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doi:10.1111/jog.12274
J. Obstet. Gynaecol. Res. Vol. 40, No. 4: 1009–1014, April 2014
Are there any differences in psychiatric symptoms and eating attitudes between pregnant women with hyperemesis gravidarum and healthy pregnant women? Bilge Burçak Annagür1, Özlem Seçilmis¸ Kerimog˘lu2, S¸ule Gündüz1 and Aybike Tazegül2 1
Department of Psychiatry, and 2Department of Obstetrics and Gynecology, Faculty of Medicine, Selçuk University, Konya, Turkey
Abstract Aim: We aimed to determine the relationship between eating attitudes and psychiatric symptoms in women with hyperemesis gravidarum (HG) and to compare these women with healthy control subjects. Methods: The study sample included 48 women with HG, and the control group had 44 pregnant women. The patients were selected from women with HG hospitalized in the obstetric inpatient clinic. All of the participants were in the first trimester of pregnancy. The participants’ sociodemographic and clinical characteristics were recorded in the obstetric clinic. All of the participants completed a Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Eating Attitudes Test (EAT) and Body Image Scale (BIS). Results: Women with HG were more likely to have had a history of HG during their previous pregnancy (P < 0.05). There was no significant difference between the study and control groups regarding obstetric history. Women with HG were more influenced by food that induced nausea. There was no significant difference between the study and control groups for pre-pregnancy nausea, food craving and the initial BMI (P > 0.05). Depression and anxiety scores were significantly higher in women with HG (P < 0.05). However, there was no significant difference between the study and control groups for body image score and eating attitude test scores (P > 0.05). Conclusion: We suggest that HG appears to be associated with depression and anxiety symptoms rather than deterioration of eating attitudes and body image. However, these results should be confirmed by prospective and clinical studies. Key words: anxiety, depression, eating attitudes, hyperemesis gravidarum.
Introduction Nausea and vomiting (NV) are the most common symptoms during the first trimester of pregnancy. These symptoms affect approximately 75% of pregnant women, and although predominantly related to early pregnancy, it may continue beyond the first trimester.1 Whereas nausea and vomiting during
pregnancy is usually self-limited, hyperemesis gravidarum (HG) is a notable medical problem that may lead to fluid, electrolyte and acid–base imbalance, dehydration, nutrition deficiency, weight loss, anemia and ketonuria, and may often lead to hospital admission.1,2 HG affects 0.5–2% of pregnant women, and 10% of those diagnosed will require at least one inpatient hospitalization.3
Received: May 10 2013. Accepted: August 12 2013. Reprint request to: Dr Bilge Burçak Annagür, Selçuk Üniversitesi, Alaeddin Keykubat Yerles¸kesi, Tıp Fakültesi, Psikiyatri AD, 42131 Selçuklu-Konya, Turkey. Email: [email protected] Conflict of interest: None declared.
© 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
1009
B. B. Annagür et al.
The pathogenesis of HG has not yet been clearly identified. Some endocrine factors, such as human chorionic gonadotropin, estrogens, progesterone and thyroid hormones, in addition to gastrointestinal dysfunction, hepatic abnormalities, autonomic nervous dysfunction and psychosomatic causes may play a role in this medical condition.4 However, it is unclear whether psychiatric symptoms may also play a role in the pathogenesis of HG. In a retrospective telephone survey, Mazzotta et al. suggested that depressive symptoms in pregnant women were found to be associated with more severe nausea and vomiting.5 Tan et al. showed that anxiety and depressive symptomatology was common in women with HG, and a risk factor could be identified.6 In a clinic-based study, Uguz et al.7 reported that mood and anxiety disorders and personality disturbances were frequently observed among women with HG, and there was a potential relationship between these psychiatric disorders and HG during pregnancy. However, the available studies on the topic have focused on mood and anxiety disorders and have been deficient in studying an association with HG and eating attitudes and eating disorders.6–9 In previous studies on the relationship between eating disorders and nausea and vomiting, women with eating disorders have been reported to have a higher rate of maternal and fetal complications,10 and pregnancy is known to be a time for increased risk for both remission from and re-emergence of eating disorder symptoms.11–13 Torgersen et al.14 suggested that eating disorders marked by the symptom of purging were associated with increased nausea and vomiting among women with bulimia nervosa and eating disorders not otherwise specified. However, they could not show any relationship between eating disorders and HG in the same study group. Koubaa et al.10 indicated that treatment and care for hyperemesis was significantly more common among women with eating disorders than for women without these disorders. In the current published work, there is no study investigating the eating attitudes of women with HG. We aimed to determine the relationship between eating attitudes and psychiatric symptoms in women with HG and to compare these women to healthy control subjects.
