Hyperemesis Gravidarum

9.   HYPEREMESIS GRAVIDARUM

 

9a.   INCIDENCE OF HYPEREMESIS GRAVIDARUM (HG)

 

The definition of HG varies in the published literature. Fairweather’s definition (10) is the one most widely used (i.e in nine studies), which states, persistent vomiting before the 20th week of gestation and of such severity to require hospital admission unassociated with coincidental medical conditions. Other authors have added in their separate definitions of HG, weight loss of more than 5% of pre-pregnancy weight (42), ketosis and/or electrolyte imbalance especially hypokalaemia. (75)

 

1.  1:150 pregnancies 43 patients with HG 0.66%                 C H Peckham (7)

2.  0.68% of 12,675 deliveries developed moderately            D Reid (1)

     severe or severe vomiting                                               

3.  0.88% of 453 patients with HG                                         J Fitzgerald (9)

4.  0.39% of births had HG                                                    D Fairweather (10) 

                                                                                           Cleveland, USA 1958-1964

5.  0.14% of births had HG in one centre                               Tokyo, 1961-1969 (10)

6.  0.32% of births had HG                                                    Registrar General for Wales and England 1958 (10)

7.  0.55% of 363 pregnancies had HG                                   R Gadsby (50)

8.  0.54% of 82 patients with HG                                           R Chin (26)

9.  0.3% of 3,068 women had HG                                          B Kallen (29)

10. 0.3% of pregnancies: 30 women had HG                         Fischer-Rasmussen (36)

11. 0.35% of pregnancies: 46 women with HG                       I Tsang (61)

12. 0.63% of live births: 164 women with HG                         A Bashiri (64)

13. There seems little doubt severe vomiting during              D Fairweather (10)                    

      pregnancy is now relatively uncommon with an                                   

      incidence probably as low as 0.1%

14. 0.3% of 1,453 women with singleton pregnancies had HG     R K H Chin (63)

15. 0.79%, 1,027,213 births. 8,186 were preceded by               J Askling (66)

      hospital admission for hyperemesis gravidarum            

16. 0.52% treated for HG, 86 with HG in study                          M A Klebanoff (20)

      population of 16,398

17. Thirty-nine women had been hospitalised because              B Kallen (132)

       of HG (1.3%). 2906 women in the study

       population reported NVP           

18. 0.9% of women had HG in first pregnancy.

      547238 Norwegian women in study                                     Trogstad (148)

           

In 18 references range 0.14% - 1.3% of pregnant women suffered from HG.
Pooled population 13,489 pregnant women had HG.

 

9b.   TIME FROM LMP UNTIL ADMISSION TO HOSPITAL DUE TO
HYPEREMESIS GRAVIDARUM

  1.  The peak incidence of admission for hyperemesis gravidarum is between 8-12 weeks, (57% of the total 217 women), while only 5% were admitted before eight weeks of gestation. (10)
  2. Time of admission to hospital varied from 4 weeks to over 20 weeks, the average being 10.4 weeks. 71% of patients were under three months pregnant. 43 patients in study. (7)
  3. Mean gestational age at initial admission to hospital was 11.1 ± 3.9 weeks in the severe hyperemesis gravidarum group and 9.5 ± 2.6 weeks in the mild hyperemesis gravidarum group (P
  4. 86 women admitted to hospital with hyperemesis gravidarum. Gestation on admission.

Weeks

Number of Patients

 

1

6-10

41

10-14

31

14-20

9(26)

  1. Admission to hospital in weeks from LMP.

Weeks

Total

Percentage

4-8

18

20.7%

8-12

50

57.5%

12-16

10

11.5%

16-20

1

1.1% (69)

