Part 1 book “Biopsychosocial factors in obstetrics and gynaecology” has contents: The brain, heart and human behaviour, domestic violence and abuse, female genital cutting, biopsychosocial aspects of eating disorders in obstetrics and gynaecology, biopsychosocial factors in chronic pelvic pain, biopsychosocial aspects of infertility,… and other contents.
Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information Biopsychosocial Factors in Obstetrics and Gynaecology © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien Manchester Academic Health Science Centre P M Shaughn O’Brien Keele University School of Medicine © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information University Printing House, Cambridge CB2 8BS, United Kingdom One Liberty Plaza, 20th Floor, New York, NY 10006, USA 477 Williamstown Road, Port Melbourne, VIC 3207, Australia 4843/24, 2nd Floor, Ansari Road, Daryaganj, Delhi – 110002, India 79 Anson Road, #06–04/06, Singapore 079906 Cambridge University Press is part of the University of Cambridge It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning, and research at the highest international levels of excellence www.cambridge.org Information on this title: www.cambridge.org/9781107120143 DOI: 10.1017/9781316341261 © Leroy C Edozien and P M Shaughn O’Brien 2017 This publication is in copyright Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published 2017 Printed in the United Kingdom by TJ International Ltd Padstow Cornwall A catalogue record for this publication is available from the British Library Library of Congress Cataloging-in-Publication Data Names: Edozien, Leroy C., editor | O’Brien, P M Shaughn, editor Title: Biopsychosocial factors in obstetrics and gynaecology / edited by Leroy C Edozien, P.M Shaughn O’Brien Description: Cambridge, United Kingdom ; New York, NY : University Printing House, 2017 | Includes bibliographical references and index Identifiers: LCCN 2017024673 | ISBN 9781107120143 Subjects: | MESH: Genital Diseases, Female – psychology | Pregnancy Complications – psychology | Women’s Health | Psychophysiology – methods Classification: LCC RG126 | NLM WP 140 | DDC 618.1/0651–dc23 LC record available at https://lccn.loc.gov/2017024673 ISBN 978-1-107-12014-3 Hardback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs of equipment that they plan to use © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information LCE: To my daughter, Nicole PMSO: To all the patients who have participated in my research studies over the past 40 years © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information Contents List of Contributors Preface xiii x Section Generic Issues Promoting and Implementing the Biopsychosocial Perspective in Obstetrics and Gynaecology: The Role of Specialist Societies Sibil Tschudin Psychosocial Context of Illness and Well-Being in Women’s Health Susan Ayers and Elizabeth Ford Epigenetics: The Bridge between Biology and Psychosocial Health 15 Leroy C Edozien Communicating Effectively: The Patient– Clinician Relationship in Women’s Healthcare 21 Jillian S Romm and Lishiana Solano Shaffer Biopsychosocial Aspects of Eating Disorders in Obstetrics and Gynaecology 31 Suzanne Abraham The Brain, Heart and Human Behaviour 41 Leroy C Edozien Complementary Medicine for Women’s Healthcare 47 Helen Hall Domestic Violence and Abuse 54 Rachel Adams and Susan Bewley Female Genital Cutting Leroy C Edozien 66 Section Gynaecology 10 Diverse Sex Development: Critical Biopsychosocial Perspectives 73 Lih-Mei Liao 11 Biopsychosocial Factors in Paediatric and Adolescent Gynaecology 82 Gail Busby, Gail Dovey-Pearce and Andrea Goddard 12 Biopsychosocial Factors in Premenstrual Syndrome 94 Deepthi Lavu, Suman Kadian and P M Shaughn O’Brien 13 Biopsychosocial Factors in Abnormal Uterine Bleeding 102 Tereza Indrielle-Kelly, Zeiad El Gizawy and P M Shaughn O’Brien 14 Biopsychosocial Aspects of Infertility 110 Lamiya Mohiyiddeen and Christian Cerra 15 Psychological and Social Aspects of Reproductive Life Events among Men 121 Jane R W Fisher and Karin Hammarberg 16 Biopsychosocial Factors in Chronic Pelvic Pain 131 Linda McGowan vii © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information Contents 17 Biopsychosocial Factors in Emergency Gynaecology 139 Olanike Bika 27 Biopsychosocial Factors in Prenatal Screening and Diagnosis for Fetal Anomaly 237 Louise D Bryant 18 Biopsychosocial Factors in Urinary Incontinence 146 Caroline E North and Jason Cooper 28 The Maternal–Fetal Relationship: Conceptualization, Measurement and Application in Practice 245 Zoe Darwin and Judi Walsh 19 Biopsychosocial Perspectives on the Menopause 160 Myra S Hunter and