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Implications for health care providers :psychological aspects of hyperemesis gravidarumAlicia Rae WestonThe University of Toledo

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Implications for health care providers: Psychological aspects of hyperemesis gravidarum

Alicia Rae Weston

The University of Toledo

2012

ii

Acknowledgements

I would like to acknowledge Dr. Susan Batten for her guidance, support, and enthusiasm

throughout this project. I would also like to thank my husband John for his constant love and

encouragement, as well as my family for their support throughout this project and this

challenging year.

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Table of Contents

Introduction ......................................................................................................................................1

Review of Literature ........................................................................................................................6

Methods..........................................................................................................................................14

Discussion ......................................................................................................................................15

Clinical Recommendations ............................................................................................................18

1

Introduction

Up to 80% of all pregnant women are affected by nausea and vomiting of pregnancy

(Gadsby, Barnie-Adshead, & Jagger, 1993). Although the symptoms of nausea and vomiting of

pregnancy (NVP) are not limited to morning hours and often occur throughout the day, NVP is

commonly referred to as “morning sickness”. The condition tends to peak around week nine of

gestation, and usually resolves by week 20. In general, NVP is mild and self-limited, but clinical

manifestations of the condition vary and many women experience symptoms throughout their

pregnancy (Gadsby et al., 1993; Ismail & Kenny, 2007; Jueckstock, Kaestner, & Mylonas, 2010;

Verberg, Gillott, Al-Fardan, & Grudzinskas, 2005). The most severe form of NVP is

hyperemesis gravidarum, a disabling condition that affects approximately 0.3 – 2.0% of all

pregnancies (Bailit, 2005; Dodds, Fell, Joseph, Allen, & Butler, 2006).

Hyperemesis gravidarum (HG) is defined differently throughout literature. Widely

accepted characteristics of HG include intractable nausea and vomiting during pregnancy,

dehydration, nutritional and electrolyte disturbances, and weight loss of greater than 5%

(Fairweather, 1968; Matthews, Dowswell, Haas, Doyle, & O'Mathuna, 2010). Operational

definitions of HG often distinguish it from NVP by the need for hospitalization and IV fluid

resuscitation (Christodoulou-Smith et al., 2011; D'Orazio, Meyerowitz, Korst, Romero, &

Goodwin, 2011; McCormack, Scott-Heyes, & McCusker, 2011; Poursharif et al., 2008). The

ICD-10 indicates that symptoms of HG must start before the 22nd week of gestation and divides

the diagnosis into two categories, mild HG and HG with metabolic disturbances (ICD-10).

Severity of symptoms can be assessed using a validated pregnancy-unique quantification of

emesis and nausea (PUQE) score that considers the number of hours and number of episodes for

nausea, emesis and retching per day (Koren et al., 2005).

2

Although the general incidence of HG is 0.3 – 2%, ethnic variation is reported (Bailit,

2005; Zhang et al., 2011). A Norwegian study that included over 900,000 births reported an

overall HG prevalence of 0.89%, but indicated significantly higher prevalence among women

born in Pakistan (2.1%), Africa excluding North Africa (3.1%), and India and Sri Lanka (3.2%)

(Vikanes, Grjibovski, Vangen, & Magnus, 2008). Similarly, a retrospective study in California

reported that non-white, non-Hispanic women were more likely to suffer from HG (Bailit, 2005).

Other populations with increased risk include younger women and those with a personal history

of hyperemesis or whose mother or sisters experienced hyperemesis (Bailit, 2005; Vikanes et al.,

2010; Zhang et al., 2011). Women carrying female fetuses, multiple gestations, and molar

pregnancies, as well as women with pre-existing diabetes mellitus, hyperthyroid disorders,

gastrointestinal disorders, asthma, and psychological illness are at increased risk (Fell, Dodds,

Joseph, Allen, & Butler, 2006). Smoking and maternal age over 30 are associated with reduced

risk for HG- (Fell et al., 2006; Kallen, Lundberg, & Aberg, 2003).

