Treatment of nausea and vomiting during pregnancy - with special focus on attitudes to and use of pharmacological treatment
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Background: Nausea and vomiting during pregnancy (NVP) is one of the most commonly experienced pregnancy complaints and has been associated with decreased quality of life and occupational and daily life functioning, as well as negative socioeconomic consequences. Though several treatment guidelines exist for NVP, including recommendations for medicines that are safe to use during pregnancy, we know little about how this condition is managed, both internationally and nationally in Norway. We also know little about attitudes to treatment of this complaint. Ginger is included in most guidelines. However, only one study exists that was designed to investigate the safety of its use during pregnancy. Objectives: The main aim of this doctorial work was to explore various aspects of treatment of NVP. The specific objectives were: 1) to investigate whether exposure to ginger, a common NVP herbal drug, was associated with an increased risk of congenital malformations or other selected negative pregnancy outcomes; 2) to explore patterns of and factors related to NVP and its treatment across countries in Europe, North America, and Australia; 3) to explore thoughts and attitudes among Norwegian pregnant women and GPs about the treatment of NVP, and to identify potential barriers to optimal care for women with NVP; 4) to investigate the treatments used for NVP according to NVP severity among women in Norway, and to assess whether maternal characteristics and attitudes were related to the use of pharmacological treatment of NVP. Methods: In order to address the above objectives, several methods and data sources were used. 1) The large population-based Norwegian Mother and Child Cohort study, which provides information on the use of ginger and several potential confounders, was linked to the Medical Birth Registry of Norway from which information on pregnancy outcomes was retrieved (Paper I). 2) The Multinational Medication Use in Pregnancy Study, a web-based cross-sectional study carried out among women and new mothers in 18 countries (Paper II). 3) Focus group discussions were used to explore thoughts about and attitudes to the treatment of NVP among pregnant women and general practitioners (Paper III). 4) A web-based cross-sectional study was conducted among pregnant women and new mothers in Norway with NVP (Paper IV). Results: The study in Paper I showed that the use of ginger during pregnancy was neither associated with any increased risk of congenital malformations nor with any increased risk of stillbirth/perinatal death, preterm birth, low birth weight, or low Apgar score. In the study in Paper II, nausea during pregnancy was reported by 73.5% of women, 17.9% of whom used conventional medicines and 8.3% herbal medicines. The prevalence of self-reported nausea and its treatment varied across countries. Education, working status and folic acid use were significantly associated with the use of conventional medicines against nausea. Respondents who suffered from nausea also had a high burden of comorbidity. In the focus group study in Paper III, the GPs thought it was important to normalise NVP symptoms. However, the women felt that their distress due to NVP was trivialised by the GPs. The women were sceptical about using medicines while pregnant, and avoidance was sought despite being ill. The GPs, who appeared to be uncertain and rather restrictive with respect to medical treatment of NVP, seemed to regard sick leave as an important part of the treatment regime. The women had good experience of graded sick leave. The Norwegian study described in Paper IV showed that, of the 712 women who were included in the study, 8.7%, 61.7% and 29.5% had mild, moderate and severe NVP, respectively. A total of 38.9% women had used one or more antiemetics, of which meclizine was the most commonly used, closely followed by metoclopramide. Different drug utilisation patterns were found between the groups of women with mild, moderate and severe NVP, and many women with moderate and severe NVP had not used medicines for NVP (70.2% and 32.9%, respectively). Sick leave was prescribed without initiating medical treatment in the case of 62.1% of the women who had been on sick leave. The women’s beliefs about medicines had an important impact on their use of medicines for NVP. Conclusion and implications: The findings of this doctorial work show that there are potential areas for improvement with respect to the management of NVP. The findings indicate 1) a need to increase awareness among healthcare personnel of the great distress women suffering from NVP may experience, and 2) that it is necessary to educate them about the recommendations in guidelines for the treatment of NVP. Due to the pregnant women’s fear of teratogenic effects of medicines, balanced evidence-based information about the maternal and foetal risks of medicines for NVP and tailored risk communication are necessary in order to reassure pregnant women in need of NVP medication.
Består avPaper I: Heitmann K, Nordeng H, Holst L (2013) Safety of ginger use in pregnancy: results from a large population-based cohort study. European Journal of Clinical Pharmacology 69 (2): 269-277. This article is not available in BORA. The published version is available at: 10.1007/s00228-012-1331-5
Paper II: Heitmann K, Holst L, Lupattelli A, Maltepe C, Nordeng H (2015) Treatment of nausea in pregnancy: a cross-sectional multinational web-based study of pregnant women and new mothers. BMC pregnancy and childbirth 15 (1):321. The article is available in BORA at: http://hdl.handle.net/1956/12085
Paper III: Heitmann K, Svendsen HC, Sporsheim IH, Holst L (2016) Nausea in pregnancy: attitudes among pregnant women and general practitioners on treatment and pregnancy care. Scandinavian Journal of Primary Health Care 34 (1): 13-20. The article is available in BORA at: http://hdl.handle.net/1956/12211
Paper IV: Heitmann K, Solheimsnes A, Havnen GC, Nordeng H, Holst L (2016) Treatment of Nausea and vomiting during pregnancy – a cross-sectional study of 712 Norwegian women. European Journal of Clinical Pharmacology 72 (5): 593-604. This article is not available in BORA. The published version is available at: 10.1007/s00228-016-2012-6