Melanie Smith 29 Reproductive Health Care for Women with Psychosocial Issues 255 Mary Hepburn 20 Biopsychosocial Factors in Gynaecological Cancer 169 Laura E Simonelli and Amy K Otto 30 Maternal Psychosocial Distress 263 Leroy C Edozien 21 Assessment and Management of Women with Nausea and Vomiting during Pregnancy: A Biopsychosocial Approach 178 David McCormack and Leroy C Edozien Section Sexual and Reproductive Health 22 Psychosexual Disorders 189 Claudine Domoney and Leila Frodsham 23 Psychosocial Aspects of Fertility Control Jonathan Schaffir 199 24 Legal and Ethical Factors in Sexual and Reproductive Health 209 Bernard M Dickens and Rebecca J Cook Section Obstetrics and Maternal Health 31 The Effects of Stress on Pregnancy: A Not-So-Evident Association Revisited 271 Denise Defey 32 Biopsychosocial Approach to the Management of Drug and Alcohol Use in Pregnancy 280 Nancy A Haug, Raquel A Osorno, Melissa A Yanovitch and Dace S Svikis 33 Biopsychosocial Factors in Preterm Labor and Delivery 292 Gabriel D Shapiro, William D Fraser and Jean R Séguin 34 Tokophobia 300 Kristina Hofberg and Yana Richens 35 Psychiatric Disorders in Pregnancy and Lactation 308 Angelika Wieck 25 The Psychobiology of Birth 219 Amali Lokugamage, Theresa Bourne and Alison Barrett 36 Psychotherapy in Pregnancy and Following Birth: Basic Principles and Transcultural Aspects 319 Mary Steen and Tahereh Ziaian 26 Assessment of Psychosocial Health during the Perinatal Period 228 Julie Jomeen 37 Biopsychosocial Factors in Intrapartum Care 328 Leroy C Edozien viii © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information Contents 38 Biopsychosocial Factors in Postnatal Care 337 Caroline Hunter and Hannah Rayment-Jones 41 Biopsychosocial Care after the Loss of a Baby 368 Leroy C Edozien 39 Birth Trauma and Post-Traumatic Stress 348 Pauline Slade and Elinor Milby 40 Vicarious Traumatization in Maternity Care Providers 359 Pauline Slade, Kayleigh Sheen and Helen Spiby Appendix: RCOG Checklist of Hints and Tips to Support Clinical Practice in the Management of Gender-Based Violence 377 Index 379 ix © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information Contributors Suzanne Abraham Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, Australia Jason Cooper Consultant Gynaecologist, Royal Stoke University Hospital, UK Rachel Adams Senior House Officer, Lewisham and Greenwich NHS Trust Zoe Darwin School of Healthcare, University of Leeds, UK Susan Ayers Centre for Maternal and Child Health Research, City University, London, UK Alison Barrett Consultant Obstetrician and Gynaecologist, Waikato Hospital, Hamilton, NZ Susan Bewley Professor of Women’s Health King’s College London, and Sexual Offences Examiner The Havens Sexual Assault Referral Centre London Olanike Bika Consultant Obstetrician and Gynaecologist, Rotherham NHS Foundation Trust Hospital, UK Theresa Bourne Associate Professor, Middlesex University, London, UK Louise D Bryant Associate Professor in Medical Psychology, Leeds Institute of Health Sciences, University of Leeds, UK Gail Busby St Mary’s Hospital, Manchester, UK Christian Cerra Specialist Trainee in Obstetrics and Gynaecology, North Western Deanery, UK Rebecca J Cook Professor Emerita, Faculty Chair in International Human Rights, University of Toronto, Canada Denise Defey School of Midwifery (School of Medicine), University of Uruguay Chair, Dept of Perinatal Psychology, Agora Institute, Uruguay Bernard M Dickens Professor Emeritus of Health Law and Policy, Faculty of Law, Faculty of Medicine and Joint Centre for Bioethics, University of Toronto, Canada Claudine Domoney Consultant Obstetrician and Gynaecologist, Chelsea and Westminster Hospital, UK Gail Dovey-Pearce Consultant Clinical Psychologist, Child Health, Northumbria Healthcare NHS Foundation Trust & Associate Researcher, Newcastle University Leroy C Edozien Consultant in Obstetrics and Gynaecology at the Central Manchester University Hospitals NHS Trust and Manchester Academic Health Science Centre, UK Jane Fisher Jean Hailes Professor of Women’s Health, Monash University, Australia Elizabeth Ford Research Fellow in Primary Care Epidemiology, Brighton and Sussex Medical School, University of Brighton, UK x © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information List of Contributors William D Fraser Professor, Department of Obstetrics and Gynecology, Université de Sherbrooke, Canada Suman Kadian Consultant Obstetrician and Gynaecologist, Royal Stoke University Hospital, UK Leila Frodsham Consultant Gynaecologist and Psychosexual Medicine Lead, Guy’s and St Thomas’ NHS Trust, London, UK Deepthi Lavu Specialist Trainee and Academic Clinical Fellow, Royal