated with prolonged nausea and vomiting during pregnancy (NVP) helps to develop prevention strategies. However, there is a lack of studies regarding risk factors of prolonged NVP. Thus, the potential risk factors of prolonged moderate and severe NVP were examined.

Methods

This is a retrospective study among pregnant women in South of China. The Pregnancy-Unique Quantification of Emesis (PUQE) scale was used to evaluate NVP. Onset before 12 weeks and persistence after 20 weeks of gestation were defined as prolonged NVP. Data on NVP and other variables were collected by standard questionnaires and medical records.

Results

A finally sample of 1739 participants were analyzed. The incidence of prolonged moderate and severe NVP was 42.1% and 1.1%, respectively. Among those with NVP, the increased risk of prolonged moderate NVP was associated with lower gestational age (OR = 0.95 per SD increase, 95% CI=0.93-0.97), being a housewife (OR = 1.30, 95% CI=1.02-1.65), pre-pregnant longer sedentary time (OR = 2.02, 95% CI=1.16-1.83), pre-pregnant lower exercise frequency (OR = 1.84, 95% CI=1.20-2.82), and history of gastrointestinal (GI) diseases (OR = 2.21, 95% CI=1.61-3.03). Persons who were a housewife (OR = 6.39, 95% CI=1.90-21.47), with pre-pregnant high frequent (always) cold drinking (OR=11.12, 95% CI=1.24-100.73), and had a history of GI diseases (OR=10.10, 95% CI=2.63-38.86) were more likely to experience prolonged severe NVP.

Conclusion

The results of the present study suggested that pregnant women unemployed, with lower gestational age, pre-pregnant longer sedentary time, less exercise, high frequent (always) cold drinking and history of GI diseases had a higher risk of prolonged NVP and should be taken more care.

Use of antihistamine medications during early pregnancy and selected birth defects: The National Birth Defects Prevention Study, 1997-2011

BACKGROUND

It is estimated that approximately 10-15% of pregnant women report antihistamine use during pregnancy. Although antihistamines are generally considered safe during pregnancy, results from published studies are inconsistent.

METHODS

Using a case-control study design we analyzed 41,148 pregnancies (30,091 cases and 11,057 controls) from the National Birth Defects Prevention Study (1997-2011). Logistic regression models were used to estimate odds ratios (OR) and 95% confidence intervals for 64 birth defect groupings in relation to early pregnancy exposure to 14 distinct antihistamines. Models were adjusted for maternal age, race, parity, education level, prenatal care, folic acid use, smoking and alcohol use, and study site.

RESULTS

Approximately 13% of cases and controls were exposed to an antihistamine during early pregnancy. Analyses were restricted to those defects where more than five cases were exposed to the antihistamine of interest, generating 340 analyses which yielded 20 (5.9%) significant positive associations (adjusted ORs ranging from 1.21 to 4.34).

CONCLUSIONS

Only a few of our findings were consistent with previous studies. There is a lack of strong evidence to conclude that birth defects are associated with exposure to antihistamines during early pregnancy.

Antipsychotic drug use in pregnancy: A multinational study from ten countries

AIM

To compare the prevalence and trends of antipsychotic drug use during pregnancy between countries across four continents.

METHODS

Individually linked health data in Denmark (2000-2012), Finland (2005-2014), Iceland (2004-2017), Norway (2005-2015), Sweden (2006-2015), Germany (2006-2015), Australia (New South Wales, 2004-2012), Hong Kong (2001-2015), UK (2006-2016), and the US (Medicaid, 2000-2013, and IBM MarketScan, 2012-2015) were used. Using a uniformed approach, we estimated the prevalence of antipsychotic use as the proportion of pregnancies where a woman filled at least one antipsychotic prescription within three months before pregnancy until birth. For the Nordic countries, data were meta-analyzed to investigate maternal characteristics associated with the use of antipsychotics.

RESULTS

We included 8,394,343 pregnancies. Typical antipsychotic use was highest in the UK (4.4%) whereas atypical antipsychotic use was highest in the US Medicaid (1.5%). Atypical antipsychotic use increased over time in most populations, reaching 2% in Australia (2012) and US Medicaid (2013). In most countries, prochlorperazine was the most commonly used typical antipsychotic and quetiapine the most commonly used atypical antipsychotic. Use of antipsychotics decreased across the trimesters of pregnancy in all populations except Finland. Antipsychotic use was elevated among smokers and those with parity ≥4 in the Nordic countries.

CONCLUSION

Antipsychotic use during pregnancy varied considerably between populations, partly explained by varying use of the typical antipsychotic prochlorperazine, which is often used for nausea and vomiting in early pregnancy. Increasing usage of atypical antipsychotics among pregnant women reflects the pattern that was previously reported for the general population.

Nausea and vomiting of pregnancy and hyperemesis gravidarum

Nausea and vomiting of pregnancy (NVP) is a common condition that affects as many as 70% of pregnant women. Although no consensus definition is available for hyperemesis gravidarum (HG), it is typically viewed as the severe form of NVP and has been reported to occur in 0.3-10.8% of pregnant women. HG can be associated with poor maternal, fetal and child outcomes. The majority of women with NVP can be managed with dietary and lifestyle changes, but more than one-third of patients experience clinically relevant symptoms that may require fluid and vitamin supplementation and/or antiemetic therapy such as, for example, combined doxylamine/pyridoxine, which is not teratogenic and may be effective in treating NVP. Ondansetron is commonly used to treat HG, but studies are urgently needed to determine whether it is safer and more effective than using first-line antiemetics. Thiamine (vitamin B1) should be introduced following protocols to prevent refeeding syndrome and Wernicke encephalopathy. Recent advances in the genetic study of NVP and HG suggest a placental component to the aetiology by implicating common variants in genes encoding placental proteins (namely GDF15 and IGFBP7) and hormone receptors (namely GFRAL and PGR). New studies on aetiology, diagnosis, management and treatment are under way. In the next decade, progress in these areas may improve maternal quality of life and limit the adverse outcomes associated with HG.