Objective
Hyperemesis gravidarum (HG) has a detrimental effect on physical and mental health. Termination of pregnancy (TOP) is reported in approximately 10%,
1
and qualitative research studies report an association with suicidal ideation.- Dean C.
- Murphy C.
I could not survive another day: improving treatment and tackling stigma: lessons from women’s experiences of abortion for severe pregnancy sickness.
https://www.pregnancysicknesssupport.org.uk/documents/HGbpasPSSreport_docx.pdf
Date: 2015
Date accessed: December 7, 2020
2
We aimed to determine the consequences of HG on TOP and suicidal ideation, with particular reference to disease severity, functional status, and perception of care.Study Design
This national cross-sectional study utilized a 14-item anonymous online survey distributed across the United Kingdom, incorporating demographic details, self-reported disease severity, consequence on functional status, mental health, details of the care experience, and opportunity for open box feedback. It was piloted by a patient advisory panel with feedback incorporated and distributed via a United Kingdom–registered HG charity. Analysis utilized chi-square or Fisher exact tests to evaluate relationships among outcomes. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for binary outcomes using univariate logistic regression models. These data included missing responses and “Don’t Know” or “Not Applicable” responses, which were handled using pairwise deletion. This is an all-available case analysis. All quantitative analyses were conducted using R version 3.6.1 (RStudio, Boston).
Results
A total of 5071 participants’ from 14 United Kingdom regions completed the survey. Approximately 74.1% (3715 of 5016) self-reported a diagnosis of HG, and a further 8.8% (441 of 5016) experienced nausea and/or vomiting at least 20 times a day. In addition, 4.9% of participants (249 of 4994) terminated a pregnancy and 52.1% (2601 of 4994) considered termination owing to HG. Moreover, 25.5% (1264 of 4964) reported occasional suicidal ideation and 6.6% (331 of 4964) reported regular suicidal ideation owing to severe sickness. TOP and suicidal ideation were associated with severity of sickness (P<.001), poor functional status (P<.001), and perception of quality of care both in primary (community family healthcare providers) and secondary (hospital) care (P<.001 and P<.001, respectively) (Table 1). Those reporting extremely poor perception of both primary and secondary care were less likely to have been offered medication compared with those reporting excellent care (OR, 23.99; 95% CI, 17.79–32.74; OR, 7.39; 95% CI, 5.65–9.76). Representative participant quotes are described in Table 2.
Table 1Features of patients’ pregnancy/management and relationship to suicidal ideation and termination of pregnancy
| Suicidal ideation | Termination of pregnancy | |||||||
|---|---|---|---|---|---|---|---|---|
| Never | Occasional | Regular | Chi-squared P value | Confirmed | Considered | Never considered | Chi-squared P value | |
| Perceived experience in primary care | ||||||||
| Excellent | 74 (405) | 20 (111) | 6 (32) | <.001 | 2 (13) | 48 (265) | 49 (270) | <.001 |
| Good | 72 (760) | 23 (249) | 5 (53) | 3 (31) | 52 (553) | 45 (485) | ||
| Satisfactory | 72 (891) | 23 (283) | 5 (59) | 3 (43) | 51 (639) | 45 (561) | ||
| Poor | 65 (734) | 29 (324) | 7 (77) | 6 (68) | 55 (623) | 40 (452) | ||
| Extremely poor | 55 (398) | 33 (236) | 12 (89) | 10 (75) | 58 (421) | 31 (225) | ||
| Perceived experience in secondary care | ||||||||
| Excellent | 74 (572) | 20 (152) | 6 (49) | <.001 | 3 (24) | 51 (396) | 46 (356) | <.001 |
| Good | 71 (840) | 24 (281) | 5 (62) | 3 (37) | 53 (628) | 44 (520) | ||
| Satisfactory | 65 (694) | 29 (313) | 6 (66) | 5 (49) | 54 (586) | 42 (453) | ||
| Poor | 62 (545) | 30 (258) | 8 (71) | 8 (66) | 55 (485) | 37 (324) | ||
| Extremely poor | 54 (232) | 33 (143) | 13 (56) | 12 (51) | 57 (250) | 31 (134) | ||
| Impact on functional status | ||||||||
| Able to function most of the time | 93 (164) | 7 (12) | 0 (0) | <.001 | 0 (0) | 10 (19) | 90 (164) | <.001 |
| Able to function some of the time/needed extra support | 81 (1156) | 17 (244) | 2 (23) | 2 (26) | 38 (542) | 60 (861) | ||
| Bedridden most of the time/needed daily support | 61 (2045) | 30 (1006) | 9 (308) | 7 (223) | 60 (2039) | 33 (1115) | ||
Values are percentage (number) unless indicated otherwise.
