Adverse effects of severe NVP on quality of pregnant women's lives

42.   ADVERSE EFFECTS OF SEVERE NVP ON QUALITY OF PREGNANT WOMEN'S LIVES

1.   If you heard that a woman might be left to suffer from nausea and vomiting for at least a couple of months, without any nursing or medical attention, you would be rather perturbed. At the same time if a condition that caused 8.5 million working hours to be lost each year in England and Wales was not addressed, you would be surprised. But this is exactly what happens when women suffer from morning sickness. (87)

2.   A study of 611 American women calling a health line for women with current nausea and vomiting of pregnancy (NVP) in Canada between February 1996 and August 1998 at approximately 8 weeks of gestation, and followed up at 20 weeks of gestation, naturally included women who exhibited more severe symptomatology of NVP compared to figures from population-based studies.  These women reported due to NVP, 39% felt depressed always or most of the time, 40% said that NVP adversely affected the relationship with their partner and 14% stated they would be less likely to consider having more children due to their experience with NVP. Two thirds of these women worked outside the home and lost a mean of 206 hours of paid employment. These data suggest that lack of an approved treatment can cause women unwarranted and preventable suffering. (88)

3.   This report focuses on 3,201 telephone callers to the NVP health-line in Canada who reported having nausea and vomiting of pregnancy (NVP) in a previous pregnancy. Half reported on pregnancies that had occurred over 4 years prior to contact with the NVP health-line. A high prevalence of reported psychosocial problems were attributed by these women to NVP. All of the following were reported more commonly among women with more severe nausea and vomiting.  Feelings of depression always, to most of the time 52%; consideration of termination of pregnancy 18%; an adverse effect on their relationship with their partner 50%; an adverse effect on their partner’s daily life 61%; the fear of the likelihood that NVP would harm their fetus 61%. The prevalence (n =108;3.4%) of elective termination of pregnancy due to NVP was relevant despite the fact that 75% of pregnancies were said to be planned. No information was obtained on previous history of depression or the quality of the relationship with women’s partners. It is therefore not clear which came first, the NVP or the psychosocial factors. However, even if the psychosocial factors reported predated pregnancy, the fact that they were independently related to use of anti-emetic medication suggests that they should be taken into consideration when managing women with NVP. (89)
There was another notable finding: there was a clinically important prevalence of psychosocial problems even among women with mild nausea and vomiting, for example 21-23% of women reported feeling depressed (due to nausea or vomiting respectively) always or most of the time, and 43% reported an adverse effect on their partner’s everyday life. (89)

In deciding whether or not to initiate anti-emetic therapy consideration should be given to the impact that NVP is having on a woman’s life. Treatment may be appropriate for less severe nausea and vomiting that does not necessarily cause dehydration and/or malnutrition. (89)

4.   In England and Wales from 1979 to 1992 a range of 25-59 legal abortions were performed annually for ICD code 643 ‘excessive vomiting of pregnancy’ (personal communication, Abortion Statistics IPSC London UK, November 1995). This corresponds to 6.0 such abortions (median 3.7-9.5) per 100,000 pregnancies and 97% (range 60-100%) of all terminations for maternal indications. (100)

5.   Over the study period, February 1996 - March 1997, pregnancies complicated by NVP were retrospectively reported to the NVP health line in Canada, 108 terminations of pregnancy due to NVP, 413 cases in which termination due to NVP had only been considered, and 2,609 pregnancies in which no termination due to NVP had been considered were reported. Women who terminated pregnancy were significantly younger and more likely to have reported NVP in an unplanned pregnancy and to be multiparious. Nausea was usually severe in all groups and worse in the group of women who terminated than in those women who never considered termination (P

6.   From February to August 1997, 260 women formed the study population of women suffering from nausea and vomiting of pregnancy who telephoned a health-line in Canada when they were less than 20 weeks pregnant. Women who contact the health line presented with more severe nausea and vomiting than the average population. (91)
60% of these women reported some degree of depression because of NVP and 50% were concerned that their NVP would impact negatively on the health of their child. Moreover, 12% of patients considered termination of pregnancy because of the severity of their NVP. This possibility reflects the severe nature of the disease in this population. In terms of lifestyle changes, 78% reported some time lost from outside employment. Almost half of the women felt that NVP adversely affected the relationship with their partner and over half of the women felt that NVP had an adverse effect of their partner’s day to day life. (91)
A large educational effort based on evidence-based management is needed among health professionals and patients to optimise management and eradicate misinformation about NVP. (91)