Stoke University Hospital, Staffordshire, UK Zeiad el Gizawy Consultant Obstetrician and Gynaecologist, Royal Stoke University Hospital, UK Lih-Mei Liao Women’s Health Division, University College London Hospitals NHS Foundation Trust, UK Andrea Goddard Department of Paediatrics, St Mary’s Hospital, London, UK Amali Lokugamage Consultant Obstetrician and Gynaecologist, Whittington Hospital, London, UK Helen Hall Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia David McCormack Maudsley Hospital, South London, and Maudsley NHS Foundation Trust, and Department of Psychological Medicine, King’s College London, UK Karin Hammarberg Jean Hailes Research Unit, School of Public Health and Preventive Medicine, Monash University, Australia Nancy A Haug PGSP-Stanford University Psy.D Consortium, Palo Alto University, Palo Alto, CA, USA Mary Hepburn Independent Consultant Obstetrician and Gynaecologist, Scotland, UK Kristina Hofberg Consultant Perinatal Psychiatrist, St George’s Hospital, Stafford, UK Caroline Hunter Midwifery Tutor, Florence Nightingale Faculty of Nursing and Midwifery, King’s College London, UK Myra S Hunter Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK Tereza Indrielle-Kelly Specialist Trainee, Royal Stoke University Hospital, Staffordshire, UK Julie Jomeen Professor of Midwifery, University of Hull, UK Linda McGowan Professor in Applied Health Research, School of Healthcare, University of Leeds Elinor Milby University of Liverpool, UK Lamiya Mohiyiddeen Consultant Gynaecologist, Department of Reproductive Medicine, St Mary’s Hospital, Manchester, UK Caroline E North Consultant Obstetrician and Gynaecologist, Royal Stoke University Hospital, UK P M Shaughn O’Brien Professor of Obstetrics and Gynaecology, Keele University School of Medicine and Consultant Obstetrician and Gynaecologist, Royal Stoke University Hospital, UK Raquel A Osorno PGSP-Stanford University Psy.D Consortium, Palo Alto University, Palo Alto, CA, USA Amy K Otto Helen F Graham Cancer Center and Research Institute, Newark, DE, USA xi © in this web service Cambridge University Press www.cambridge.org Cambridge University Press 978-1-107-12014-3 — Biopsychosocial Factors in Obstetrics and Gynaecology Edited by Leroy C Edozien , P M Shaughn O'Brien Frontmatter More Information List of Contributors Hannah Rayment-Jones Tutor in Midwifery, Florence Nightingale School of Nursing and Midwifery, King’s College London, UK Yana Richens Consultant Midwife, University College Hospital, London, UK Jillian S Romm Associate Professor, Department of Obstetrics and Gynecology, Oregon Health Sciences University, Portland, Oregon, USA Jonathan Schaffir Associate Professor, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio, USA Jean R Séguin Department of Psychiatry, Université de Montréal, CHU Ste-Justine Research Center, Canada Lishiana Solano Shaffer Assistant Professor, Department of Obstetrics and Gynecology, Oregon Health Sciences University, Portland, Oregon, USA Gabriel D Shapiro Department of Epidemiology, Biostatistics and Occupational Health, McGill University, USA Kayleigh Sheen Postdoctoral Research Associate, University of Liverpool, UK Laura E Simonelli Helen F Graham Cancer Center and Research Institute at Newark, DE, USA Melanie Smith Manchester and Salford Pain Centre, Manchester, UK Helen Spiby Professor of Midwifery, University of Nottingham and Honorary Professor, University of Queensland, Australia Mary Steen Professor of Midwifery, University of South Australia, Adelaide, Australia Dace S Svikis Professor, Department of Psychology, Virginia Commonwealth University, USA Sibil Tschudin Department of Obstetrics and Gynecology, University Hospital Basel, Switzerland Judi Walsh School of Psychology, University of East Anglia, UK Angelika Wieck Consultant in Perinatal Psychiatry, Manchester Mental Health and Social Care Trust, Manchester, UK Melissa A Yanovitch PGSP-Stanford University Psy.D Consortium, Palo Alto University, Palo Alto, CA, USA Tahereh Ziaian Senior Lecturer, Division of Health Sciences, University of South Australia, Adelaide, Australia Pauline Slade Professor of Clinical Psychology and Consultant Clinical Psychologist, University of Liverpool, UK Editorial advisers: British Society of Biopsychosocial Obstetrics and Gynaecology (BSBOG) Executive Committee xii © in this web service Cambridge University Press www.cambridge.org Section Gynaecology Social Factors Role Changes and Social Isolation Impaired social functioning is associated with increased distress and decreased quality of life Survivors with more social contacts and social support have been found to be less negatively affected by their cancer, reporting