Journal of Obstetrics and Gynaecology, 2015; Early Online: 1–4 © 2015 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2015.1004529
ORIGINAL ARTICLE
Is there relationship between social support, psychological distress, mood disorders and emesis gravidarum? G. Balık, Y.B. Tekin & M. Kağıtcı
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/24/15 For personal use only.
Department of Obstetrics and Gynecology, Recep Tayyip Erdogan University Medicine School, Rize, Turkey
Objective: Emesis Gravidarum (EG) is common medical condition in pregnancy with significant negatively effects on daily social life, physical and psychological health. In this study, relationship of social support, psychological distress and mood disorders on EG were investigated. Methods: The pregnant women with mild EG were accepted as control group and moderate and severe EG were accepted as patient group. All patients completed sociodemographic data collection form, Pregnancy-Unique Quantification of Emesis and Nausea scale (PUQE-24), Symptom Check List questionnaire (SCL-90 R), Spielberger state-trait anxiety inventory (STAI), Beck depression inventory (BDI) and Multidimensional Scale of Perceived Social Support (MSPSS). STAI, BDI, MSPSS and GSI (global symptom index) scores of the patients and control groups were compared. Results: Statistically significant differences were found between the patients and control group on STAI score, BDI score and GSI scores. No statistically significant were found between the patients and control group on MSPSS score. Conclusion: Social support does not prevent patients from EG. But, there is a clear relationship between EG and psychological distress. Thus, psychiatric evaluation should be done in patients with EG. Obstetricians should encourage their patients to have psychiatric support. Further studies on relationship of psychosocial factors and EG are needed. Keywords: Anxiety, emesis gravidarum, pregnancy, psychosocial aspects, psychiatric support, social support
psychoanalytic literature describes vomiting as a psychosomatic symptom and considered as a hysterical defence against unconscious wishes (Katon et al. 1980). The psychosocial factors which thought to be play role in the aetiology of EG are stress, lack of support from family and friends, adoption, general feeling of unhappiness and negative experiences of the past pregnancies. Pregnancy prevents depression and other psychological disorders of pregnant women. The most common mood disorders of the women are anxiety and major depression in pregnant women. The prevalence of major depression is 10–15% in pregnant women (Llewellyn et al. 1977). The best determinant risk factor for depression in pregnancy is the history of mood disorders before pregnancy. Adolescent pregnancy, the number of children, undesired pregnancy, family history and social support deficiency increase depression risk (Uguz et al. 2012). Pregnancy usually hides the symptoms of anxiety, so the real prevalence cannot be determined. Pregnancy is an important period of women’s life. The adaption of motherhood could be traumatic for a lot of women. Family, friends or relatives can help the women for the adaptation of motherhood. The deficiency of social support may negatively affect women (Chou et al. 2008; Kuo et al. 2007). However, there is no consensus in the literature whether there is a relationship between social support and EG. In the present study, we aimed to investigate the relationship of social support, psychological distress and mood disorders on EG.
Introduction
Materials and methods
Emesis gravidarum (EG) is a common medical condition which has significant effects on physical, psychological and quality of life of pregnant women. EG usually starts at the 4 weeks’ gestation. Symptoms affecting up to 85% of pregnant women and usually resolve by midpregnancy regardless of severity and therapy. Pregnant women may need pharmacologic therapy, if the pregnancy is complicated by severe EG. The most severe form of EG is hyperemesis gravidarum (HG) and affects up to 2% of pregnant women (Cardwell 2012). EG and especially HG can be physically and mentally quite traumatic for the sufferer. EG has negative impact on their pregnancy experience. The exact aetiology of EG is unknown but biological, physiological, psychological and socio-cultural factors were blamed. The studies on the aetiology are focussed on both physiological and psychosocial factors. The
A cross-sectional study was conducted with 148 pregnant women at first trimester, who came for routine antenatal visit to our clinic between 1 January 2013 and 15 June 2013. Written informed consent was taken from all the pregnant women. The 24-h Pregnancy-Unique Quantification of Emesis/ Nausea (PUQE-24) test was used to evaluate the severity of nausea and vomiting. The patient group was conducted with the women whose PUQE-24 score was over 6 and the control group was the women whose score was on and under 6. Sociodemographic questionnaire gathered information about the participant’s weight, height, age, educational level, smoking, occupational status, marital status, psychological disorders and family history. All patients were tested for basic biochemical and urine tests. The patients with a history of
Correspondence: Gülşah Balık, MD, Recep Tayyip Erdogan University Medicine School, Rize, Turkey and Recep Tayyip Erdogan University Training and Research Hospital, Islampaşa Mahallesi, Sehitler Caddesi, No: 74, Rize, Turkey. E-mail: [email protected]
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G. Balık et al.
medical disorders, chronic medication intake, hyperthyroidism, psychological disorders, hepatic disorders, urinary tract infections or intracranial disorders, twin pregnancy, molar pregnancy and missed abortion were excluded from the study. Severity of EG symptoms was measured by the validated PUQE-24 test. All participants completed the forms for sociodemographic data collection form, the Symptom Checklist-90Revised (SCL-90-R), Spielberger’s State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI) and Multidimensional Scale of Perceived Social Support (MSPSS). STAI, BDI, MSPSS and global severity index (GSI) (according to SCL-90-R) scores of the patients and control group were compared.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/24/15 For personal use only.
