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Therapeutic abortions due to severe morning sickness Unacceptable combination

Paolo Mazzota, BSC; Laura Magee, MD; Gideon Koren, MD, FRCPC

June, 1997

ABSTRACT

QUESTION

Some of my pregnant patients suffer from severe morning sickness. I am hesitant to prescribe them an antiemetic due to fetal safety. What is the right approach here?

ANSWER

Considering the negative consequences of HG (hyperemesis gravidarum) including therapeutic abortions, low birth weight and psychiatric morbidity, the treatment of morning sickness or the prevention of HG should be addressed seriously.
Consequently, women with morning sickness unresponsive to non-pharmacological agents should be prescribed an antiemetic drug. In Canada, Diclectin (Doxylamine/Vitamin B6) is the only drug approved by Health Canada for this indication.
It's recommended dosage for nausea or vomiting which occurs during the day is 2 tablets at bedtime, 1 tablet in the morning and one tablet in midafternoon. If the symptoms emerge only in the morning, 2 tablets at bedtime should be sufficient.

Paolo Mazzotta, Laura Magee, Gideon Koren


Morning sickness afflicts as many as fifty percent of pregnant women, commonly during the first trimester.1 While in their mild forms the nausea and vomiting (NVP) adversely affect the quality of life of the pregnant woman and her family, severe cases (hyperemesis gravidarum) can lead to dehydration and electrolyte imbalance which often necessitate hospitalization and may be life threatening if not treated promptly.2 Hyperemesis gravidarum has been associated with increased risk of fetal loss and smaller birth weight.2

During the last few years we have become aware of sporadic cases of women reported to have terminated otherwise wanted pregnancies due to severe forms of morning sickness. The objectives of the present study were to establish whether severe forms of morning sickness are indeed a cause for therapeutic abortion and to characterize this pattern of events.

After approval by our hospital's Research Ethics Board we advertised in newspapers, women's and family magazines and the electronic media in Canada and the US, an invitation for women to report their range of experiences with morning sickness. A structured questionnaire was used to cover various clinical aspects of the nausea and vomiting in pregnancy, therapies used, impact on the family and quality of life. Cases of therapeutic abortions were matched by gravity to women who considered termination but eventually continued the pregnancy, as well as to the next caller. The three groups were compared in several characteristics by non parametric methods.

Case 1:
A 30 year old G3 married university student suffered from severe NVP during this planned pregnancy. Nausea occurred every 30 min. and she vomited on average 15 times a day. Her physician did not recommend any medication to her as he/she believed none of the antiemetics were safe. She lost 12 kg of body weight and lost her consciousness 3 times. She required hospitalization on 3 occasions during the first 3 months of her pregnancy. She lost 4 months of University studies and her husband needed to take time off his work to care for their child. Eventually she decided to terminate the pregnancy despite wanting very much to have another child.

Case 2:
A 34 year old married G3 court clerk had 3 abortions due to NVP inducing a seizure disorder. Typically she would lose 5-7 kg during the first 3 months of her pregnancy. She was on diclectin (Doxylamine and Vitamin B6) and Stemetil (Prochlorperazine) but neither had any effect. She lost 1 month of work and her seizure disorder was poorly controlled due to her vomiting which occurred 20-30 times a day. Abortion occurred in all cases due to her poor physical and neurological condition.

In a 2 month period, 1100 women were interviewed by us as to their experience related to morning sickness. Of those, 17 reported to have terminated an otherwise wanted pregnancy due to severe forms of morning sickness. In none of these cases were other causes for termination of pregnancy identified (socioeconomic or medical) except for one case (Case 2) where the hyperemesis worsened a medical problem. In none of these was the pregnancy terminated due to life threatening complications of NVP. An additional 42 women reported to have considered termination of pregnancy as a means of discontinuing their severe symptoms.

Women with hyperemesis gravidarum (HG) who eventually terminated pregnancy had a mean of 9.3 6.5 episodes of vomiting per day, lost on average 5.9 3.8 kg of body weight and 20 21 days of work. The women with HG who considered termination but eventually continued with their pregnancies had a significantly larger weight loss than either those who terminated or the control group. Their children were of significantly smaller birth weight than the controls (2942 592 vs 3737 337 g, P=0.0025), (Table 1).

Table 1: Characteristics of women with severe NVP who terminated their pregnancy, intended to terminate or did not.

Women who had TA Women who intended but did not terminate Controls (next caller)
Length of NVP (months)
till abortion
5.22.2 (3-8)
5.22 (2-8)
No. of vomiting/day
9.36.5 (3-25)
7.34 (1-15)
6.74 (1-24)
Use of antiemetics
60%
40%
40%
Hospitalization
35%
55%
40%
Loss of weight (kg) during pregnancy **5.93.8 (1-18) **8.32.2*** (2-25) 5.4***4.9 (1-12)
Loss of work (days)
2021 (0-90)
6474 (0-225)
5052 (0-180)
Quit work (no.)
1
1
2
Birth weight (g)
-
2942592*
(2072-3864)
*3737337
(3158-4327
All data: mean SD P (range).
NVP: Nausea and vomiting of pregnancy.
* P=0.0025; ** P=0.02; *** P=0.05



Only 4 of the women who terminated the pregnancy (23%) reported day to day support by their spouses/ partners in carrying out home and family chores during the HG, compared to 60% among those who eventually did not terminate (p < 0.05). Of those who terminated and were offered antiemetics, dimenhydrinate (Gravol) was the most widely used (n=9); despite being used as recommended by the package, it had a partial effect in only 2 cases and stemetil in 1 case. Diclectin (Doxylamine and Vitamin B6) was used in 2 cases, and in only one of them in a potentially effective dose. All women with severe manifestations of HG reported unique and quite homogeneous psychological symptomatology (Table 2), including symptoms of depression, isolation, hopelessness and fear. Commonly, women felt that the NVP was not taken seriously enough by their spouses and physicians alike.