fewer symptoms of anxiety and depression, better role functioning, more energy and better health than those who are more socially isolated [40] Patients often experience significant interference to their social activities and family life Many of the physical sequelae of treatment can impact daily activities, ability to work and body image For example, urinary incontinence [10], lymphoedema [54] or cognitive impairment [5] can create feelings of embarrassment or decreased self-confidence and are associated with social withdrawal Fertility issues, sexual dysfunction and menopausal symptoms stemming from cancer treatment leave some patients feeling like ‘damaged goods’, which may also contribute to social isolation [31] Reducing or stopping work may result in disconnection from social contacts as well Although cancer survivors in general are at an elevated risk of unemployment compared to healthy individuals, gynaecologic (and breast) cancer survivors are even more likely to choose to stop working or reduce their work hours than other cancer survivors [53] Younger survivors in particular appear to report greater interference in their social and family lives; however, they report better role functioning than older survivors, as measured by limitations on work, daily activities and pursuing hobbies [53] Changes in Sexual Relationships Partners of women with gynaecological cancer are also affected by loss of sexuality and intimacy Resentment, withdrawal and relationship conflict can develop due to partner’s mixed responses, including worrying about the patient’s health, and desiring sexual activity but feeling guilty [30] Conversely, some research has suggested that patients’ feelings of intimacy during sexual activity may actually increase following their diagnosis [28] Health Disparities Additional social factors such as income and racial disparities can impact cancer outcomes As already mentioned, gynaecological cancer rates and mortality 21 are higher in less-developed regions of the world [2] In the United States, low-income and minority women are less likely to receive adjuvant treatment, less likely to adhere to treatment and more likely to die from gynaecologic cancers [37] Low-income women with gynaecologic cancer report greater unmet supportive care needs related to physical/daily living and practical concerns, and African-American women report greater unmet sexuality and psychological needs compared to their Caucasian counterparts [55] Patient navigation [37] and multidisciplinary care, including psychology, physical therapy, and social work [55], to target unmet needs may improve adherence and subsequent outcomes Summary The biopsychosocial and quality-of-life impairment of gynaecological cancer is extensive, from multisystem physical sequelae, to depression and anxiety, to role and relationship changes and social isolation As summarized, some of these issues can be addressed with multidisciplinary approaches including medical, physical therapy and psychological treatments, whilst others have fewer approaches available Research has been less devoted to gynaecological cancers compared to other cancers affecting women, and a more concentrated effort at the many and sometimes unique issues gynaecologic cancer survivors face is warranted Additionally, since many survivors not have access to or awareness of the full range of resources available, research should also continue to examine health disparities and develop outreach options for underdeveloped regions and underserved populations Key Points • Gynaecological cancers account for 11% of all cancers diagnosed in women • The gynaecological cancer patient’s physical and emotional symptom burden negatively impacts health-related and overall quality of life • Quality-of-life concerns in gynaecological cancer vary by disease site and can include issues related to physical functioning (e.g urinary and faecal incontinence, dyspareunia, lymphoedema) and psychosocial functioning (e.g body image concerns, role changes, anxiety, depression, sexual dysfunction) 11:49:10 Biopsychosocial Factors in Gynaecological Cancer • Cognitive changes such as memory loss, shortterm memory impairment and difficulty concentrating or learning new skills are common following treatment for gynaecological cancer • For many cancer patients, anxiety is often focussed around fear of cancer recurrence • Although about a quarter of all cancer patients experience depression, few are offered treatment for their depressive symptoms This is thought to be due to the underestimation of depressive symptoms on the part of providers as well as the expectation among both patients and providers that