Measures PUQE-24 It was modified by Koren et al. from the Rhodes scoring system to provide a more appropriate means for measuring EG severity. This index is based on three physical symptoms which are assessed during the last 24 h in the patient: the duration of nausea in hours, and the number of retching and vomiting episodes on an average day from the beginning of pregnancy. Question 1 described nausea, question 2 described vomiting and question 3 described retching within the last 12 h. Scores for each of the three items ranged from 1 to 5, with 5 being the most severely symptomatic. The total score can range between 3 and 15, with 3–6 representing mild symptoms, 7–12 moderate symptoms and 13–15 representing severe symptoms (Koren et al. 2002).
SCL-90-R SCL-90-R is a self-reporting outcome measure in psychiatric research and primary care settings, which was designed by Derogatis (1983). It is a widely used and well-searched instrument for investigation of psychological distress and psychopathology. Dag (1991) validated the Turkish version of the SCL-90-R. Researchers have used the questionnaire to evaluate the Turkish population in the literature. 90 items in the questionnaire include somatization, obsessive–compulsive disorder, interpersonal sensitivity, depression, anxiety, anger–hostility, phobic anxiety, paranoid ideation and psychotic-related questions. Each item is rated based on the Likert score, a five-point scale (0–4) from ‘not at all to extremely’. In clinical practice the SCL-90-R is used to reflect the GSI of individuals. The sum of scores rated is divided into the total number of questions. The result gives the GSI of the patient. The patients can be mentioned as being normal (⬍ 0.5), having moderate psychological disorders (0.5–1) and having severe psychological disorders (⬎ 1) according to GSI score. Ethical approval for the study was obtained from Ethics Committee at Recep Tayyip Erdogan University Medicine School.
Statistical analysis Statistical analyses were performed using the SPSS for the Windows version 19.0 programme. A value of p ⬍ 0.05 was considered statistically significant. Chi-square and Mann–Whitney U tests were used to compare differences between patient and control groups.
Results MSPSS MSPSS is a brief scale to assess perceived social support developed by Zimet et al. (1988). Eker et al. (2000) have standardised a Turkish language version of the MSPSS and demonstrated a similar factor structure of that instrument in a non-Western population. The MSPSS is a measure of perceived social support from family, friends and significant others each of which accounts for up to 28 points (out of a maximum of 84), which is scored on a scale from 1 to 7 (1, very strongly disagree; 2, strongly disagree; 3, mildly disagree; 4, neutral; 5, mildly agree; 6, strongly agree; and 7, very strongly agree). The scale has proven reliability and validity to assess social support in pregnancy. The higher the score is, the higher the level of perceived social support.
We included 148 participants in the study; 77 (52%) of 148 were in the control group and 71 (48%) of them were in the patient group. The mean PUQE score of the control and the patient groups were 4.4 ⫾ 1.13 (3–6) and 9.7 ⫾ 2.16 (7–15), respectively. No statistically significant differences were found between the groups on the demographic features. The demographic features of the participants are shown in Table I. No statistically significant differences were found between patient and control groups on MSPSS scoring (p ⬎ 0.05) (Table II).
Table I. Demographic data of the Patients and control groups.
BDI Individual questions of the BDI assess mood, pessimism, sense of failure, self-dissatisfaction, guilt, punishment, self-dislike, selfaccusation, suicidal ideas, crying, irritability, social withdrawal, body image, work difficulties, insomnia, fatigue, appetite, weight loss, bodily pre-occupation and loss of libido. Each response is assigned as score, ranging from 0 (not at all bothered) to 3 (severely bothered), indicating the severity of the symptoms. Hisli (2000) have validated the Turkish version of this standard questionnaire.
STAI STAI was designed and standardised by Spielberger et al. (1983) to evaluate anxiety. Öner and Le Compte (1998) validated the Turkish version of the STAI. The STAI is composed of separate State and Trait scales. Each item is scored on a scale from 1 to 4 (1, not at all; 2, somewhat; 3, moderately so; and 4, very much so). Total scores change between 20 and 80. The scale has demonstrated good validity and reliability in assessing anxiety in pregnancy. Higher scores indicate higher anxiety.