7.   Each year, a significant number of women are admitted to hospital for hyperemesis gravidarum and many require such interventions as total parental nutrition. Early recognition and management therefore have a significant effect on the quality of life during pregnancy, as well as a financial impact on the health care system. Management of this problem is multi-faceted. It includes early recognition, dietary and lifestyle advice as well as pharmaceutical and alternative forms of therapeutic interventions. (92)
Conclusion. Nausea and vomiting are frequent symptoms in pregnant women which can affect their quality of life significantly. It is recommended that all health practitioners should question women early in their pregnancies about the presence of these symptoms and offer intervention with advice about diet, lifestyle adjustment and medical treatment. (92)

8.   Twenty-seven women who were experiencing different degrees of nausea and vomiting were selected from 147 pregnant women and asked to participate in semi-structured telephone interviews. All participants reported changes in family, social or occupational functioning as a result of these symptoms. Nausea and vomiting can impose substantial lifestyle limitations on pregnant women that can have short and long-term consequences for them and their families. (54)

9.   Another cost of severe nausea and vomiting of pregnancy is the effect on the quality of life of the pregnant woman and her family. Quality of life may be considered to have the following dimensions: i) physical functioning, e.g. work, household activities; ii) social functioning e.g. disruption of normal social activities; iii) psychological functioning, e.g. anxiety and depression; iv) disease and treatment related symptoms, here severe nausea. All of these are drastically affected by nausea of the severity that leads of hospitalisation.    (93)

10.   593 women with nausea and/or vomiting presented at a mean gestational age of 8.5 weeks. The majority of these women reported that nausea and vomiting affected their ability to carry out day to day activities, with the greatest interference reported to household activities, 89%. Cooking, shopping, washing and cleaning activities were also restricted. 483 women, 81% took longer to get things done in general and 389 women, 65%, carried out the bare minimum of activities during the early weeks of pregnancy. Amongst 269 women, 70% thought they were less effective parents. Women interacted less well with their children, made greater use of crèches and placed greater reliance on existing childcare arrangements, with close relatives assisting. (81)
Women’s sense of loss of well-being and health status during these early months was considerable and emphasises the misery many experience. There is a need for health professionals to disseminate information on effective treatment measures and for employers, family and friends to provide emotional and practical help to ease the burden of NVP many experience during the early weeks of pregnancy.  (81)

11.   The majority of women still suffer some form of nausea or vomiting in early pregnancy and although not a life threatening condition, it often remains a cause of much discomfort and concern to the pregnant patient and her family. Numerous treatments have been tried. Even if considered safe, they may be rejected by informed women who are aware of catastrophes caused by drugs in pregnancy. (27)

12.   NVP produced additional worries about the effect on the baby. Women asked, how does this effect the baby? or, does this mean there is anything wrong with the baby? and expressed concern that some harm would come from the violent vomiting and perceived lack of adequate nutrition. 27 women in study. (103)

13.   Whether or not neurosis may be the cause of vomiting (in Hyperemesis Gravidarum) we are convinced that the health and even the life of the patient depends upon one’s ability to control the symptoms. (Written in 1938). (14)

14.   A review of stressors identified by women with nausea and vomiting of pregnancy reinforces the challenges imposed by the pressure of severe nausea and vomiting at a time that should be filled with anticipation and assumption of the mother-to-be role. These stressors seen in their entirety illustrate why these women are so in need of nursing care:-

         Lack of understanding and support from others.

         Inability to take vitamins or eat healthily.

         Taking medications perceived risky.

         Missing out on the fun of being pregnant.

         Loss of “normal” pregnancy.

         Loss of work days or quitting work.

         Putting life “on hold”.

         Longing to eat and drink normally.

         Money expended on care and support.

         Lack of energy, fatigue.

         Irritability and lack of enjoyment of life.

         Memory loss or inability to think clearly.

         Burden of care and time on others.

         Lack of socialisation and isolation.

         Inability to prepare for birth and arrival of baby.

         Inability to care for family and home.

         Fear of painful treatments.

         Wanting pregnancy over or to end the misery.

         Others’ perception that hyperemesis is only in her mind.

         Reluctance of doctors to treat because of cost of liability.