Hyperemesis is second only to preterm labor in the leading causes for hospitalization

during pregnancy (Gazmararian et al., 2002). In addition to metabolic and nutritional

disturbances caused by HG, complications can include Mallory-Weiss tears, pneumothorax,

splenic avulsion, and acute renal failure (American College of Obstetrics and Gynecology

[ACOG], 2004; Bottomley & Bourne, 2009). Wernicke’s encephalopathy due to thiamine

deficiency and osmotic demyelination are rare complications of HG (Ismail & Kenny, 2007).

Regarding birth outcomes, a 2011 systematic review reported increased rates of low birth weight

(LBW), small for gestational age (SGA) infants, and pre-term labor among patients with HG, but

found no association with fetal anomalies, perinatal death, or low Apgar scores (Veenendaal, van

Abeelen, Painter, van der Post, & Roseboom, 2011). Weight gain less than 7 kg has been

3

determined as an independent risk factor for LBW, cesarean section, and pre-term labor (Dodds

et al., 2006). Long-term effects specific to HG remain largely unknown. One study reported an

increased risk of testicular cancer in male fetuses of HG affected pregnancies (Veenendaal et al.,

2011).

Treatment of hyperemesis begins with non-pharmacological interventions such as diet

and lifestyle modifications, ginger, and acupressure (Jueckstock et al., 2010). First-line

pharmacologic treatment includes vitamin B6 and doxylamine (ACOG, 2004). Other antiemetics

such as metoclopramide, dimenhydrinate, promethazine, prochlorperazine, chlorpromazine, and

odansentron are also used (ACOG, 2004; Sonkusare, 2011). Studies are conflicting on the

efficacy of these drugs (Goodwin et al., 2008). Severe vomiting is treated with intravenous

hydration, and thiamine is administered intravenously to prevent Wernicke’s encephalopathy

(Lee & Saha, 2011). Corticosteroids are considered only in severe and refractory cases of HG

(ACOG, 2004). If IV fluids are insufficient, nasogastric tubes, percutaneous endoscopic

gastronomy tubes, or jejunostomy tubes may be used for enteral feeding. Parenteral nutrition is a

last resort in the treatment of refractory HG, and is administered via a peripheral venous or

central venous catheter. Total parenteral nutrition is associated with increased maternal

morbidity including venous thromboembolism, endocarditis, and infection (Jueckstock et al.,

2010; Lee & Saha, 2011).

The etiology of HG remains a mystery. There are numerous proposed mechanisms

including hCG, estrogen and progesterone, the bacteria H. pylori, pregnancy-associated

thyrotoxicosis, as well as ACTH, serotonin, growth hormone, leptin, and prolactin (Bailit, 2005;

Golberg, Szilagyi, & Graves, 2007; Verberg et al., 2005; Zhang et al., 2011). Although endocrine

4

hypotheses behind HG are generally favored in the literature, multifactorial etiology of the

condition cannot be excluded (Verberg et al., 2005).

Another proposed etiology for HG considers hyperemesis as a psychosomatic illness. The

initial suggestion that hyperemesis gravidarum is a manifestation of neurosis came from

Kaltenbach in 1891 (Fairweather, 1968). The lack of a discrete biological cause for HG

combined with the increasing popularity of psychodynamic theory in the early 20th century likely

contributed to the persistence of psychogenesis as a prominent theory for HG. Though a

psychosomatic etiology for HG is not objectively determined in literature, the theory remains a

controversial topic, and dealing with the psychological aspects of HG continues to be a key issue

in patient care (Munch, 2000b, 2002; Munch & Schmitz, 2006; Power, Thomson, & Waterman,

2010).

Psychoanalytic theorists describe pregnancy as a time of crisis for the expectant mother,

whose self-perception and social role are changed by the impending birth of her baby. Pregnancy

is described as a time when a woman’s relationship with her own mother is analyzed;

psychogenic theories of HG emphasize that the health of a woman’s relationship with her mother

is revealed in the woman’s reaction to pregnancy. Vomiting is considered a psychosomatic

symptom and vomiting during pregnancy may represent psychological turmoil within the

expectant mother. In this way, the psychoanalytic theorists postulate that HG is a type of

conversion disorder. (Buckwalter & Simpson, 2002; el-Mallakh, Liebowitz, & Hale, 1990).