Age (mean years, SD) Gestational age (mean weeks, SD) Number of Pregnancy (mean, SD) Body Mass index (kg/m2) (mean, SD) Occupation (n %) Worker Government official House wife Pregnancy Desire (n %) Unwanted Pregnancy Planned pregnancy Educational Status (n %) Elementary school Secondary school High school College
Patients (n ⫽ 71)
Control (n ⫽ 77)
P value
28.26 ⫾ 5.32 8.79 ⫾ 2.21
27.81 ⫾ 5.42 8.23 ⫾ 2.51
0.610 0.185
2.01 ⫾ 0.78
1.83 ⫾ 0.82
0.162
25.61 ⫾ 5.70
24.26 ⫾ 3.98
0.274
10 (43%) 8 (40%) 53 (50.4%)
13 (57%) 12 (60%) 52 (49.6%)
55 (49.5%) 16 (43.2%)
56 (50.5%) 21 (56.8%)
22 (56.4%) 15 (55.5%) 22 (46.8%) 12 (34.2%)
17 (43.6%) 12 (44.5%) 25 (53.2%) 23 (65.8%)
0.291
0.506
0.114
Psychological distress, mood disorders and emesis gravidarum 3 Table II. Comparison of MSPSS scores of the patient and control group. MSPSS subgroups
Patient (n ⫽ 71) (mean ⫾ SD)
Control (n ⫽ 77) (mean ⫾ SD)
P value
Family Friend Others Total
21.93 ⫾ 7.50 19.96 ⫾ 7.99 15.93 ⫾ 8.37 58.0 ⫾ 19.34
23.69 ⫾ 6.24 20.36 ⫾ 7.87 18.06 ⫾ 7.86 62.12 ⫾ 18.16
0.465 0.95 0.121 0.191
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Statistically significant differences were found between the patients and control group on total STAI score (p ⫽ 0.001). A statistically significant differences were found on the mean values of GSI according to SCL-90 R (p ⫽ 0.00). The differences between patient and the control groups on mean BDI score was statistically significant (p ⫽ 0.009) (Table III).
Discussion EG is a common disease which is complicated by psychological and socio-cultural factors. EG may cause not only physical identity changes of the pregnant women but also their daily social life. Psychiatric sequel may continue even postpartum. The aetiology of EG remains unknown, but a number of possible causes have been investigated. Psychological factors such as lack of emotional support, depression and personality disorders have been considered to be possible causes of EG in the literature (Meighan and Wood 2005). Although there are some studies on the association between EG and psychological factors in the literature, an objective relationship has not been established. The causal relationship between EG and psychiatric disorders is unclear because of very limited published data. Kramer et al. (2013) suggest that screening for EG should be ongoing throughout pregnancy. In one study (Fell et al. 2006), it was demonstrated that there was a relative risk of psychiatric illness among pregnant women with a history of hyperemesis when compared with that among healthy women. In another study (Seng et al. 2007), an association was found between pre-pregnancy diagnosed psychiatric conditions (e.g. depression, anxiety or drug abuse) and HG. Simpson et al. (2001) demonstrated that women suffering from HG were more likely to suffer from somatisation, anxiety, psychoticism and obsessive–compulsive symptoms. They reported that HG was more common among women with long-standing conversion disorder but there was no support that HG was a psychosomatic condition. There is a complex interaction between HG and biological, psychological, sociocultural factors (Simpson et al. 2001; Munch et al. 2011). To understand the psychological effects of hyperemesis gravidarum, using an objective scale is necessary. SCL-90-R questionnaire is a practical and effective test to screen patients psychologically, especially women who are hospitalised for hyperemesis gravidarum (Pirimoglu et al. 2010). In the present study, Table III. The mean GSI, STAI and BDI scores of the Patient and control groups.