depression is a normal part of the cancer experience • Many women respond to worries about death with avoidance strategies like distraction; others take a more task-oriented approach, making lists and getting legal documentation in order, or an emotionoriented approach, using positive self-talk and relying on ‘inner psychological strength’ to cope • Psychosocial assessment should be part of the routine care of women with gynaecological cancer Tools for doing this are available 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Gynecological cancer survivors: Assessment of psychological distress and unmet supportive care needs J Psychosoc Oncol 2011;29(5):534–551 An exploratory study J Psychosoc Oncol 2007;26(1):53–68 [49] Lopez-Acevedo M, Lowery WJ, Lowery AW, Lee PS, Havrilesky LJ Palliative and hospice care in gynecologic cancer: A review Gynecol Oncol 2013;131(1):215–221 [50] Havrilesky LJ Palliative services enhance the quality and value of gynecologic cancer care Gynecol Oncol 2014;1(132):1–2 [51] Simonelli LE, Fowler J, Maxwell GL, Andersen BL Physical sequelae and depressive symptoms in gynecologic cancer survivors: Meaning in life as a mediator Ann Behav Med 2008;35(3):275–284 [52] Andersen BL, Woods XA, Copeland LJ Sexual self-schema and sexual morbidity among gynecologic cancer survivors J Consult Clin Psychol 1997;65(2):221–229 [53] Bifulco G, De Rosa N, Tornesello M, Piccoli R, Bertrando A, Lavitola G, et al Quality of life, lifestyle behavior and employment experience: A comparison between young and midlife survivors of gynecology early stage cancers Gynecol Oncol 2012;124(3):444–451 [47] Kim H Understanding Death Anxiety in Women with Gynecologic Cancer 2009 [54] Carter J, Penson R, Barakat R, Wenzel L Contemporary quality of life issues affecting gynecologic cancer survivors Hematol Oncol Clin North Am 2012;26(1):169–194 [48] Sigal JJ, Ouimet MC, Margolese R, Panarello L, Stibernik V, Bescec S How patients with less-advanced and more-advanced cancer deal with three death-related fears: [55] Simonelli LE, Pasipanodya E Health Disparities in Unmet Support Needs of Women with Gynecologic Cancer: An Exploratory Study J Psychosoc Oncol 2014;32(6):727–734 21 11:49:10 177 Chapter 21 Assessment and Management of Women with Nausea and Vomiting during Pregnancy A Biopsychosocial Approach David McCormack and Leroy C Edozien Introduction Nausea and vomiting are very common symptoms experienced during pregnancy, with approximately 80% of pregnant women experiencing some vomiting and/or nausea and 52% having both nausea and vomiting [1] A smaller number of pregnant women, approximately 0.3 to 1.5%, will experience hyperemesis gravidarum (HG), which is a severe and intractable form of nausea and vomiting during pregnancy (NVP), typically starting between the fourth and sixth weeks of gestation and resolving before the end of the 22nd week, with around 13% reporting it as lasting beyond 20 weeks’ gestation [1–3] NVP is associated with negative physical, social and psychological effects [4–6] Severe and persistent vomiting, particularly if left untreated, can lead to maternal weight loss, dehydration and electrolyte imbalance; if electrolyte disturbance occurs, there is some evidence that this presents an elevated risk of lower birth weight and fetal anomalies [7–9] Aetiology of Nausea and Vomiting during Pregnancy At present the precise aetiology of NVP is unknown, and the exact relationship between mild-moderate symptoms (i.e typical NVP) and the more uncommon severe and persistent presentation of symptoms (i.e HG) is unclear There have been many aetiological theories proposed including genetic, biochemical, immunological and conceptualizing it as being fetoprotective or a by-product of maternal-embryo conflict [10–12] In addition, psychological theories have been advanced [13] Psychological theories range from viewing NVP as a form of conversion/somatization disorder through 22 to seeing it as a result of behavioural conditioning The psychological approach conceptualizing NVP as a form of conversion disorder is underpinned by the assumption that the symptoms observed are the physical manifestation of ambivalence of attitude from the mother towards her developing baby (i.e fetus), and/or overwhelming psychical conflict or dysphoric affect [14] Despite a number of nuanced theoretical accounts and research carried out in this area, there is little evidence to support the conversion/somatization theory [15, 16] Another notable psychological theory, the behavioural conditioning formulation, attempts to account for persistent NVP by proposing that stimuli which would not normally trigger NVP, such as, food, places, people