Historical research regarding the psychology of HG has consisted primarily of qualitative

patient interviews. Even within these qualitative studies, the results were mixed. Harvey and

Sherfey (1954) identified through patient interviews that women with HG suffered from a

pervasive immaturity, and also linked the disorder with sexual aversion and high maternal

5

attachment. Guze and Majerus (1960) reported no significant difference in patients with HG

versus control patients.

Fairweather (1968) used objective measurements including Minnesota Multiphasic

Personality Index (MMPI) and Cornell Medical Index (CMI) to investigate psychological

associations in HG. He concluded that between 75 and 80 percent of hyperemesis could be

contributed to psychiatric factors. However, while he reported an association between hysterical

personalities and HG using the MMPI, there were no significant differences in the CMI scores

between HG and control groups (Fairweather, 1968).

Objective demonstration of the relationship between HG and psychopathology has not

been accomplished thus far. Methodological problems of the aforementioned studies include

qualitative designs, small sample sizes, and a historically male gender bias in medicine. Recent

literature emphasizes a biological cause for HG over a psychogenic cause, but it also emphasizes

that the psychological aspects of HG cannot be ignored. The distinction between psychological

source of illness and psychological effect of illness is often blurred in the context of

hyperemesis, and can affect patient care. Patients with hyperemesis are in a fragile psychological

state as well as physical state, and research shows that they are sensitive to providers who might

dismiss their symptoms as psychosomatic (Munch, 2000a, 2000b). In light of historical debate

surrounding HG and psychology, this paper intends to review the current literature regarding

psychology and HG and develop recommendations for improving psychosocial morbidity

amongst women who suffer from this debilitating disorder.

6

Review of Literature

Several studies have been published in the past 15 years investigating the relationship

between psychology and hyperemesis gravidarum. Two prominent veins of research regarding

HG and psychology have emerged. One involves investigating pre-existing psychopathology and

psychopathology concurrent with the symptoms of HG; the other reveals psychopathological

sequelae of the disorder. Both veins contribute to the current consensus regarding HG and

psychology.

A case-controlled retrospective study published by Seng, Schrot, van De Ven, and

Liberzon (2007) reported prior service use for psychological disorders amongst women who

experienced HG during pregnancy and those who did not. Sample size was 11, 224 women

including 208 women with documented HG. Specific psychological conditions investigated

included anxiety, depression, and substance abuse, as well as the prevalence of psychosomatic

disorders such as chronic fatigue, irritable bowel syndrome, and pelvic pain/dysmenorrhea. All

analyzed service use occurred prior to pregnancy. When analyzed individually, only depression

and pelvic pain/dysmenorrhea demonstrated increased prior service use among women with HG.

The authors reported, however, that service use for any of the three psychosomatic disorders

increased risk of an HG-affected pregnancy; likewise, prior service use for any of the three

psychological conditions also conferred an increased risk for HG. Service use in the same

woman for both a somatic and psychological disorder increased the likelihood of HG by four

times. Based on their analysis, the authors concluded that approximately 10- 20% of HG might

be attributable to psychological pathology (Seng, Schrot, van De Ven, & Liberzon, 2007).

In a retrospective study of nearly 1.2 million births in the Netherlands over six years,

Roseboom, Ravelli, van der Post, and Painter (2011) demonstrated that women who experienced

7

HG during pregnancy were significantly more likely to have a pre-existing psychiatric illness.

The study compared demographic information including prior medical diagnoses and pregnancy

outcome data among women with and without HG. Other conditions associated with increased

HG incidence included younger age, primiparity, non-Western origin, low socio-economic

status, pre-existing or pregnancy-induced hypertension, pre-existing or gestational diabetes

mellitus, substance abuse, female fetus, and assisted reproduction (Roseboom, Ravelli, van der

Post, & Painter, 2011).

Vasconcelos et al. (2007) investigated differences in pregnancy risk factors among

women with obsessive-compulsive disorder (OCD) versus the general population. Sample size

for the study was 138; 68 patients with OCD were compared with 70 control patients. The

authors reported that women with pre-existing OCD were more likely to experience HG during

their pregnancy (Vasconcelos et al., 2007).