  1. Mean week for first admission for hyperemesis gravidarum week 10. 25 women with HG in study. (94)
  2. 50 women with hyperemesis gravidarum divided into two groups. 25 women in each. Gestational age at first hospitalisation in weeks.
    Group A (11.2 ± 3.17)      Group B (11.5 ± 2.96)         (105)
    Patients were admitted to Groups A or B according to the different treatment they received.
  3. 46 women admitted to hospital with hyperemesis gravidarum. All diagnoses were made prior to 13 weeks gestation, range 6-13 weeks. Mean = 9 weeks. (61)
  4. The mean gestational age for admission due to hyperemesis gravidarum was 11.0 ± 2.7 weeks for 56 women in Group A and 10.8 ± 2.7 weeks in 54 women in Group B. Patients were admitted to Groups A or B according to the different treatment they received. (116)
  5. Mean gestational age for admission to hospital with hyperemesis gravidarum 8.7 ± 0.7 weeks. 10 patients. (117)
  6. Women with hyperemesis gravidarum weight loss of more than 5% and severe enough to require admission to hospital in accordance with the criteria of Fairweather gestational age 10.2 ± 2.3 weeks, n = 8. (134)
  7. The average gestational age of first treatment for HG = 8.6 weeks.
    1224 women with HG in this study (152).

 

Summary:           

Mean weeks for hospital admission for hyperemesis gravidarum are 10-11 weeks from LMP.

 

9c.   LENGTH OF STAY IN HOSPITAL FOR HYPEREMESIS GRAVIDARUM PATIENTS

 

  1. Forty-six patients with hyperemesis gravidarum. Mean hospital stay 1.8 days, range 1-10 days. (61)
  2. It will be noted that nearly half of the patients were discharged in a week or less and that over two-thirds were well enough to go home by the tenth day, leaving less than one-third who were under treatment for more than 10 days. (14)
  3. Average hospital stay 12.8 days per patient, 89 women with HG admitted to hospital. (69)
  4. The majority of hyperemesis patients failing conservative therapy, stay 5 to 9 days in hospital and are then discharged to a home total parenternal nutrition programme. (73)
  5. 50 women with HG divided into two groups of 25. Besides usual treatment one group received Diazepam 10mg bd by iv infusion then 5mg bd for 7 days. The mean hospital stay was shorter in the Diazepam group. 1.5 ± 1.9 v 5.6 ± 1.6 days.    (105)
  6. Annually in the United States more than 50,000 women are hospitalised with the diagnosis of hyperemesis gravidarum, with an average hospital stay of 4 days per patient. Paper dated 2000. (106)
  7. There was no significant difference in the average total length of hospital stay between Group A (9.4 ± 5.8 days) and Group B (7.2 ± 5.8 days). Both groups HG; Group A n = 30, Group B n = 34. Group A weight loss > 5% of pre-pregnancy weight. Group B maintained at least 95% of their pre-pregnancy weight. (42)
  8. Length of stay in hospital for various pregnancy related conditions for women who had a live birth n = 3003. Hyperemesis Gravidarum 337 women. Mean length of stay 3.0 days. (128)
  9. 1825 women in study. Among the 84.4% of hospitalisations for which length of stay was known, the median length of stay for hyperemesis gravidarum was 3 days. (129)
  10. Of 109 women with hyperemesis gravidarum, 39 (28%) were admitted on multiple occasions. The average length of stay was slightly longer for the women admitted on multiple occasions. 5.5 ± 6.0 v 4.2 ± 2.4 days P
  11. Mean length of stay in hospital for 130 pregnancies 3.7 days. (150) after treatment with metoclopramide and diphenhydramine combination.

Summary:           

The average length of stay in hospital for HG is between 3 and 4 days.

 

9d.   RE-ADMISSIONS TO HOSPITAL DUE TO HYPEREMESIS GRAVIDARUM

 

  1. 25% of patients required re-admission to hospital due to recurrence of symptoms, but the author goes on to say that some patients may have been discharged originally too soon. (10)

 

  1. 360 women during 12 years, 1925-1936. Were admitted to wards because of vomiting that seems intractable enough to require hospitalisation. 29 (8.0%) readmitted one or more times because of recurrent symptoms. (14)

 