Table 2: Characteristic Behavioral Symptomatology In Women who Terminated or Considered Termination of Pregnancy due to Hyperemesis Gravidarum.

-Depression
-Lack of energy and initiative
-Anhedonia
-Isolation
-Feelings of being neglected by husband/boyfriend
-Feelings that NVP is not taken seriously by treating physicians
-Physicians and family members believing the NVP is due to rejection of the baby
-Frustrations
-Adverse effects on family's relationships - breakups
-Hopelessness
-Fears of severe morbidity and death


Reported Long-Term Effect of the Hyperemesis:
Decision not to have another child
Family breakage due to the strained relationship during pregnancy


Severe forms of nausea and vomiting of pregnancy have been associated with a variety of maternal and fetal risks.2 Hyperemesis gravidarum is defined as vomiting that occurs for the first time before the 20th week of gestation and is of sufficient severity to cause weight loss, fluid electrolyte and acid-base imbalances.3 While maternal mortality is extremely rare in developed countries, morbidity secondary to severe dehydration does occur.2 The risk of prematurity, smaller birth weight and CNS malformations is higher than in unaffected pregnancies.2 Therapeutic abortions due to substantial maternal morbidity and suffering have rarely been reported4 thus creating a false impression that this is not a likely consequence of hyperemesis gravidarum.
Older literature has suggested that hyperemesis gravidarum may reflect a conscious or subconscious rejection of the pregnancy.5 This view is not supported by evidence, and is utterly rejected by our present study showing women ready to endure immense suffering before giving up a wanted pregnancy. Our study confirms previous reports of lower birth weight in newborns of women suffering from hyperemesis gravidarum.2 Our controlled comparison confirms that women who consider termination of an otherwise wanted pregnancy experienced worse symptomatology than their matched controls; despite similar numbers of vomiting per day, they have lost significantly more weight and have had children of significantly lower birth weight.

Our study depicts a grim picture of the medical management of this condition. Many women were not offered antiemetics due to ignorance of medical staff believing that common antiemetics are teratogenic, or due to their own fears of such effect. Today there is in Canada a safe medication, Diclectin, approved by Health Canada and indicated in the CPS for morning sickness. Our study suggests that women who terminate their pregnancy differ from those who eventually continue pregnancy to term by having less support from their husbands or partners and tending to use less hospital services. These trends are of apparent importance when one considers the severe behavioral morbidity encountered in these women (Table 2). Our data concur with previous studies showing depressed symptomatology of depression isolation and a sense of helplessness.6 In 1972 Farkas and Farkas stated their belief that "hyperemesis gravidarum represents a protest reaction against pregnancy, as a result of psychical conflicts, especially from family and home environment".7 This view is utterly rejected by the evidence collected in the present study. Beyond being unfounded scientifically, this view represents an appalling assault on women's behavior during one of the worst periods of their lives. Several women reported in our study that either their physicians or husbands/ partners implied directly or indirectly that their hyperemesis is a controlled behavior reflecting rejection of the pregnancy. This indicates that the theory advanced by Farkas is still widely thought to appropriately describe this condition. The unique behavioral syndrome associated with NVP may either be secondary to the physical condition, or alternatively may be a primary response to hormonal changes.2 Clearly, management of the NVP and correction of the fluid and electrolyte imbalances must be accompanied by addressing the psychiatric morbidity if one wishes to prevent unnecessary therapeutic abortions.

References

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  • Soules MR, Hughes CL, Garcia JA, et al: Nausea and vomiting of pregnancy: Role of human chorionic gonadotropin and 17-hydroxyprogesterone. Obstet Gynecol 1980; 55: 696-700.
  • Hod M, Orvieti R, Kaplan B, Friedman S, Ovadia J: Hyperemesis gravidarum; A review. J Reprod Med 1994; 39: 605-612.
  • Fairweather DVI: Nausea and vomiting in pregnancy. Am J Obstet Gynecol 1968; 102: 135-
  • Chatwani A, Schwartz R: A Severe Case of Hyperemesis Gravidarum. Am J Obstet Gynecol 1982 Aug 15; 143 (8): 964-5.
  • Klein HR, Potter H, Dyke RB: Anxiety in pregnancy and childbirth. New York, Paul B. Hoeber 1950.
  • Iatrakis GM, Sakellaropoulos GG, Kourkoubas AH, et al: Vomiting and nausea in the first 12 weeks of pregnancy. Psychother Psychosom 1988; 49: 22-24.
  • Farkas G, Farkas G Jr: The psychologic etiology of the hyperemesis gravidarum. In Psychosomatic Medicine in Obstetrics and Gynecology. Edited by N Morris, Basel S Karger, 1972, pp. 175-177.
  • Neutel CI, Johansen HL: Measuring drug effectiveness by default: The case of bendectin. Can J Publ Health 1995; 86: 66-70.
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