Simpson et al. (2001) investigated the role of personality and psychological factors in HG

by conducting two studies, one involving women currently experiencing HG and the other

involving postpartum analysis. In the first study, the authors administered the Minnesota

Multiphasic Personality Index - 2 (MMPI-2) and the Symptom Check List-90 Revised (SCL -90-

R) to nine women with HG and ten pregnant women without HG. The authors reported that

women affected by HG scored significantly higher in the hypochondriasis and conversion

hysteria scales of the MMPI-2; significant differences were also seen in the depression,

psychasthenia, and schizophrenia scales of the MMPI-2. For the SCL-90-R, women with HG

scored significantly higher on the somatization, obsessive-compulsive, depression, anxiety, and

psychoticism scales. In the second study, non-pregnant women who experienced HG in their

most recent pregnancy were compared with non-pregnant women who had not experienced HG

8

in their most recent pregnancy. The authors reported that between these groups there were no

significant differences in any scales of the MMPI -2 and SCL-90-R. Simpson et al. concluded

that the differences in MMPI-2 and SCL-90-R scores were likely the result and not the source of

HG symptoms, given that no difference in scores was recorded after resolution of symptoms.

They were careful to add, however, that the possibility of a psychological component to HG

could not be ignored (Simpson et al., 2001).

D’orazio et al. (2011) also investigated personality traits and somatic factors among

women with HG, choosing to compare women with HG to those with NVP. Tests used included

the MMPI-2, the Beck Depression Inventory II (BDI II), and the Health-Related Quality of Life

for Nausea and Vomiting of Pregnancy (NVPQoL). The study measured responses that

corresponded with hypochondriasis, depression, hysteria, paranoia, schizophrenia,

emotionalizing and internalizing dysfunction, antisocial behaviors, ideas of persecutions, and

more. The authors reported no significant differences between the two groups. Sample size of the

study was 39 women, matched for age, marital status, years of education, and race or ethnicity.

The authors determined that it was no more likely for a woman with HG to have a personality

disorder or psychological disorder than a women suffering from common NVP (D'Orazio et al.,

2011).

McCarthy et al. (2011) reported differences between women with HG and those without

HG in anxiety, depression, perceived stress, and pregnancy-related behavior changes. The

authors used the Short Form State-Trait Anxiety Inventory (STAI), the Edinburgh Postnatal

Depression Scale (EPDS), and the Perceived Stress Scale (PSS). Behavioral responses to

pregnancy were measured using a scale that considered self-reported behavior patterns and

activity restrictions. Only nulliparous women were included in the study. The sample size

9

included 164 patients with HG and 3,259 control participants. The patients were tested twice

during pregnancy, which allowed the authors to record scores during and after HG symptoms.

The authors reported that women with HG scored significantly higher in perceived stress,

anxiety, depression, and behavioral limitations due to pregnancy. Improvement in HG symptoms

was associated in the study with improved scores on perceived stress and depression, as well as

decreased behavioral limitations. However, the authors reported that high anxiety scores

persisted among women with HG even five weeks after symptom improvement. McCarthy et al.

concluded that perceived stress, depression, and activity restriction are likely consequences of

HG symptoms, whereas anxiety may be an associated factor in the onset of HG (2011).

Uguz, Gezginc, Kayhan, Cicek, and Kantarci (2012) compared rates of mood, anxiety,

and personality disorders between 52 women with HG to 90 control participants using structured

clinical interviews and criteria of the Diagnostic Statistical Manual of Mental Disorders (DSM).

The DSM-IV was used to determine mood and anxiety disorders, while the DSM-III was used to

determine personality disorders due to the lack of a validated Turkish equivalent for the DSM-IV

tool regarding personality disorders. The authors relied upon patient report to determine the onset

of psychological symptoms. The authors reported that women with HG were more likely to

suffer from any mood or anxiety disorder, and any personality disorder. Specifically, patients

with HG were more likely to suffer from major depressive disorder, generalized anxiety disorder,

obsessive-compulsive personality disorder, and avoidant personality disorder. Of the patients

with HG who reported psychological symptoms, 70.5% reported symptom onset prior to

pregnancy. The authors suggested that a potential connection exists between HG and certain

mood, anxiety, and personality disorders, but did not report a conclusive directionality in the

relationship between HG and these disorders (Uguz, Gezginc, Kayhan, Cicek, & Kantarci, 2012).