GSI BDI STAI –I STAI –II STAI Total
Control (n ⫽ 77) (mean ⫾ SD)
Patient (n ⫽ 71) (mean ⫾ SD)
P value
0.61 ⫾ 0.41 8.83 ⫾ 8.38 34.51 ⫾ 15.02 39.92 ⫾ 16.62 74.65 ⫾ 30.42
0.96 ⫾ 0.64 11.89 ⫾ 8.71 41.68 ⫾ 10.37 45.23 ⫾ 10.63 86.65 ⫾ 19.76
0.00 0.009 0.000 0.113 0.001
we used SCL-90-R questionnaire and found that women with moderate and severe EG have increased GSI scores compared with those with mild EG. This finding adds additional evidence to the literature that women with EG have risk for psychological distress. Uguz et al. (2012) found that the most common psychiatric disorders in women with HG were major depression and generalised anxiety disorder. The severity of EG correlated independently with the level of anxiety/insomnia and depression (Davis 2004). Jahangiri et al. (2011) reported a correlation between depression, anxiety, and nausea and vomiting during pregnancy. In contrast, Bozzo et al. (2011) reported no association between depressive symptoms and EG. In our study, we found that BDI and STAI scores were high in women with moderate and severe EG when compared with those with mild EG. We think that anxiety and depression are a risk factor for EG in pregnant women. Several studies do not find differences between social factors and stress, such as marital status, planned pregnancy and positive feelings about the pregnancy (Vellacott et al. 1988; Wolkind and Zajicek 1978). Family supports were shown to be a strong correlation for the quality of life of pregnant women after birth (Chou et al. 2006). In one study (Katon 1980), social factors have also been reported to be associated with HG. However, the relationship between EG and social support level was not found to be statistically significant. On the contrary, Chou et al. (2008) suggest that there is no relationship between social support and EG. In the present study, no statistically significant differences were found between control and patient groups on MSPSS scores. This finding suggests that social support is not enough to prevent EG. The degree of perceived stress and maternal psychosocial adaptation may be related to the severity of EG (Kou 2007; Kramer et al. 2013). Fitzgerald (1984) reported that women with undesired pregnancy suffer from EG more than women with planned pregnancy. In the present study we did not find statistically significant differences between groups, whether the pregnancy was planned or not. In our experience, women with EG do not consider themselves to have a psychological problem and do not generally want a psychology-based therapeutic approach. Many women feel helpless and incapable and misunderstood by their relatives. This study adds evidence that those suffering with EG may be more anxious and depressed than women without EG. We still do not know that EG causes psychological distress or is it the opposite? However, it is obvious that the sufferers of EG have psychological distress. Therefore, health professionals need to be aware that extra psychological support may be necessary during the treatment and follow-up of moderate-to-severe EG pregnant women.
Conclusion EG not only affects the physical health of pregnant women, but can also negatively impact their psychosocial functioning. The care givers should understand and appreciate that EG is a disease which is not caused by the patient herself. The psychological aspects of severe emesis should also be considered. Comprehensive biopsychosocial assessment and intervention by a perinatal health care team are essential for women suffering from nausea and vomiting during pregnancy. Further studies on association of psychosocial factors and EG are needed.
Acknowledgements No financial support was received.
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Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
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References Bozzo P, Einarson TR, Koren G, Einarson A. 2011. Nausea and vomiting of pregnancy (NVP) and depression: cause or effect? Clinical and Investigative Medicine 34:E245. Cardwell MS. 2012. Pregnancy sickness: a biopsychological perspective. Obstetrical and Gynecological Survey 67:645–652. Chou FH, Chen CH, Kuo SH, Tzeng YL. 2006. Experience of Taiwanese women living with nausea and vomiting during pregnancy. Journal of Midwifery & Womens Health 51:370–375. Chou FH, Kuo SH, Wang RH. 2008. A longitudinal study of nausea and vomiting, fatigue and perceived stress in, and social support for, pregnant women through the three trimesters. Kaohsiung Journal of Medical Sciences 24:306–314. Dag I. 1991. Belirti Tarama Listesi (SCL 90-R) nin universite ogrencileri icin guvenirligi ve gecerliligi (The reliability and validity of SCL-90-R for university students). Turk Psikiyatri Dergisi 2:5–12. Davis M. 2004. Nausea and vomiting of pregnancy: an evidence-based review. Journal of Perinatal & Neonatal Nursing 18:312–328. Eker D, Arkar H, Yaldiz H. 2000. Generality of support sources and psychometric properties of a scale of perceived social support in Turkey. Social Psychiatry and Psychiatric Epidemiology 35:228–233. Fell DB, Dodds L, Joseph KS, Allen VM, Butler B. 2006. Risk factors for hyperemesis gravidarum requiring hospital admission during pregnancy. Obstetrics and Gynecology 107:277–284. Fitzgerald CM. 1984. Nausea and vomiting in pregnancy. British Journal of Obstetrics and Gynaecology 57:159–165. Hisli N. 1988. Beck depresyon envanterinin gecerligi [A study on the validity of Beck Depression Inventory]. Journal of Psychology (Psikoloji Dergisi), 6:118–122 (in Turkish, no English abstract available). Jahangiri F, Hirshfeld-Cytron J, Goldman K, Pavone ME, Gerber S, Klock SC. 2011. Correlation between depression, anxiety, and nausea and vomiting during pregnancy in an in vitro fertilization population: a pilot study. Journal of Psychosomatic Obstetrics Gynaecology 32: 113–118. Llewellyn M, Stowe Z, Nemerrof D. 1997. Depression during pregnancy and the puerperium. Journal of Clinical Psychiatry 58:26–32. Kuo SH, Wang RH, Tseng HC, Jian SY. 2007. A comparison of different severities of nausea and vomiting during pregnancy relative to stress,