  1. Of 140 patients with hyperemesis gravidarum, 70 (50%), were admitted on only a single occasion accounting for 32% of the 320 admissions. 39 (28%) were admitted on multiple occasions and were responsible for 51% of admissions (2.9 ± 1.1 admissions per patients range 2-6). 31 patients were lost to follow-up or elected to have a therapeutic abortion. (33)
  2. 42 women with hyperemesis gravidarum, 29 were admitted once (69%), 13 were admitted twice or more (31%). (76)
  3. 25% (10); 28% (33), 31% (76) of women were readmitted to hospital on one or more occasions due to HG. In about 25% of women, the condition recurs when treatment is stopped. However, oral methylprednisolone treatment does reduce the need for readmission to hospital for HG. (99)
  4. Evalutation of efficacy of methylprednisolone (MSPS) versus placebo (PCO) in HG.
    14 women in MPS group. 11 in PCO group. MPS group 12, 4mg tabs for 3 days then 10 day taper decreasing 1 tab per day.
    Recurrence of vomiting after randomisation occurred in 4 (29%) and 8 (73%) MPS and PCO respectively. P = 0.05.
    Readmissions for repeat treatment occurred in 1 (7%) MPS and 4 (36%) PCO respectively.
    A short course of MPS in patients with HG decreases the likelihood of a recurrence of vomiting and readmission for HG. (94)
  5. A randomised controlled trial comparing oral methylprednisolone (M) and oral promethazine (P). 40 patients enrolled over 11 months, 20 in each group. M = 16mg,
    P = 25mg three times daily, both for 3 days. M tapered over 2 weeks, P dose maintained unchanged for two weeks. Patients who continued to vomit after 2 days had study medication discontinued. 3 in group M and 2 in group P failed treatment. No women in M group but 5 in 17 (29.4%) in P group were readmitted for HG within 2 weeks of discharge. (P = 0.0001). (95)
  6. Re-admission to hospital due to recurrence of HG 19.2% after treatment with metoclopramide and diphenhydramine combination. 130 pregnancies in study. (150)
  7. The number of women requiring a second admission due to renewed symptoms was less in the Diazepam group, 4% than the other group, 27%. The difference was significant. 50 women with HG. (105)
  8. The length of stay in hospital and the number of admissions required are not good indications of the severity of the condition. (28)
  9. Of the 19 (35%) of women in each group, Group A and Group B who needed readmission to hospital, 11 in Group B and 8 in Group A were readmitted within 2 weeks of their first admission. (116)
  10. It has been found that patients have a high relapse rate if they are discharged too soon. Ideally, the patient should show consistent weight gain and not just cessation of vomiting and re-hydration. (126)

Summary           

 About 25% of women with HG require readmission to hospital. This percentage is greatly reduced if Methylprednisolone or Diazepam are used for treatment of HG.

 

9e.   PROMPT RECOVERY AFTER THERAPEUTIC ABORTION OR AFTER DELIVERY FOR HYPEREMESIS GRAVIDARUM AND NVP PATIENTS

 

  1. 32 patients were subjected to therapeutic abortion. Of those, 23 recovered promptly. (The other nine may have had super-added infection - raised temperature and died). (14) (1938 paper)
  2. One patient’s condition was so serious as to warrant induction of therapeutic abortion, which was followed by prompt recovery. (7) (1929 paper).
  3. NVP goes off immediately (within three or four hours) after termination of pregnancy in over 90% of women whose termination took place usually at 9-10 weeks from LMP  (Kumar and Barnie-Adshead - not published). 1980.
  4. In those women whose hyperemesis continues throughout pregnancy, the nausea lifts within a minute or two of the placental circulation closing down. (Professor R. Taylor Personal Communication).
  5. Patient’s statements about cessation of pregnancy sickness.
    “Symptoms generally disappear as soon as the baby is born or even before I went into labour and ate two cooked meals straight away. After the birth I could eat anything”.
    ‘Beyond Morning Sickness’ by Liz Frazer.
    Mother and Baby Journal October 2005, Page 42. 11/10/2005.
  6. Post termination some women expressed a lingering depression and anxiety, although nausea was usually reported to disappear quickly. One woman stated that her symptoms of NVP were completely resolved upon wakening after her termination. (145)

 

9f.   THE IMPORTANCE OF HYPEREMESIS GRAVIDARUM IN EARLY PREGNANCY INCIDENCE AND COST

 