Methods Setting and sample The patients were selected from women with HG hospitalized in the Obstetric Inpatient Clinic of Selçuk
1010
University Hospital. The study was approved by the Selçuk University Medical Faculty’s ethics committee. The study’s objectives and procedures were explained, and written informed consent was given in accordance with the Declaration of Helsinki. Inclusion criteria were an age of 18–40 years and ability to communicate and to read and write Turkish. The exclusion criteria were severe medical illnesses (e.g. uncontrolled endocrine abnormalities, cardiovascular and pulmonary system diseases), gestational problems (e.g. imminent abortion, trophoblastic disease and ectopic pregnancy), or a history of schizophrenia or related psychotic disorders. Forty-eight patients with HG who required hospitalization due to dehydration, ketonuria, weight loss, and severe nausea and vomiting during their first trimester were included in the study. Gestational week was detected with ultrasound screening on the basis of the last menstruation date. After recording the participants’ sociodemographic and clinical characteristics in the obstetric clinic, patients were referred to the psychiatry department. After receiving medical treatment, patients with HG completed a Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Eating Attitudes Test (EAT) and Body Image Scale (BIS). A control cohort of 44 pregnant women without nausea and vomiting during the first trimester was recruited from the same obstetric outpatient clinic. The control group also completed the same self questionnaires.
Measures BDI The BDI is a 21-item self-report questionnaire that assesses severity of depression. Individuals are asked to rate themselves on a 0–3 spectrum (0 = least, 3 = most) with a score range of 0–63. The cut-offs used are: 0–8, no depression; 9–13, minimal depression; 14–19, mild depression; 20–28, moderate depression; and 29–63, severe depression. The total score is the sum of all items. The Turkish version of the BDI used in this study has been validated in Turkish populations.15 BAI The BAI is a 21-item self-report questionnaire. Each item is rated on a 4-point Likert scale ranging from 0 for not at all to 3 for severely. The total score ranges 0–63. A high overall score indicates a high level of anxiety. The Turkish version of the BAI used in this study has been validated in Turkish populations.16
© 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
Eating attitudes in hyperemesis gravidarum
EAT The EAT measures the meal-related behavior and attitude of patients with eating disorders and measures the possible disorders in the eating behavior of normal individuals. This self-administered questionnaire uses a Likert-type scale with six degrees and 40 items. The total points directly relate to the level of psychopathology. This instrument was developed by Garner and Garfinkel for screening eating disorders in adolescents older than 11 years.17 The Turkish version of EAT was validated by Erol and Savas¸ır.18 The cut-off point is assumed as 30 points for impaired eating behavior. BIS The BIS measures the satisfaction from various parts of the body. This self-questionnaire was developed by Secord and Jourard in 1953.19 The BIS uses a Likert-type scale and is composed of 40 items. It has no cut-off point. Low points indicate dissatisfaction. The Turkish version of BIS has been validated by Hovardaog˘lu in 1993.20 Body mass index (BMI) Patient BMI was calculated as the ratio of weight (kg) to height (m) squared (kg/m2).
Statistical analysis The data were analyzed using the Statistical Package for the Social Sciences version 15.0 for Windows. All variables were tested with the Kolmogorov–Smirnov test to determine whether their distributions were normal.
For comparisons within the study group, either Student’s t-test or Mann–Whitney U-test (when the data were not normally distributed) was used for continuous variables, and either the χ2-test or Fisher’s exact test was used for categorical variables. All P-values were two-tailed, and the statistical significance was set at P < 0.05.
Results The mean age of the sample (n = 92) was 27.7 ± 5.1 years. All of the participants were married. Half of the participants were primary school graduates (n = 50, 54.3%). Most of the participants were unemployed (n = 85, 92.4%) and had medium economic status (n = 83, 90.2%). All the women were in the first trimester of gestation, 30 (32.6%) women were primigravida and 26 (28.3%) women had a history of abortion. The mean number of children was 0.94 ± 0.94. There was no significant difference between the patients and control groups regarding sociodemographic characteristics (Table 1). Table 2 shows the clinical characteristics of the pregnant women with and without HG. Compared to women without HG, women with HG were more likely to have had a history of HG during their previous pregnancy. We found no significant difference between the patient and control groups for primigravida, multiple fetus, history of abortion, number of pregnancies, number of children and planned pregnancy. Regarding the eating characteristics of the study
Table 1 Sociodemographic characteristics of the study sample
Age, mean ± SD, years† Education, n (%)‡ Elementary High School University Employment status, n (%)§ Employed Economic status, n (%)‡ Low economic Medium economic Good economic Spouse’s education, n (%)‡ Elementary High School University
HG group (n = 48)
Control group (n = 44)
P
27.5 ± 5.3 0.171 30 (62.5) 13 (27.1) 5 (10.4) 0.051 1 (2.1) 0.512 5 (10.4) 42 (87.5) 1 (2.1) 0.643 17 (35.4) 20 (41.7) 11 (22.9)
27.9 ± 4.8
0.701
20 (45.5) 14 (31.8) 10 (22.7) 6 (13.6) 3 (6.8) 41 (93.2) 0 (0) 12 (27.3) 19 (43.2) 13 (29.5)
†Independent Student’s t-test. ‡χ2-Test. §Fisher’s exact test. HG, hyperemesis gravidarum; SD, standard deviation.