social support and maternal adaptation. Journal of Midwifery & Womens Health 52:e1–7. Koren G, Boskovic R, Hard M, Maltepe C, Navioz Y, Einarson A. 2002. PUQE (Pregnancy-Unique Quantification of Emesis and Nausea) scoring system for nausea and vomiting of pregnancy. American Journal of Obstetrics and Gynecology 186(5 Suppl Understanding):S228–S231. Katon WJ, Ries RK, Bokan JA, Kleinman A. 1980. Hyperemesis gravidarum: a biopsychosocial perspective. International Journal of Psychological Medicine 10:151–162. Kramer J, Bowen A, Stewart N, Muhajarine N. 2013. Nausea and vomiting of pregnancy: prevalence, severity and relation to psychosocial health. MCN American Journal of Maternal/Child Nursing 38:21–27. Derogatis LR, SCL-90-R. 1983. Administration, Scoring & Procedures. Manual-II, Clinical Psychometric Research, Towson, Md, USA. Meighan M, Wood AF. 2005. The impact of hyperemesis gravidarum on maternal role assumption. Journal of Obstetric, Gynecologic, and Neonatal Nursing 34:172–179 Munch S, Korst LM, Hernandez GD, Romero R, Goodwin TM. 2011. Healthrelated quality of life in women with nausea and vomiting of pregnancy: the importance of psychosocial context. Journal of Perinatology 31:10–20 Öner N, Le Compte A. 1998. A Handbook for State-Trait. Ankara: Turkey, Bogazici Yayinlari. Pirimoglu ZM, Guzelmeric K, Alpay B, Balcik O, Unal O, Turan MC. 2010. Psychological factors of hyperemesis gravidarum by using the SCL90-R questionnaire. Clinical and Experimental Obstetrics Gynecology 37:56–59. Seng JS, Schrot JA, van De Ven C, Liberzon I. 2007. Service use data analysis of pre-pregnancy psychiatric and somatic diagnoses in women with hyperemesis gravidarum. Journal of Psychosomatic Obstetrics Gynaecology 28:209–217. Simpson SW, Goodwin TM, Robins SB, Rizzo AA, Howes RA, et al. 2001. Psychological factors and hyperemesis gravidarum. Journal of Women’s Health and Gender-Based Medicine 10:471–477. Spielberger CD, Gorsuch RL, Lushene RE. 1983. Manual for the state-trait anxiety inventory. Palo Alto, California: Consulting Psychologists Press. Uguz F, Gezginc K, Kayhan F, Cicek E, Kantarci AH. 2012. Is hyperemesis gravidarum associated with mood, anxiety and personality disorders: a case-control study? General Hospital Psychiatry 34:398–402 Vellacott ID, Cooke EJ, James CE. 1988. Nausea and vomiting in early pregnancy. International Journal of Gynecology & Obstetrics 27:57–62. Wolkind S, Zajicek E. 1978. Psycho-social correlates of nausea and vomiting in pregnancy. Journal of Psychosomatic Research 22:1–5. Zimet G, Dahlem N, Zimet S, Farley G. 1988. The multidimensional scale of perceived social support. Journal of Personality Assessment 52:30–41.
ORIGINAL ARTICLE
Is there relationship between social support, psychological distress, mood disorders and emesis gravidarum? G. Balık, Y.B. Tekin & M. Kağıtcı
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/24/15 For personal use only.
Department of Obstetrics and Gynecology, Recep Tayyip Erdogan University Medicine School, Rize, Turkey
Objective: Emesis Gravidarum (EG) is common medical condition in pregnancy with significant negatively effects on daily social life, physical and psychological health. In this study, relationship of social support, psychological distress and mood disorders on EG were investigated. Methods: The pregnant women with mild EG were accepted as control group and moderate and severe EG were accepted as patient group. All patients completed sociodemographic data collection form, Pregnancy-Unique Quantification of Emesis and Nausea scale (PUQE-24), Symptom Check List questionnaire (SCL-90 R), Spielberger state-trait anxiety inventory (STAI), Beck depression inventory (BDI) and Multidimensional Scale of Perceived Social Support (MSPSS). STAI, BDI, MSPSS and GSI (global symptom index) scores of the patients and control groups were compared. Results: Statistically significant differences were found between the patients and control group on STAI score, BDI score and GSI scores. No statistically significant were found between the patients and control group on MSPSS score. Conclusion: Social support does not prevent patients from EG. But, there is a clear relationship between EG and psychological distress. Thus, psychiatric evaluation should be done in patients with EG. Obstetricians should encourage their patients to have psychiatric support. Further studies on relationship of psychosocial factors and EG are needed. Keywords: Anxiety, emesis gravidarum, pregnancy, psychosocial aspects, psychiatric support, social support
psychoanalytic literature describes vomiting as a psychosomatic symptom and considered as a hysterical defence against unconscious wishes (Katon et al. 1980). The psychosocial factors which thought to be play role in the aetiology of EG are stress, lack of support from family and friends, adoption, general feeling of unhappiness and negative experiences of the past pregnancies. Pregnancy prevents depression and other psychological disorders of pregnant women. The most common mood disorders of the women are anxiety and major depression in pregnant women. The prevalence of major depression is 10–15% in pregnant women (Llewellyn et al. 1977). The best determinant risk factor for depression in pregnancy is the history of mood disorders before pregnancy. Adolescent pregnancy, the number of children, undesired pregnancy, family history and social support deficiency increase depression risk (Uguz et al. 2012). Pregnancy usually hides the symptoms of anxiety, so the real prevalence cannot be determined. Pregnancy is an important period of women’s life. The adaption of motherhood could be traumatic for a lot of women. Family, friends or relatives can help the women for the adaptation of motherhood. The deficiency of social support may negatively affect women (Chou et al. 2008; Kuo et al. 2007). However, there is no consensus in the literature whether there is a relationship between social support and EG. In the present study, we aimed to investigate the relationship of social support, psychological distress and mood disorders on EG.