10

Pirimoglu et al. (2010) reported significantly higher global severity index (GSI) scores

among 34 women currently experiencing HG versus 34 women experiencing normal pregnancy.

Within the GSI subscales, significant differences existed between the groups in somatization,

obsessive-compulsiveness, depression, and anxiety. The authors commented that the direction of

effect between HG and increased GSI could not be determined from the study. All women were

tested in the first trimester, during active symptoms of HG (Pirimoglu et al., 2010).

The Hospital Anxiety and Depression Scale (HADS) was used by Tan, Vani, Lim, and

Omar (2010) to identify anxiety and depression among 209 women experiencing HG. Of the 209

women, 46.9% fulfilled the HADS criteria for anxiety and 47.8% fulfilled criteria for depression.

If a patient fulfilled criteria for either anxiety or depression, they were 15.8 times more likely to

fulfill criteria for both conditions. The authors reported a significant relationship between paid

employment and increased risk for anxiety, and an inverse relationship between depression and

history of miscarriage. Taking into consideration several markers for clinical severity of HG such

as ketonuria, hematocrit, leukocytosis, hyponatremia, urea, hypokalemia, and creatinine, only

high hematocrit was associated with increased depression caseness; no other relationship

emerged between severity of HG and anxiety or depression caseness. Directionality of the

relationship between HG, anxiety and depression could not be established (Tan, Vani, Lim, &

Omar, 2010).

Şimşek et al. (2012) administered the Beck Depression Scale (BDI) and Beck Anxiety

Inventory (BAI) to pregnant women with and without HG, and reported significantly higher

scores in the HG group for both depression and anxiety. The study included 41 patients with HG

and 45 control patients. Data was collected from the patients with HG at the time of admission to

the hospital; data from control patients was collected in an out-patient setting. The authors

11

reported that it was unclear whether the difference between groups reflected a cause or

consequence of HG (Şimşek et al., 2012).

Investigations specifically designed to report psychological sequelae of HG include

several objective as well as qualitative studies. Christodoulou-Smith et al. (2011) reported a

relationship between HG and post-traumatic stress. The study involved 377 women with HG and

233 controls. Women who previously experienced HG during pregnancy were identified as

having increased stress symptoms of post-traumatic stress disorder (PTSD), and patients who

met criteria for post-traumatic stress syndrome (PTSS) demonstrated increased negative

psychosocial outcomes including occupational, marital, and psychological difficulties

(Christodoulou-Smith et al., 2011). Seng et al. (2001) reported an association between PTSD and

HG in an earlier study investigating 455 women with diagnosed PTSD and 638 controls. Seng et

al. noted that women with PTSD were 3.9 times more likely to suffer from HG during

pregnancy, but did not actually establish in the study whether the diagnosis of PTSD occurred

before or after experiencing HG (2001).

A prospective, case-controlled study by McComack et al. (2011) investigated the impact

of HG on maternal-fetal attachment during pregnancy. Several objective scales were used

including the Maternal Antenatal Attachment Scale (MAAS), Brief Symptom Inventory 18 (BSI-

18), Prenatal Distress Questionnaire (PDQ), Social Functioning Questionnaire (SFQ) and Short

Form Social Support Questionnaire (SSQ6). During symptoms of HG, maternal-fetal attachment

was adversely affected; after symptom resolution, no significant difference in maternal-fetal

attachment was reported between the HG and control groups. Secondarily, the authors reported

increased depression, anxiety, and somatization among women currently experiencing HG

symptoms despite no significant differences between the HG group and controls regarding social

12

support, social functioning, and satisfaction with social support. McCormack et al. (2011)

concluded that the effect of HG on maternal-fetal attachment was minimal and limited to severe

symptoms.

A prior qualitative study by Meighan and Wood (2005) reported stronger adverse effects

of HG on maternal role assumption. In-depth interviews of eight women with HG revealed

themes of social isolation and a delay in maternal role assumption. The women reported

decreased excitement about motherhood due to illness, and described hostile and disbelieving

reactions of co-workers and friends with regard to their symptoms. Meighan and Wood (2005)

reported that the women seemed distracted from usual maternal role assumption because of their

illness, and were less able to prepare for labor and delivery.