© 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
1011
B. B. Annagür et al.
Table 2 Clinical characteristics of the study sample
Primigravida, n (%)† Multiple fetus, n (%)† History of abortion, n (%)† History of HG, n (%)† Planned pregnancy, n (%)† Pre-pregnancy nausea, n (%)† Nausea with the smell of food, n (%)† Food craving, n (%)† No. of pregnancies, mean ± SD‡ No. of children, mean ± SD‡ Initial BMI, mean ± SD‡ BDI score, mean ± SD§ BAI score, mean ± SD‡ Body Image Scale score, mean ± SD‡ EAT score, mean ± SD‡
HG group (n = 48)
Control group (n = 44)
P
17 (35.4) 3 (6.3) 10 (20.8) 25 (52.1) 32 (66.7) 5 (10.4) 46 (95.8) 28 (58.3) 2.3 ± 1.4 1.08 ± 1.0 23.9 ± 4.4 15.7 ± 9.3 17.8 ± 12.8 90.8 ± 24.8 23.18 ± 12.4
13 (29.5) 0 (0) 16 (36.4) 11 (25) 34 (77.3) 0 (0) 28 (63.6) 21 (47.7) 2.3 ± 1.2 0.79 ± 0.8 23.8 ± 4.7 9.1 ± 6.6 11.6 ± 9.6 87.5 ± 21.5 22.50 ± 11.2
0.657 0.243 0.111 0.010 0.354 0.057
doi:10.1111/jog.12274
J. Obstet. Gynaecol. Res. Vol. 40, No. 4: 1009–1014, April 2014
Are there any differences in psychiatric symptoms and eating attitudes between pregnant women with hyperemesis gravidarum and healthy pregnant women? Bilge Burçak Annagür1, Özlem Seçilmis¸ Kerimog˘lu2, S¸ule Gündüz1 and Aybike Tazegül2 1
Department of Psychiatry, and 2Department of Obstetrics and Gynecology, Faculty of Medicine, Selçuk University, Konya, Turkey
Abstract Aim: We aimed to determine the relationship between eating attitudes and psychiatric symptoms in women with hyperemesis gravidarum (HG) and to compare these women with healthy control subjects. Methods: The study sample included 48 women with HG, and the control group had 44 pregnant women. The patients were selected from women with HG hospitalized in the obstetric inpatient clinic. All of the participants were in the first trimester of pregnancy. The participants’ sociodemographic and clinical characteristics were recorded in the obstetric clinic. All of the participants completed a Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Eating Attitudes Test (EAT) and Body Image Scale (BIS). Results: Women with HG were more likely to have had a history of HG during their previous pregnancy (P < 0.05). There was no significant difference between the study and control groups regarding obstetric history. Women with HG were more influenced by food that induced nausea. There was no significant difference between the study and control groups for pre-pregnancy nausea, food craving and the initial BMI (P > 0.05). Depression and anxiety scores were significantly higher in women with HG (P < 0.05). However, there was no significant difference between the study and control groups for body image score and eating attitude test scores (P > 0.05). Conclusion: We suggest that HG appears to be associated with depression and anxiety symptoms rather than deterioration of eating attitudes and body image. However, these results should be confirmed by prospective and clinical studies. Key words: anxiety, depression, eating attitudes, hyperemesis gravidarum.
Introduction Nausea and vomiting (NV) are the most common symptoms during the first trimester of pregnancy. These symptoms affect approximately 75% of pregnant women, and although predominantly related to early pregnancy, it may continue beyond the first trimester.1 Whereas nausea and vomiting during
pregnancy is usually self-limited, hyperemesis gravidarum (HG) is a notable medical problem that may lead to fluid, electrolyte and acid–base imbalance, dehydration, nutrition deficiency, weight loss, anemia and ketonuria, and may often lead to hospital admission.1,2 HG affects 0.5–2% of pregnant women, and 10% of those diagnosed will require at least one inpatient hospitalization.3
Received: May 10 2013. Accepted: August 12 2013. Reprint request to: Dr Bilge Burçak Annagür, Selçuk Üniversitesi, Alaeddin Keykubat Yerles¸kesi, Tıp Fakültesi, Psikiyatri AD, 42131 Selçuklu-Konya, Turkey. Email: [email protected] Conflict of interest: None declared.