         Weight loss or inadequate weight gain for gestational age of baby.

         Fluctuating emotions due to hormones and illness.

         Sense of inadequacy and failure at being unable to cope and function.

         Fear of pain or difficult birth.

         Fear of morbidity or death.

         Difficulty bonding with infant.

         Lack of energy and socialisation with other children.

         Lack of excitement about infant’s arrival.

         (From www.hyperemesis.org).  (143)

15.   Department of health official abortion statistics 1992-2006 excessive vomiting in pregnancy relating to abortion.

 

YEAR

 

TOTAL

YEAR

 

TOTAL

1992

=

25

1999

=

25

1993

=

2

2000

=

15

1994

=

24

2001

=

16

1995

=

37

2002

=

 

1996

=

23

2003

=

 

1997

=

15

2004

=

 

1998

=

31

2005

=

 

 

Totals under 10 are suppressed for reasons of confidentiality in line with Office for National Statistics Guidance 2005. (144)

  1. Women who actually terminated were more likely to report a negative attitude from their care giver. At least a third reported no help from their care giver. It is not surprising that most of them (87%) expressed the reason for their termination “no hope of relief” (145).
    In a target group of women with an history of hyperemesis gravidarum n=808, 15% (121) reported terminating at least one pregnancy because of this condition. Among those who did or did not terminate 19% reported a fear of the pregnancy and 37% either decided or deliberated to forgo future pregnancies after their HG experience. 191 (23.6%) wanted to limit family size, 224 (27%) wanted no more pregnancies and 38 (4%) were sterilised. (145)
  2. In addition to increased hospital admissions some women experience significant psychosocial morbidity caused by nausea and vomiting of pregnancy resulting in pregnancy termination. (124)

Summary

Adverse effects of severe NVP on quality of pregnant women’s lives.

(14) (87) (88) (89) (100) (90) (91) (92) (54) (93) (27) (81) (103) (124) (143) (145)
(Department of Health Official Abortion Statistics)                                    Total:  Seventeen References

Pooled population 5647 women with severe NVP

 

Areas of women’s lives effected

  • Felt depressed most of the time. (88) = 39%; (89) = 52%; (91) = 60%
  • Adversely effected the relationship with their partner.

         (88) = 40%; (89) = 50%; (91) = 45%

  • Had an adverse effect on their partner’s daily life. (89) = 61%; (91) = 55%
  • Less effective parent. (81) = 70%
  • Worried that NVP would impact negatively on the health of their child.

         (91) = 50%

  • Women less likely to have more children. (88) = 14% (145) = 27%
  • Consideration of termination of pregnancy due to NVP. (89) = 18%; (91) = 12%
  • Elective termination of pregnancy due to excessive vomiting in pregnancy.

(89) = 3.4%; (90) = 25-59 terminations annually 1979-92.

1992 - 2001 = 15-37 terminations annually (90)

2002 - 2006 =

  • In a large group of women with a history of hyperemesis gravidarum n=805, n121 = 15% reported terminating at least one pregnancy because of this condition. (145)

 

Even mild NVP’s effect on pregnant women’s quality of life

 

  • Feeling depressed most of the time. (89) = 21-23%
  • Adverse effect on partner’s everyday life. (89) = 43%

 

42a.   DOES NVP REQUIRE TREATMENT?
PREFERABLY EARLY TREATMENT OF NVP ADVISABLE

1.   Patients in the trial had symptoms of relatively acute onset which were mainly of moderate severity. The treatment of nausea and vomiting most commonly started one or two weeks after the first symptoms commenced. 28 women in study. (17)

2.   This report focused on 3,201 telephone callers to the NVP helpline in Canada who reported having nausea and vomiting in a previous pregnancy. There was a clinically important prevalence of psychosocial problems even among women with mild nausea and vomiting, for example 21-23% of women reported feeling depressed (due to nausea or vomiting respectively) always or most of the time, and 43% reported an adverse effect on their partner’s everyday life. In deciding whether or not to initiate anti-emetic treatment therapy, consideration should be given to the impact that NVP is having on a woman’s life. Treatment may be appropriate for less severe nausea and vomiting that does not necessarily cause dehydration and/or malnutrition. (89)

3.   All know that effectively treating symptoms of NVP in early pregnancy can make a woman less sick and decrease the time it takes to recover.