Introduction
Materials and methods
Emesis gravidarum (EG) is a common medical condition which has significant effects on physical, psychological and quality of life of pregnant women. EG usually starts at the 4 weeks’ gestation. Symptoms affecting up to 85% of pregnant women and usually resolve by midpregnancy regardless of severity and therapy. Pregnant women may need pharmacologic therapy, if the pregnancy is complicated by severe EG. The most severe form of EG is hyperemesis gravidarum (HG) and affects up to 2% of pregnant women (Cardwell 2012). EG and especially HG can be physically and mentally quite traumatic for the sufferer. EG has negative impact on their pregnancy experience. The exact aetiology of EG is unknown but biological, physiological, psychological and socio-cultural factors were blamed. The studies on the aetiology are focussed on both physiological and psychosocial factors. The
A cross-sectional study was conducted with 148 pregnant women at first trimester, who came for routine antenatal visit to our clinic between 1 January 2013 and 15 June 2013. Written informed consent was taken from all the pregnant women. The 24-h Pregnancy-Unique Quantification of Emesis/ Nausea (PUQE-24) test was used to evaluate the severity of nausea and vomiting. The patient group was conducted with the women whose PUQE-24 score was over 6 and the control group was the women whose score was on and under 6. Sociodemographic questionnaire gathered information about the participant’s weight, height, age, educational level, smoking, occupational status, marital status, psychological disorders and family history. All patients were tested for basic biochemical and urine tests. The patients with a history of
Correspondence: Gülşah Balık, MD, Recep Tayyip Erdogan University Medicine School, Rize, Turkey and Recep Tayyip Erdogan University Training and Research Hospital, Islampaşa Mahallesi, Sehitler Caddesi, No: 74, Rize, Turkey. E-mail: [email protected]
2
G. Balık et al.
medical disorders, chronic medication intake, hyperthyroidism, psychological disorders, hepatic disorders, urinary tract infections or intracranial disorders, twin pregnancy, molar pregnancy and missed abortion were excluded from the study. Severity of EG symptoms was measured by the validated PUQE-24 test. All participants completed the forms for sociodemographic data collection form, the Symptom Checklist-90Revised (SCL-90-R), Spielberger’s State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI) and Multidimensional Scale of Perceived Social Support (MSPSS). STAI, BDI, MSPSS and global severity index (GSI) (according to SCL-90-R) scores of the patients and control group were compared.
J Obstet Gynaecol Downloaded from informahealthcare.com by Nyu Medical Center on 06/24/15 For personal use only.
Measures PUQE-24 It was modified by Koren et al. from the Rhodes scoring system to provide a more appropriate means for measuring EG severity. This index is based on three physical symptoms which are assessed during the last 24 h in the patient: the duration of nausea in hours, and the number of retching and vomiting episodes on an average day from the beginning of pregnancy. Question 1 described nausea, question 2 described vomiting and question 3 described retching within the last 12 h. Scores for each of the three items ranged from 1 to 5, with 5 being the most severely symptomatic. The total score can range between 3 and 15, with 3–6 representing mild symptoms, 7–12 moderate symptoms and 13–15 representing severe symptoms (Koren et al. 2002).
SCL-90-R SCL-90-R is a self-reporting outcome measure in psychiatric research and primary care settings, which was designed by Derogatis (1983). It is a widely used and well-searched instrument for investigation of psychological distress and psychopathology. Dag (1991) validated the Turkish version of the SCL-90-R. Researchers have used the questionnaire to evaluate the Turkish population in the literature. 90 items in the questionnaire include somatization, obsessive–compulsive disorder, interpersonal sensitivity, depression, anxiety, anger–hostility, phobic anxiety, paranoid ideation and psychotic-related questions. Each item is rated based on the Likert score, a five-point scale (0–4) from ‘not at all to extremely’. In clinical practice the SCL-90-R is used to reflect the GSI of individuals. The sum of scores rated is divided into the total number of questions. The result gives the GSI of the patient. The patients can be mentioned as being normal (⬍ 0.5), having moderate psychological disorders (0.5–1) and having severe psychological disorders (⬎ 1) according to GSI score. Ethical approval for the study was obtained from Ethics Committee at Recep Tayyip Erdogan University Medicine School.