  1. The hospitalisation ratios for leading obstetric and non-obstetric causes of hospitalisation listed as primary diagnoses. Although pre-term labour was listed most frequently (35%) as the principle diagnosis with a ration of 4.6 hospitalisations per 100 deliveries, most admissions were not directly labour related diagnoses. Other specific conditions with ratio > 1.0 hospitalisations/100 deliveries were genito-urinary tract infections 1.2, vomiting 1.1. All other conditions have a ratio of
  2. Hyperemesis gravidarum is the most common indication for hospital admission during the first part of pregnancy and is second only to pre-term labour as the most common reason for hospitalisation during pregnancy. (124)
  3. Women who have a live birth, 45,166 in study population, were primarily hospitalised for pre-term labour 24%, hyperemesis gravidarum 9.3%, hypertension 9.1%, kidney disorders 6% and prolonged premature rupture of membranes 6%. (128)
  4. Overall 26.8 ± 1.6% of women, 1825 women in study population, were hospitalised antenatally. Of the estimated 702 antenatal hospitalisations 44.0% were related to pre-term labour, 10.3% to pre-eclampsia, 5.5% to hyperemesis and 4.7% to urinary tract or kidney infections. (129)
    From conception - 19 weeks gestation, 30.2% of admissions were due to hyperemesis, the highest figure for any condition.
  5. Annually in the United States, more than 50,000 women are hospitalised with the diagnosis of hyperemesis gravidarum. (106)
  6. Finished admission episodes for a primary diagnosis of excessive vomiting in pregnancy (ICD-9 643, ICD-10 021) NHS hospitals in England 1989/90 - 2003/04. This is based on ICD-9 code 643 for the years 1989/90 to 1994/95 and ICD-10 code 021 for the years 1995/96 - 2003/04.

 

YEAR

FINISHED ADMISSION

EPISIODE

YEAR

FINISHED ADMISSION

EPISODE

 
 

1989/90

8,637

1997/98

16,369

 

1990/91

9,607

1998/99

17,618

 

1991/92

11,959

1999/00

17,453

 

1992/93

12,543

2000/01

19,244

 

1993/94

13,421

2001/02

19,156

 

1994/95

14,067

2002/03

20,299

 

1995/96

14,991

2003/04

22,181

 

1996/97

14,722

 

 

 

 

Source Hospital Episode Statistics (H.E.S).            Department of Health 22 Feb 2005.

Personal Communication.                                    London SE1 6LH

 

 

The increase in finished hospital admission episodes for excessive vomiting of pregnancy in England increased by 2 ½ times between 1989/90 and 2003/04.

 

An approximate estimate of the cost of Hyperemesis Gravidarum to the National Health Service in England for the year 2003/04 may be 22,181 finished hospital episodes multiplied by the estimated cost of each admission at £470 per day, multiplied by the average length of stay in hospital per patient at 3.5 days (item 9c of this review) = £ 36,481,745. This figure does not take account of the financial implication of time lost from paid employment for approximately 30% of working women (item 41 of this review) due to severe nausea and vomiting of pregnancy, or the cost of consultations with Midwives and General Practitioners before admission.

 

7.   Finished Admission Episodes of Excessive Vomiting in Pregnancy NHS Hospitals in England. Code ICD-10-021.

 

Financial Years 2004/05 - 2005/06

 

2004 - 2005            23,738

2005 - 2006            25,685

 

“Copyright ã 2007, Reused with the permission of the Information Centre. All rights reserved”.

There has been an almost three-fold increase in hospital admission for excessive vomiting in pregnancy in England in the years from 1989/90 until 2005/06. The authors of this review consider the principal cause of this increase to be the lack of early treatment of NVP in England during those years.  Similar comments by eight authors (R142a).

 

            Finished admission Episodes of Excessive Vomiting in Pregnancy NHS Hospitals in            

            England.  Code ICD-10-201.

 

Financial Year 2006-2007

 

2006-2007            25,420

 

“Copyright ã 2008. Reused with the permission of the Health and Social Care Information Centre.  All rights reserved.”

 

8.   Charges for inpatient management of HG total more than 18 million dollars per year in California alone. California performed 13% of all live births in the U.S.A. in 1999. Thus nationally we can estimate that approximately 200,000,000 dollars is charged annually for inpatient treatment of hyperemesis gravidarum. (149)

9.    From the perspective of society the total cost per woman week was $132, $335, $653 per woman with mild, moderate or severe NVP respectively. $ = Canadian Dollars
The majority of cost items (see table 3 of article) showed an increase with increasing severity of  NVP. (153)

 

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