Treatment of Nausea and Vomiting in Pregnancy

Factors Associated With ED Revisits

Brian R. Sharp, MD; Kristen M. Sharp, MD; Brian Patterson, MD; Suzanne Dooley-Hash, MD

Disclosures

Western J Emerg Med. 2016;17(5):585-590. 

In This Article

Abstract and Introduction

Abstract

Introduction: Nausea and vomiting in pregnancy (NVP) is a condition that commonly affects women in the first trimester of pregnancy. Despite frequently leading to emergency department (ED) visits, little evidence exists to characterize the nature of ED visits or to guide its treatment in the ED. Our objectives were to evaluate the treatment of NVP in the ED and to identify factors that predict return visits to the ED for NVP.

Methods: We conducted a retrospective database analysis using the electronic medical record from a single, large academic hospital. Demographic and treatment variables were collected using a chart review of 113 ED patient visits with a billing diagnosis of "nausea and vomiting in pregnancy" or "hyperemesis gravidarum." Logistic regression analysis was used with a primary outcome of return visit to the ED for the same diagnoses.

Results: There was wide treatment variability of nausea and vomiting in pregnancy patients in the ED. Of the 113 patient visits, 38 (33.6%) had a return ED visit for NVP. High gravidity (OR 1.31, 95% CI [1.06–1.61]), high parity (OR 1.50 95% CI [1.12–2.00]), and early gestational age (OR 0.74 95% CI [0.60–0.90]) were associated with an increase in return ED visits in univariate logistic regression models, while only early gestational age (OR 0.74 95% CI [0.59–0.91]) was associated with increased return ED visits in a multiple regression model. Admission to the hospital was found to decrease the likelihood of return ED visits (p=0.002).

Conclusion: NVP can be difficult to manage and has a high ED return visit rate. Optimizing care with aggressive, standardized treatment in the ED and upon discharge, particularly if factors predictive of return ED visits are present, may improve quality of care and reduce ED utilization for this condition.

Introduction

Background

Nausea and vomiting in pregnancy (NVP) refers to a spectrum of symptoms that affect 50–90% of all pregnant women, typically in the first trimester and can adversely affect both maternal and fetal health.[1–3] Hyperemesis gravidarum (HEG) represents the most severe form of NVP and is present in approximately 0.5 to 2 percent of pregnancies.[1,4,5] HEG is often characterized by maternal weight loss and fluid, electrolyte, and nutritional abnormalities[3] and is the most common indication for hospitalization during early pregnancy with an average of 1.3 hospital admissions per HEG patient. It is second only to preterm labor as the most common reason for hospitalization during pregnancy[6,7] and carries up to a 25% hospital readmission rate.[8] HEG is also the most common cause of pregnant patients missing time at work (average hospital stay of 2.6–4 days) and reduced quality of life.[1,8] The obstetric literature suggests factors predisposing patients to the severe variants of NVP include nulliparity, younger patient age, non-white race, and the presence of comorbidities including pre-existing diabetes, depression or other psychiatric illness, asthma, and hyperthyroid disease.[1,9] Although diagnostic tests indicative of starvation and dehydration such as ketonuria, abnormal electrolytes, liver function tests, and hematocrit have traditionally been used as markers for severe NVP, there have been multiple studies showing that these may not successfully predict hospital readmission.[4,9]

Patients with NVP and HEG are frequently assessed and treated in the emergency department (ED), yet little is known regarding the quality of care that they receive or their rates of ED utilization. We are aware of no peer-reviewed publications to date in either the ED or obstetric literature that specifically assesses the care of this condition in the ED or provides guidelines for its treatment in this setting. The American College of Obstetrics and Gynecology (ACOG) has published practice guidelines on the treatment of NVP that are often referenced for this condition but are not specifically focused on care in the ED.[10]

We hypothesize that NVP treated in the ED does indeed have a high re-visit rate and that the variables of decreased patient age, decreased gestational age, decreased maternal gravidity, the presence of multiple gestation pregnancies, and the presence of lab abnormalities are associated with a higher likelihood for return ED visits for treatment of NVP. We also aimed to assess treatment patterns of NVP in the ED.

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