Statistical analysis Statistical analyses were performed using the SPSS for the Windows version 19.0 programme. A value of p ⬍ 0.05 was considered statistically significant. Chi-square and Mann–Whitney U tests were used to compare differences between patient and control groups.
Results MSPSS MSPSS is a brief scale to assess perceived social support developed by Zimet et al. (1988). Eker et al. (2000) have standardised a Turkish language version of the MSPSS and demonstrated a similar factor structure of that instrument in a non-Western population. The MSPSS is a measure of perceived social support from family, friends and significant others each of which accounts for up to 28 points (out of a maximum of 84), which is scored on a scale from 1 to 7 (1, very strongly disagree; 2, strongly disagree; 3, mildly disagree; 4, neutral; 5, mildly agree; 6, strongly agree; and 7, very strongly agree). The scale has proven reliability and validity to assess social support in pregnancy. The higher the score is, the higher the level of perceived social support.
We included 148 participants in the study; 77 (52%) of 148 were in the control group and 71 (48%) of them were in the patient group. The mean PUQE score of the control and the patient groups were 4.4 ⫾ 1.13 (3–6) and 9.7 ⫾ 2.16 (7–15), respectively. No statistically significant differences were found between the groups on the demographic features. The demographic features of the participants are shown in Table I. No statistically significant differences were found between patient and control groups on MSPSS scoring (p ⬎ 0.05) (Table II).
Table I. Demographic data of the Patients and control groups.
BDI Individual questions of the BDI assess mood, pessimism, sense of failure, self-dissatisfaction, guilt, punishment, self-dislike, selfaccusation, suicidal ideas, crying, irritability, social withdrawal, body image, work difficulties, insomnia, fatigue, appetite, weight loss, bodily pre-occupation and loss of libido. Each response is assigned as score, ranging from 0 (not at all bothered) to 3 (severely bothered), indicating the severity of the symptoms. Hisli (2000) have validated the Turkish version of this standard questionnaire.
STAI STAI was designed and standardised by Spielberger et al. (1983) to evaluate anxiety. Öner and Le Compte (1998) validated the Turkish version of the STAI. The STAI is composed of separate State and Trait scales. Each item is scored on a scale from 1 to 4 (1, not at all; 2, somewhat; 3, moderately so; and 4, very much so). Total scores change between 20 and 80. The scale has demonstrated good validity and reliability in assessing anxiety in pregnancy. Higher scores indicate higher anxiety.
Age (mean years, SD) Gestational age (mean weeks, SD) Number of Pregnancy (mean, SD) Body Mass index (kg/m2) (mean, SD) Occupation (n %) Worker Government official House wife Pregnancy Desire (n %) Unwanted Pregnancy Planned pregnancy Educational Status (n %) Elementary school Secondary school High school College
Patients (n ⫽ 71)
Control (n ⫽ 77)
P value
28.26 ⫾ 5.32 8.79 ⫾ 2.21
27.81 ⫾ 5.42 8.23 ⫾ 2.51
0.610 0.185
2.01 ⫾ 0.78
1.83 ⫾ 0.82
0.162
25.61 ⫾ 5.70
24.26 ⫾ 3.98
0.274
10 (43%) 8 (40%) 53 (50.4%)
13 (57%) 12 (60%) 52 (49.6%)
55 (49.5%) 16 (43.2%)
56 (50.5%) 21 (56.8%)
22 (56.4%) 15 (55.5%) 22 (46.8%) 12 (34.2%)
17 (43.6%) 12 (44.5%) 25 (53.2%) 23 (65.8%)
0.291
0.506
0.114
Psychological distress, mood disorders and emesis gravidarum 3 Table II. Comparison of MSPSS scores of the patient and control group. MSPSS subgroups
Patient (n ⫽ 71) (mean ⫾ SD)
Control (n ⫽ 77) (mean ⫾ SD)
P value
Family Friend Others Total
21.93 ⫾ 7.50 19.96 ⫾ 7.99 15.93 ⫾ 8.37 58.0 ⫾ 19.34
23.69 ⫾ 6.24 20.36 ⫾ 7.87 18.06 ⫾ 7.86 62.12 ⫾ 18.16
0.465 0.95 0.121 0.191
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Statistically significant differences were found between the patients and control group on total STAI score (p ⫽ 0.001). A statistically significant differences were found on the mean values of GSI according to SCL-90 R (p ⫽ 0.00). The differences between patient and the control groups on mean BDI score was statistically significant (p ⫽ 0.009) (Table III).