A qualitative study by Poursharif et al. (2008) reported that more than 80% of women

who experienced HG during pregnancy report negative psychosocial sequelae. The study

included 808 women with a history of HG. Examples of negative psychosocial sequelae included

socioeconomic problems, marital problems, and changed attitudes toward family and pregnancy.

Specifically, 6.7% of women in the study reported a relationship between HG and psychological

conditions such as anxiety and depression. Elective termination of pregnancy was reported by

15.2% of women (Poursharif et al., 2008).

Munch, Korst, Hernandez, Romero, and Goodwin (2011) reported health-related quality

of life (HRQoL) among 61 pregnant women, comparing 19 women with HG to 48 women with

NVP and 8 asymptomatic women. HRQoL was measured using the Nausea and Vomiting of

Pregnancy Quality of Life Questionnaire (NVPQoL), and the Short Form-36 (SF36). Patients

with HG had significantly lower health-related quality of life compared with the NVP and

control groups. Patient-perceived severity of symptoms was more influential than an actual

13

diagnosis of HG on HRQoL. Other psychosocial factors such as depression measured by the

SCL90, married or partnered status, and age greater than 30 also correlated with low HRQoL

(Munch, Korst, Hernandez, Romero, & Goodwin, 2011).

Power et al. (2010) investigated the psychological impact of HG using qualitative

methodology with patients and health care providers. Interviews with 18 women affected by HG

elicited themes such as the overwhelming burden of HG, as well as the adverse psychological

effect of unbelieving and skeptical attitudes toward HG. Transcriptions from seven focus groups

of healthcare workers in various levels of care-giving were also analyzed, revealing themes of

frustration with HG and HG patients. The study reported assumption of HG as a purely

psychological problem, feelings of mistrust over patient symptoms, invalidation of HG severity,

and frustration with lack of community care for HG as essential contributors to the stigmatization

of HG. Negative psychological implications, as well as adverse effects on general healthcare for

HG patients, were addressed by the study (Power et al., 2010).

Although the past 15 years of research regarding HG and psychology have yielded

studies with a wide variety of designs and emphases, the themes of psychogenesis and

psychosocial impact prevail throughout the reports. The relationship between psychopathology

and hyperemesis continues to be explored through these two themes. (Harvey & Sherfey, 1954;

Majerus, Guze, Delong, & Robins, 1960)

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Methods

A review of the literature was conducted using PubMed, CINAHL, PsycINFO and

Psychology and Behavioral Sciences Collection. Search terms included hyperemesis gravidarum,

psychological, psychology, patient attitudes, providers, patient, nausea and vomiting of

pregnancy, and pernicious vomiting of pregnancy. A manual review of the literature was also

conducted from articles obtained in the initial searches. Articles not available in English were

excluded. Historical articles were reviewed to provide background on hyperemesis, however

only articles published within the last 15 years were included in the review of current literature.

Qualitative and quantitative research studies were included. Studies that did not specify

hyperemesis gravidarum as a separate condition in their investigation were excluded. Articles

published more than 15 years ago were not considered when forming clinical recommendations.

15

Discussion

The recent literature regarding HG reflects conflicting conclusions about the

psychological factors surrounding the condition. The idea of psychopathology as a cause for HG

continues to be controversial. D’Orazio et al. (2011) refuted the association of HG with

disordered personality and psychological conditions, and Simpson et al. (2001) concluded that

differences in personality and psychological symptoms among patients with HG were more

likely the result of HG symptoms and not the source. On the other side of the issue Seng, Schrot,

van De Ven, and Liberzon (2007) reasoned that 10-20% of HG cases could be psychogenic, and

Seng et al. (2001) and Vasconcelos et al. (2007) report increased HG among patients with PTSD

and OCD. Uguz, Gezginc, Kayhan, Cicek, and Kantarci (2012) also reported possible

associations between HG and several mood, anxiety, and personality disorders.

Results from Pirimoglu et al. (2010), Şimşek et al. (2012), and Tan, Vani, Lim, and Omar

(2010) were inconclusive regarding the directionality between psychopathology and HG.