© 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
1009
B. B. Annagür et al.
The pathogenesis of HG has not yet been clearly identified. Some endocrine factors, such as human chorionic gonadotropin, estrogens, progesterone and thyroid hormones, in addition to gastrointestinal dysfunction, hepatic abnormalities, autonomic nervous dysfunction and psychosomatic causes may play a role in this medical condition.4 However, it is unclear whether psychiatric symptoms may also play a role in the pathogenesis of HG. In a retrospective telephone survey, Mazzotta et al. suggested that depressive symptoms in pregnant women were found to be associated with more severe nausea and vomiting.5 Tan et al. showed that anxiety and depressive symptomatology was common in women with HG, and a risk factor could be identified.6 In a clinic-based study, Uguz et al.7 reported that mood and anxiety disorders and personality disturbances were frequently observed among women with HG, and there was a potential relationship between these psychiatric disorders and HG during pregnancy. However, the available studies on the topic have focused on mood and anxiety disorders and have been deficient in studying an association with HG and eating attitudes and eating disorders.6–9 In previous studies on the relationship between eating disorders and nausea and vomiting, women with eating disorders have been reported to have a higher rate of maternal and fetal complications,10 and pregnancy is known to be a time for increased risk for both remission from and re-emergence of eating disorder symptoms.11–13 Torgersen et al.14 suggested that eating disorders marked by the symptom of purging were associated with increased nausea and vomiting among women with bulimia nervosa and eating disorders not otherwise specified. However, they could not show any relationship between eating disorders and HG in the same study group. Koubaa et al.10 indicated that treatment and care for hyperemesis was significantly more common among women with eating disorders than for women without these disorders. In the current published work, there is no study investigating the eating attitudes of women with HG. We aimed to determine the relationship between eating attitudes and psychiatric symptoms in women with HG and to compare these women to healthy control subjects.
Methods Setting and sample The patients were selected from women with HG hospitalized in the Obstetric Inpatient Clinic of Selçuk
1010
University Hospital. The study was approved by the Selçuk University Medical Faculty’s ethics committee. The study’s objectives and procedures were explained, and written informed consent was given in accordance with the Declaration of Helsinki. Inclusion criteria were an age of 18–40 years and ability to communicate and to read and write Turkish. The exclusion criteria were severe medical illnesses (e.g. uncontrolled endocrine abnormalities, cardiovascular and pulmonary system diseases), gestational problems (e.g. imminent abortion, trophoblastic disease and ectopic pregnancy), or a history of schizophrenia or related psychotic disorders. Forty-eight patients with HG who required hospitalization due to dehydration, ketonuria, weight loss, and severe nausea and vomiting during their first trimester were included in the study. Gestational week was detected with ultrasound screening on the basis of the last menstruation date. After recording the participants’ sociodemographic and clinical characteristics in the obstetric clinic, patients were referred to the psychiatry department. After receiving medical treatment, patients with HG completed a Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Eating Attitudes Test (EAT) and Body Image Scale (BIS). A control cohort of 44 pregnant women without nausea and vomiting during the first trimester was recruited from the same obstetric outpatient clinic. The control group also completed the same self questionnaires.
Measures BDI The BDI is a 21-item self-report questionnaire that assesses severity of depression. Individuals are asked to rate themselves on a 0–3 spectrum (0 = least, 3 = most) with a score range of 0–63. The cut-offs used are: 0–8, no depression; 9–13, minimal depression; 14–19, mild depression; 20–28, moderate depression; and 29–63, severe depression. The total score is the sum of all items. The Turkish version of the BDI used in this study has been validated in Turkish populations.15 BAI The BAI is a 21-item self-report questionnaire. Each item is rated on a 4-point Likert scale ranging from 0 for not at all to 3 for severely. The total score ranges 0–63. A high overall score indicates a high level of anxiety. The Turkish version of the BAI used in this study has been validated in Turkish populations.16
© 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
Eating attitudes in hyperemesis gravidarum
EAT The EAT measures the meal-related behavior and attitude of patients with eating disorders and measures the possible disorders in the eating behavior of normal individuals. This self-administered questionnaire uses a Likert-type scale with six degrees and 40 items. The total points directly relate to the level of psychopathology. This instrument was developed by Garner and Garfinkel for screening eating disorders in adolescents older than 11 years.17 The Turkish version of EAT was validated by Erol and Savas¸ır.18 The cut-off point is assumed as 30 points for impaired eating behavior. BIS The BIS measures the satisfaction from various parts of the body. This self-questionnaire was developed by Secord and Jourard in 1953.19 The BIS uses a Likert-type scale and is composed of 40 items. It has no cut-off point. Low points indicate dissatisfaction. The Turkish version of BIS has been validated by Hovardaog˘lu in 1993.20 Body mass index (BMI) Patient BMI was calculated as the ratio of weight (kg) to height (m) squared (kg/m2).