and normal physiologic symptoms (i.e unconditioned stimuli), become ‘conditioned stimuli’ after repeated episodes of typical NVP That is, food, places, people etc through repeated pairings/association with NVP become by themselves capable of inducing nausea and vomiting (i.e the unconditioned stimuli become conditioned stimuli) As a consequence, nausea and vomiting becomes more frequent and persistent [17] The explanation as to why all women with NVP not develop more severe and persistent symptoms rests on the assumption that some women are more susceptible to conditioning than others (e.g individual differences in autonomic nervous system functioning, particularly having a more reactive sympathetic nervous system) There is some limited evidence to support this assumption, for example an interesting small non-prospective study found that pregnant women with HG were more hypnotizable (i.e more prone to conditioning) than pregnant women without HG [18] Preliminary data showing that hypnosis may be effective at reducing NVP for some women appears to lend further 13:56:46 Assessment and Management of Women with Nausea and Vomiting during Pregnancy support to the role of conditioning; however, fully powered and methodologically rigorous research studies are needed to confirm this [19] Overall, while the behavioural conditioning theory may help explain why some pregnant women with mild nausea and vomiting of pregnancy go on to develop more severe symptoms, it does not provide a persuasively robust aetiological account for why the symptoms occur in the first place The majority of the research supporting a psychogenic origin of NVP and HG suffers from methodological problems Typically, published studies in this area seldom include control comparison groups, are not prospective, and most of the studies are cross-sectional in design As a consequence, based on present data, the direction of effect is difficult to establish That is, are psychological effects the cause of nausea and vomiting or the result? There is growing evidence that psychological effects are secondary to NVP and HG [20] Currently there appears to be insufficient evidence for a psychogenic origin However, it does appear as though NVP can negatively impact on the psychological and emotional well-being of pregnant women, and it seems theoretically plausible that psychological distress and behavioural conditioning could play a role in exacerbating symptoms for some women [21] At present pursuing a biological line of enquiry and studying the role of hormones such as oestrogen, progesterone and particularly human chorionic gonadotropin (hCG) may prove fruitful in better understanding the aetiology of NVP and HG While hCG seems very likely to play an important role in the aetiology of NVP and HG, there is insufficient evidence that it is causal For example, some women who not experience NVP have been found to have elevated levels of hCG [22] This has led some to speculate that this may be attributable to biological activity of different isoforms of hCG in addition to individual differences among women regarding their sensitivity to emetogenic stimuli [23] It has also been theorized that hCG may play a role in increasing the production of prostaglandin E2 and this then is a key factor in what causes NVP [24] It seems likely that what causes and maintains NVP may turn out to be multifactorial and that there may be slightly different variables at play depending on the individual woman and her present circumstances That is, similar to other medical conditions (e.g chronic pelvic pain [25], see Chapter 16), psychological, environmental and social factors may unhelpfully interact with 22 Biological (e.g rising levels of hCG) Nausea and vomiting Environmental (e.g food, odours) Psychosocial effects (e.g stress) Figure 21.1 A biopsychosocial model of nausea and vomiting of pregnancy physiological processes, which may then exacerbate symptoms and negatively affect functioning and quality of life Taking this more complex multifactorial view of what causes and maintains NVP has led some researchers to propose that a biopsychosocial approach be adopted [26] Informed by this approach a simple hypothetical model is presented in Figure 21.1 Within this model the hypothesized driver for the symptoms is biological (e.g rising levels of hCG), which increases the risk of NVP Triggers for NVP episodes may be internal (e.g physiological) or external (e.g environmental – such as food odours) and/or a complex interplay of both internal and external factors Within this model resultant NVP then effectively becomes a psychological and social stressor, contributing to psychological