McCarthy et al. (2011) suggested that while anxiety may be associated with onset of HG,

depression, stress and behavior limiatations are more likely effects of HG symptoms. Taking the

above literature into consideration, it appears there is still no clear consensus on the

psychogenesis of HG. However, it also seems apparent that Fairweather’s original claim

attributing 80% of HG cases as psychogenic is not well-supported by current literature

(Fairweather, 1968).

Independent of psychology’s role in the etiology of HG, recent literature does appear to

be in agreement regarding the negative psychological effects of HG. Meighan and Wood (2005),

Christodoulou-Smith et al. (2011), Poursharif et al. (2008), Power et al. (2010) and Munch,

16

Korst, Hernandez, Romero, and Goodwin (2011) all report significant psychological sequelae of

the condition.

Recent HG literature also reveals several more basic issues to consider when approaching

the topic of hyperemesis. First, the operational definitions of HG vary from study to study. In

two of the studies included in this review, HG was defined simply by the record of a diagnosis,

with no other criteria listed (Roseboom et al., 2011; Tan et al., 2010). Several studies required

hospital treatment of symptoms in their operational definition of HG (D'Orazio et al., 2011;

McCormack et al., 2011; Munch et al., 2011; Simpson et al., 2001; Uguz et al., 2012).

Christodoulou-Smith et al. (2011), Munch, Korst, Hernandez, Romero, and Goodwin (2011), and

D’Orazio et al. (2010) specified treatment with intravenous fluids or parenteral nutrition as part

of their definition for HG.

The ICD -9 criteria for HG was cited by Seng, Schrot, van De Ven, and Liberzon (2007),

and McCormack et al. (2011) used the ICD-10 criteria for HG. Dehydration was included in the

criteria for HG by Pirimoglu et al. (2010), Power et al. (2010), and Simsek et al. (2012). Two of

the studies required 5% or more weight loss in their definition of HG (Pirimoglu et al., 2010;

Şimşek et al., 2012). Ketonuria was cited in the definition of HG by Power et al. (2010) and

Pirimoglu et al. (2010). Overall, the current literature demonstrates a lack of standardization for

the operational definition of HG.

Another issue presented by the current HG literature is the wide variety of tools used to

collect and measure data. Poursharif et al. (2008) and Power et al. (2010) used qualitative study

designs to interpret the psychological impact of HG on patients. The remaining studies used

various objective means of analysis as listed in the literature review. Within the objective tools

used, only the MMPI-2 (D'Orazio et al., 2011; Simpson et al., 2001) the BDI (D'Orazio et al.,

17

2011; Şimşek et al., 2012), the NVPQoL (D'Orazio et al., 2011; Munch et al., 2011) and the

SCL-90 (Munch et al., 2011; Simpson et al., 2001) were used in more than one study of HG.

Sample issues persist in recent studies on HG. Sample sizes continue to be small with a

few exceptions (Christodoulou-Smith et al., 2011; McCarthy et al., 2011; Poursharif et al., 2008;

Roseboom et al., 2011; Tan et al., 2010). Samples often also present difficulties in terms of

generalizability, as many are from a local hospital or region. In the literature reviewed, only

Poursharif et al. (2008) and McCarthy et al. (2012) report data from multiple countries. Two

studies were reported from the United Kingdom (McCormack et al., 2011; Power et al., 2010).

Three reported data from Turkey (Pirimoglu et al., 2010; Şimşek et al., 2012; Uguz et al., 2012).

Seven studies report data from the United States (Christodoulou-Smith et al., 2011; D'Orazio et

al., 2011; Meighan & Wood, 2005; Munch et al., 2011; Seng et al., 2001; Seng et al., 2007;

Simpson et al., 2001). Vasconcelos et al. (2007) reported data from Brazil, and Tan et al. (2010)

reported data from Malaysia.

18

Clinical Recommendations

The literature is clear about the negative psychosocial impact HG can have on women

affected by the condition, demonstrating the need for increased psychosocial support of women

with HG (Christodoulou-Smith et al., 2011; Meighan & Wood, 2005; Munch et al., 2011;

Poursharif et al., 2008; Power et al., 2010). Identifying women at increased risk for psychosocial

morbidity – those with lower socioeconomic status, those who have less social support, who are

the sole wage-earner for their family, or who have a history of infertility, abuse, or miscarriage –

is an important first clinical step (Poursharif et al., 2008). Additionally, although the literature

suggests that HG may have psychological origins in only a small percentage of cases, identifying

those cases early is also important in providing optimal care for HG. It would be wise to take a

thorough psychological history in all obstetric patients, including history of abuse, substance

abuse, and any mental health disorders. Consider those conditions which have been associated

with HG, such as PTSD and OCD, in the differential diagnosis for patients with symptoms of

HG (Seng et al., 2001).