Statistical analysis The data were analyzed using the Statistical Package for the Social Sciences version 15.0 for Windows. All variables were tested with the Kolmogorov–Smirnov test to determine whether their distributions were normal.
For comparisons within the study group, either Student’s t-test or Mann–Whitney U-test (when the data were not normally distributed) was used for continuous variables, and either the χ2-test or Fisher’s exact test was used for categorical variables. All P-values were two-tailed, and the statistical significance was set at P < 0.05.
Results The mean age of the sample (n = 92) was 27.7 ± 5.1 years. All of the participants were married. Half of the participants were primary school graduates (n = 50, 54.3%). Most of the participants were unemployed (n = 85, 92.4%) and had medium economic status (n = 83, 90.2%). All the women were in the first trimester of gestation, 30 (32.6%) women were primigravida and 26 (28.3%) women had a history of abortion. The mean number of children was 0.94 ± 0.94. There was no significant difference between the patients and control groups regarding sociodemographic characteristics (Table 1). Table 2 shows the clinical characteristics of the pregnant women with and without HG. Compared to women without HG, women with HG were more likely to have had a history of HG during their previous pregnancy. We found no significant difference between the patient and control groups for primigravida, multiple fetus, history of abortion, number of pregnancies, number of children and planned pregnancy. Regarding the eating characteristics of the study
Table 1 Sociodemographic characteristics of the study sample
Age, mean ± SD, years† Education, n (%)‡ Elementary High School University Employment status, n (%)§ Employed Economic status, n (%)‡ Low economic Medium economic Good economic Spouse’s education, n (%)‡ Elementary High School University
HG group (n = 48)
Control group (n = 44)
P
27.5 ± 5.3 0.171 30 (62.5) 13 (27.1) 5 (10.4) 0.051 1 (2.1) 0.512 5 (10.4) 42 (87.5) 1 (2.1) 0.643 17 (35.4) 20 (41.7) 11 (22.9)
27.9 ± 4.8
0.701
20 (45.5) 14 (31.8) 10 (22.7) 6 (13.6) 3 (6.8) 41 (93.2) 0 (0) 12 (27.3) 19 (43.2) 13 (29.5)
†Independent Student’s t-test. ‡χ2-Test. §Fisher’s exact test. HG, hyperemesis gravidarum; SD, standard deviation.
© 2013 The Authors Journal of Obstetrics and Gynaecology Research © 2013 Japan Society of Obstetrics and Gynecology
1011
B. B. Annagür et al.
Table 2 Clinical characteristics of the study sample
Primigravida, n (%)† Multiple fetus, n (%)† History of abortion, n (%)† History of HG, n (%)† Planned pregnancy, n (%)† Pre-pregnancy nausea, n (%)† Nausea with the smell of food, n (%)† Food craving, n (%)† No. of pregnancies, mean ± SD‡ No. of children, mean ± SD‡ Initial BMI, mean ± SD‡ BDI score, mean ± SD§ BAI score, mean ± SD‡ Body Image Scale score, mean ± SD‡ EAT score, mean ± SD‡
HG group (n = 48)
Control group (n = 44)
P
17 (35.4) 3 (6.3) 10 (20.8) 25 (52.1) 32 (66.7) 5 (10.4) 46 (95.8) 28 (58.3) 2.3 ± 1.4 1.08 ± 1.0 23.9 ± 4.4 15.7 ± 9.3 17.8 ± 12.8 90.8 ± 24.8 23.18 ± 12.4
13 (29.5) 0 (0) 16 (36.4) 11 (25) 34 (77.3) 0 (0) 28 (63.6) 21 (47.7) 2.3 ± 1.2 0.79 ± 0.8 23.8 ± 4.7 9.1 ± 6.6 11.6 ± 9.6 87.5 ± 21.5 22.50 ± 11.2
0.657 0.243 0.111 0.010 0.354 0.057
