The largest study on pregnant women with excessive nausea and vomiting (hyperemesis gravidarum) has identified increased risks of numerous neuropsychiatric and mental health outcomes.
Researchers from King’s College London and South London and Maudsley NHS Foundation Trust conducted a study involving 476,857 pregnant women diagnosed with hyperemesis gravidarum (HG) from 135 healthcare providers worldwide. The study is the first to explore an array of neuropsychiatric and mental health outcomes for women with HG.
They performed a retrospective cohort study using the TriNetX Global Collaborative Network, a network collecting anonymised electronic healthcare record data from 18 different countries.
Hyperemesis gravidarum (HG) affects up to 3.6% of all pregnancies. HG is the most common cause of hospitalisation in the first trimester of pregnancy, and the majority of HG cases (but not all) resolve from the second trimester. Women with HG experience prolonged and severe nausea and vomiting, leading to dehydration and weight loss. Women may feel anxious about leaving home, isolated, and unsure that they will be able to cope with the rest of the pregnancy. Individuals with HG have reported various mental health challenges such as anxiety and depression, with over half of women considering termination of pregnancy.
Maternal risk factors for HG vary greatly from biological (thyroid and parathyroid disease, Type 1 diabetes, or histories of past pregnancies) to socioeconomic deprivation and ethnicity. In addition, a study published last year identified that sensitivity to a hormone called GDF-15 may be a driver for the disorder.
In this study, researchers looked at 24 neuropsychiatric and mental health related outcomes reported within a year of diagnosis. They found over 50% increased risk in 13 conditions, including post-partum psychosis and post-traumatic stress disorder. The risks were doubled for Wernicke’s encephalopathy (neurological condition due to vitamin B1 deficiency) refeeding syndrome (complications arising when food is introduced too quickly to someone who has been malnourished), eating disorders, and depression, particularly post-partum depression, which was 2.7 times more likely.
Many pregnant women experience nausea and vomiting but for women with HG this occurs at a level which is far from “normal” and as such it can be profoundly debilitating. Whilst we already knew from previous research that women with HG are at an increased risk of anxiety, depression and PTSD, our study not only confirmed these findings, but also demonstrated an increased risk of severe mental health conditions, including psychosis and eating disorders, as well as increased risk of Wernicke’s encephalopathy, a serious neuropsychiatric disorder where a deficiency of the vitamin thiamine leads to problems with memory and coordination. Many of these conditions would warrant urgent referral to specialist services for urgent assessment and treatment to ensure safety of mother and child.”
Dr. Hamilton Morrin, Doctoral Fellow at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London
In the ICD-11, the latest International Classification of Diseases by the World Health Organisation, HG is subcategorised into “mild HG” and “HG with metabolic disturbance”. The latter is characterised by carbohydrate depletion, dehydration, or electrolyte imbalance. The researchers also looked at whether this categorisation is correlated with mental health outcomes. Importantly, cases of HG with metabolic disturbance (perceived as more severe) showed significantly reduced risk of depression compared to mild HG. This finding highlights the importance of adequate mental health screening and support for all women with HG, regardless of perceived severity.
“What we found is that the internationally recognised categorisation of HG based on metabolic disturbance works well to identify individuals who require treatment for their physical health but may not always be suitable for identifying those at need of mental health support. The severity of HG does not directly correlate with the degree of impact on mental health, and as clinicians, we have a responsibility to ensure these women receive adequate integrated care across both physical and mental health.”, said Dr Hamilton Morrin.
Dr Thomas Pollak, Clinical Reader and Consultant Neuropsychiatrist at King’s College London and the senior author of the study added “Until recently, there has been something of a disconnect between how the medical community has regarded the mental health impact of HG and how women themselves describe their experience. Our findings show that this gap is not only real but can be very serious. HG can be associated with severe psychiatric disorders that require urgent recognition and joined-up physical and mental healthcare from the very start of pregnancy.”
Neuropsychiatric and mental health outcomes in hyperemesis gravidarum: A retrospective cohort study was published in The Lancet Obstetrics, Gynaecology, & Women’s Health.
The study is funded by the National Institute for Health Research (NIHR).