During the course of HG, the literature suggests that patients would benefit from

comprehensive and multi-disciplinary care plans with a special emphasis on increasing the

patient’s social support (Kim, Connolly, Cristancho, Zappone, & Weinrieb, 2009; Poursharif et

al., 2008; Soltani & Taylor, 2003). Social work, home health nursing, and psychological

counseling can all be incorporated alongside primary obstetric care to form a multidisciplinary

team (Kim et al., 2009). For patients who do have pre-existing mental health disorders,

psychological interventions and certain pharmacotherapies can be incorporated into this

comprehensive care plan. If the patient has an established therapist, encourage them to seek the

care of that therapist again during pregnancy for increased support (Seng et al., 2007).

19

For all patients regardless of previous psychiatric history, one of the simplest ways to

support your patient is to listen to them and allow the patient to unload some of their burden

(Kim et al., 2009). Screening all HG patients for mood, anxiety and personality disorders is also

reasonable and can help guide care plans (Uguz et al., 2012). Special emphasis should be placed

on identifying symptoms of depression or anxiety throughout the pregnancy, and all HG patients

would benefit from a strategy for anxiety management (McCarthy, et al., 2011).

Due to the possibility that women might feel too sick to organize delivery logistics or

contemplate the transition to motherhood, Meighan and Wood (2005) also suggest offering

additional labor coaching and postpartum follow-up for patients with HG. Multi-disciplinary

efforts should continue for patients with HG well into the postpartum period, when they may

need reassurance regarding the delay that some women with HG experience in maternal-fetal

attachment (Meighan & Wood).

To decrease negative psychosocial effects related to hospital admission and

stigmatization of HG, it is important develop competency in managing HG through an out-

patient setting. Staying abreast of the best out-patient management strategies for HG will help

maintain a sense of normalcy for the patient by avoiding the stress of hospitalization. It will also

decrease the risk of patients being ill-received by hospital staff or stigmatized as psychological

patients. Specifically, Power et al (2010) suggested increasing the use of intravenous fluid

administration in the out-patient setting to decrease hospitalization. As always, however, one

must recognize the limitations of out-patient management and chose admission when justified by

the patient’s condition.

Lastly, the literature suggests that providers should prepare themselves for negative

patient reactions to psychiatry referrals (Kim et al., 2009; Power et al., 2010). Patients may take

20

offense at the suggestion of psychiatric counseling, especially if done insensitively; effort should

be taken to resist labeling patients as borderline or hostile simply based on their reaction. It is

also important to note that while psychological health and counseling options should always be

discussed with patients who have HG, clinical judgment ought to guide the degree of discussion

and the degree of psychiatric intervention suggested.

Although the relationship between psychology and hyperemesis continues to be

somewhat controversial, recent literature clearly supports the fact that hyperemesis carries with it

a heavy psychosocial burden. Clinically, this current understanding of HG can help shape efforts

to increase social and psychological support of patients with HG and improve patient care for

this population.)

21

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Abstract

Objective: Hyperemesis gravidarum (HG) is a condition of severe nausea and vomiting that

affects up to 2% of pregnant women. Though the etiology of HG remains unclear, historic

theories of HG as a psychogenic disorder continue to inform the literature and care of HG. This

review assesses the current literature regarding psychology and HG, and addresses the clinical

implications of that literature for improving patient care. Method: A literature review was

conducted using PubMed, CINAHL, PsycINFO and Psychology and Behavioral Sciences

Collection. Results: Forty-eight articles were referenced in this review. Sixteen studies published

in the past 15 years were included in the Review of Literature. Conclusion: Current literature

continues to reveal conflicting conclusions regarding psychology’s role in HG etiology. The

negative psychological sequelae of HG, however, are well established by current HG literature

and should inform a sensitive, wholistic approach to caring for patients with HG.