         (Key Speech by T Goodwin. Hyperemesis.org.uk. Updated March 2006).

4.   The value of drug treatment, if any, is at the stage of intractable vomiting when any of the stated anti-emetics, e.g. anti-histamines or phenothiazines, may be used to counter the feeling of nausea. If one can control the symptoms at this stage then it is likely that a large number of women can be prevented from developing excessive vomiting which, if prolonged, leads to hyperemesis gravidarum. (101)

5.   Nausea and vomiting are frequent symptoms in pregnant women, which can effect their quality of life significantly. It is recommended that all health practitioners should question women early in their pregnancies about the presence of these symptoms and offer intervention with advice about diet, lifestyle adjustment and medical treatment. (92)

6.   There is no clear-cut division between morning sickness and what is excessive vomiting of pregnancy. It is only a matter of degree and both conditions should be treated. Probably the only value of drug therapy is at the stage of morning sickness when anti-emetics or mild sedatives may counter the feeling of nausea, and prevent the woman from developing excessive vomiting and entering the vicious cycle of dehydration, starvation and electrolyte imbalance. (75)

7.   Benefits and recommendations. Nausea and vomiting of pregnancy (NVP) has a profound effect on women’s health and quality of life during pregnancy as well as a financial impact on the health care systems, and its early recognition and management are recommended. Cost including hospitalisation, additional office visits and time lost from work may be reduced if NVP is treated early. (115)

8.   It is important to recognise and treat those patients early who suffer from the extreme form of hyperemesis gravidarum to avoid adverse outcomes in both mother and baby.    (126)

9.   On June 9th, 1983, Bendectin tablets widely used throughout the world to treat nausea and vomiting during pregnancy, were voluntarily removed from the market by the manufacturer, Merrill Dow. At the time the company faced 327 pending US product liability suits - eventually all lawsuits which came to court were dismissed.  The company estimated that the drug was used in 33 million pregnancies by 1983.  A generic version, Diclectin, which contains Doxylamine (an anti-histamine with anti-nauseant properties) and Pyridoxine (Vit B6), has been available in Canada since 1983 with gradually increasing sales. Sales reached about 23% of the previous annual sales of Bendectin in Canada and USA by 1989. Bendectin was shown to be effective by default, as lack of use of the drug resulted in a measurable increase in rates of hospitalisation for the symptoms of excessive vomiting during pregnancy, which it was designed to control. (93)

10.   We are convinced that the health and even the life of the patient suffering from hyperemesis gravidarum depend upon one’s ability to control the symptoms. (Written in 1938). (14)

11.   A study of 611 American women who exhibited the more severe symptomatology of nausea and vomiting of pregnancy reported that due to NVP, 39% felt depressed always or most of the time, 40% said that NVP adversely affected the relationship with their partner, and 14% stated that they would be less likely to consider having more children due to their experience with NVP. Two thirds of these women worked outside the home and lost a mean of 206 hours of paid employment. These data suggest that lack of an approved treatment can cause women unwanted and preventable suffering. (88)

12.   If you heard that a woman might be left to suffer from nausea and vomiting for at least a couple of months, without any nursing or medical attention, you would be rather perturbed. At the same time if a condition that caused 8.5 million working hours to be lost in England and Wales each year was not addressed, you would be surprised. But this is exactly what happens when women suffer from morning sickness. (87)

13.   There is no reason to believe that alleviating the symptoms of normal NVP (e.g. excluding hyperemesis gravidarum) will improve the outcome of the pregnancy. Indeed doing so could have the opposite effect if it interferes with the expulsion of potentially dangerous foods, or with learning to avoid them. (86)

14.   Once symptoms of nausea and vomiting progress, treatment can become more difficult; treatment in the early stages may prevent more serious complications including hospitalisation. (124)


Summary

 

NVP needs treatment. (14) (17) (75) (87) (88) (89) (92) (93) (101) (115) (124) (126) (Goodwin)                                                                                                                        Total:            Thirteen References

 

Preferably early treatment of NVP advisable.

(17) (75) (89) (92) (101) (115) (124) (126) (Goodwin)                        Total:            Nine References

 

NVP should not be treated. (86)                                                           Total:            One Reference

Did you know?

Hyperemesis Gravidarum rarely ends at 12 weeks of pregnancy. It typically improves in the middle of pregnancy, but symptoms often last until birth.

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