Nana. Hyperemesis gravidarum is associated with increased rates of termination of pregnancy and suicidal ideation. Am J Obstet Gynecol 2021.
Table 2Representative quotes
| Outcome | Representative quote |
|---|---|
| Termination of pregnancy | “I could not take it anymore and asked for a termination. It was that or I think I would have taken my own life. I had nothing left.” |
| Suicidal ideation | “I felt scared and alone and attempted suicide when it felt like the only way out.” |
| Mental health | “I also think looking back that I was very depressed, but nobody even asked how I was feeling at any of my midwife/doctor appointments.” |
| Perceived quality of care | “I wasn’t taken seriously until I’d lost 2 stone; I was made to feel like another first-time mum who was unable to cope.” |
| Access to medications | “I was told that it was safer to persist with the symptoms than to risk harm to my unborn child.” |
Nana. Hyperemesis gravidarum is associated with increased rates of termination of pregnancy and suicidal ideation. Am J Obstet Gynecol 2021.
Conclusion
This study has limitations that may limit its broader implication; for example, online data collected from self-selected participants likely introduce bias and certain population groups may be underrepresented. Nonetheless, the data reflect lived experiences of women responding to the survey and can be used to positively affect care and improve outcomes in HG. The comments made in the free text boxes are a strength of the study and may provide further insight for healthcare professions as to how to better support patients with this condition.
Some women in the pregnancy termination and suicidal ideation groups were underprescribed antiemetic agents. Practical solutions that can be integrated into clinical practice include ensuring clinicians are aware of safe and effective treatments for HG and signposting those less familiar with treatments to reliable guidance.
3
,Royal College of Obstetricians and Gynaecologists
The management of nausea and vomiting of pregnancy and hyperemesis gravidarum.
The management of nausea and vomiting of pregnancy and hyperemesis gravidarum.
https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf
Date: 2016
Date accessed: December 7, 2020
4
The observation that participants’ perception of care was lower in the TOP and suicidal ideation groups highlights likely shortcomings in how practitioners screen and manage mental health problems. This is important because suicide is the second most common cause of direct maternal death in the United Kingdom.
5
Practice standards should be improved by embedding mental health screening into clinical consultations with vigilance paid to “red flag” features. If identified, a holistic, multidisciplinary approach with early mental health team involvement may improve quality of life and reduce maternal/fetal morbidity and mortality.3
Royal College of Obstetricians and Gynaecologists
The management of nausea and vomiting of pregnancy and hyperemesis gravidarum.
The management of nausea and vomiting of pregnancy and hyperemesis gravidarum.
https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf
Date: 2016
Date accessed: December 7, 2020
References
- I could not survive another day: improving treatment and tackling stigma: lessons from women’s experiences of abortion for severe pregnancy sickness.(Available at:)https://www.pregnancysicknesssupport.org.uk/documents/HGbpasPSSreport_docx.pdfDate: 2015Date accessed: December 7, 2020
- Reviewing the effect of hyperemesis gravidarum on women’s lives and mental health.Br J Midwifery. 2018; 26: 109-119
- The management of nausea and vomiting of pregnancy and hyperemesis gravidarum.(Available at:)https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdfDate: 2016Date accessed: December 7, 2020
- ACOG Practice Bulletin No. 189: nausea and vomiting of pregnancy.Obstet Gynecol. 2018; 131: e15-e30
- Saving Lives, Improving Mothers’ Care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2015-17.National Perinatal Epidemiology Unit, University of Oxford, Oxford2019
Article info
Publication history
Published online: March 10, 2021
Footnotes
The authors report no conflict of interest.
Drs Dean and Williamson are joint senior authors.
Identification
Copyright
© 2021 Elsevier Inc. All rights reserved.