Discussion EG is a common disease which is complicated by psychological and socio-cultural factors. EG may cause not only physical identity changes of the pregnant women but also their daily social life. Psychiatric sequel may continue even postpartum. The aetiology of EG remains unknown, but a number of possible causes have been investigated. Psychological factors such as lack of emotional support, depression and personality disorders have been considered to be possible causes of EG in the literature (Meighan and Wood 2005). Although there are some studies on the association between EG and psychological factors in the literature, an objective relationship has not been established. The causal relationship between EG and psychiatric disorders is unclear because of very limited published data. Kramer et al. (2013) suggest that screening for EG should be ongoing throughout pregnancy. In one study (Fell et al. 2006), it was demonstrated that there was a relative risk of psychiatric illness among pregnant women with a history of hyperemesis when compared with that among healthy women. In another study (Seng et al. 2007), an association was found between pre-pregnancy diagnosed psychiatric conditions (e.g. depression, anxiety or drug abuse) and HG. Simpson et al. (2001) demonstrated that women suffering from HG were more likely to suffer from somatisation, anxiety, psychoticism and obsessive–compulsive symptoms. They reported that HG was more common among women with long-standing conversion disorder but there was no support that HG was a psychosomatic condition. There is a complex interaction between HG and biological, psychological, sociocultural factors (Simpson et al. 2001; Munch et al. 2011). To understand the psychological effects of hyperemesis gravidarum, using an objective scale is necessary. SCL-90-R questionnaire is a practical and effective test to screen patients psychologically, especially women who are hospitalised for hyperemesis gravidarum (Pirimoglu et al. 2010). In the present study, Table III. The mean GSI, STAI and BDI scores of the Patient and control groups.
GSI BDI STAI –I STAI –II STAI Total
Control (n ⫽ 77) (mean ⫾ SD)
Patient (n ⫽ 71) (mean ⫾ SD)
P value
0.61 ⫾ 0.41 8.83 ⫾ 8.38 34.51 ⫾ 15.02 39.92 ⫾ 16.62 74.65 ⫾ 30.42
0.96 ⫾ 0.64 11.89 ⫾ 8.71 41.68 ⫾ 10.37 45.23 ⫾ 10.63 86.65 ⫾ 19.76
0.00 0.009 0.000 0.113 0.001
we used SCL-90-R questionnaire and found that women with moderate and severe EG have increased GSI scores compared with those with mild EG. This finding adds additional evidence to the literature that women with EG have risk for psychological distress. Uguz et al. (2012) found that the most common psychiatric disorders in women with HG were major depression and generalised anxiety disorder. The severity of EG correlated independently with the level of anxiety/insomnia and depression (Davis 2004). Jahangiri et al. (2011) reported a correlation between depression, anxiety, and nausea and vomiting during pregnancy. In contrast, Bozzo et al. (2011) reported no association between depressive symptoms and EG. In our study, we found that BDI and STAI scores were high in women with moderate and severe EG when compared with those with mild EG. We think that anxiety and depression are a risk factor for EG in pregnant women. Several studies do not find differences between social factors and stress, such as marital status, planned pregnancy and positive feelings about the pregnancy (Vellacott et al. 1988; Wolkind and Zajicek 1978). Family supports were shown to be a strong correlation for the quality of life of pregnant women after birth (Chou et al. 2006). In one study (Katon 1980), social factors have also been reported to be associated with HG. However, the relationship between EG and social support level was not found to be statistically significant. On the contrary, Chou et al. (2008) suggest that there is no relationship between social support and EG. In the present study, no statistically significant differences were found between control and patient groups on MSPSS scores. This finding suggests that social support is not enough to prevent EG. The degree of perceived stress and maternal psychosocial adaptation may be related to the severity of EG (Kou 2007; Kramer et al. 2013). Fitzgerald (1984) reported that women with undesired pregnancy suffer from EG more than women with planned pregnancy. In the present study we did not find statistically significant differences between groups, whether the pregnancy was planned or not. In our experience, women with EG do not consider themselves to have a psychological problem and do not generally want a psychology-based therapeutic approach. Many women feel helpless and incapable and misunderstood by their relatives. This study adds evidence that those suffering with EG may be more anxious and depressed than women without EG. We still do not know that EG causes psychological distress or is it the opposite? However, it is obvious that the sufferers of EG have psychological distress. Therefore, health professionals need to be aware that extra psychological support may be necessary during the treatment and follow-up of moderate-to-severe EG pregnant women.
Conclusion EG not only affects the physical health of pregnant women, but can also negatively impact their psychosocial functioning. The care givers should understand and appreciate that EG is a disease which is not caused by the patient herself. The psychological aspects of severe emesis should also be considered. Comprehensive biopsychosocial assessment and intervention by a perinatal health care team are essential for women suffering from nausea and vomiting during pregnancy. Further studies on association of psychosocial factors and EG are needed.
Acknowledgements No financial support was received.
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G. Balık et al.
Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.
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