distress and negative social effects The negative social effects may include challenges in performing occupational duties, and placing a strain on relationships leading to insufficient social support being available [6] It seems plausible that social effects and psychological distress could then negatively interact with one another (e.g strained relationships may increase anxiety and in turn anxiety contributes to making relationships with others more strained), and these psychosocial effects, particularly stress and anxiety, may then further increase the risk of nausea and vomiting and/or exacerbate symptoms [27] Taking a biopsychosocial approach may prove a useful paradigm to use both in the search for what 13:56:46 179 Section Gynaecology causes and maintains NVP and as a framework for its assessment and management Assessment In line with the biopsychosocial approach we will firstly outline how to carry out a biopsychosocial assessment of NVP and HG We will start out with the medical assessment before moving on to look at how to assess the psychological and social aspects Medical The first step is to take a careful history which includes assessing the onset of symptoms, the typical duration and severity of nausea and vomiting, and asking the patient about any associated symptoms (e.g weight loss, abdominal pain) and/or other conditions that they may have (e.g diabetes) Examination and investigation should then be guided by history and include taking the patient’s temperature, pulse, blood pressure and testing the urine for ketones, and looking for signs of dehydration It is crucial before diagnosing NVP that other causes for the symptoms are excluded; this is particularly relevant when symptoms commence after week ten of gestation and when attendant symptoms other than fatigue are present [23] Making a diagnosis of NVP involves a process of exclusion As NVP might not be directly related to the pregnancy itself, it is routine practice to exclude other causes, including gastroenteritis, metabolic disorders, thyroid and other endocrine conditions, appendicitis, nephrolithiasis etc [28–32] Once NVP is confirmed it is important to then establish if the symptoms suggest typical NVP (i.e mild-moderate symptoms) or HG (i.e severe and persistent symptoms) with or without metabolic imbalance The use of a standardized measure is recommended; for instance, the Pregnancy-Unique Quantification of Emesis (PUQE) is a brief validated measure which enables symptoms to be classed as mild, moderate or severe [33] ICD-10 defines HG as severe and persistent NVP starting before the end of the 22nd week of gestation [3] (ICD-10, code 021.1) It is associated with dehydration, ketonuria and weight loss [32] Psychological There is evidence that NVP / HG negatively impact on functioning and is associated with psychological 22 and emotional difficulties [5,20] As a result one should sensitively enquire as to how the patient is coping, how they feel generally and when they experience symptoms, if their daily activities are affected by their symptoms and/or how they are feeling emotionally This should help gain some understanding of their social functioning and emotional well-being The Whooley questions, while primarily intended to screen for depression, can be helpful to facilitate discussion of emotional issues generally [34] They consist of the following: (1) During the past month have you been bothered by feeling down, depressed or hopeless? (2) During the past month, have you been bothered by having little interest or pleasure in doing things? As the Whooley questions not assess other common psychological and emotional difficulties associated with NVP and HG (e.g anxiety problems), it is important to enquire about such symptoms National Institute for Health and Care Excellence (NICE) guidance for antenatal and postnatal mental health recommends when assessing depression and anxiety to also consider using the 2-item Generalized Anxiety Disorder scale (GAD-2) [35]: (1) Over the last two weeks, how often have you been bothered by feeling nervous, anxious or on edge? Not at all (score = 0) Several days (score = 1) More than half the days (score = 2) Nearly every day (score = 3) (2) Over the last two weeks, how often have you been bothered by not being able to stop or control worrying Not at all (score = 0) Several days (score = 1) More than half the days (score = 2) Nearly every day (score = 3) If the patient answers yes to either of the Whooley questions and/or scores or more on the 2-item anxiety scale (GAD-2) [36], it would likely be helpful to assess her past and current mental health in more detail Administering standardized measures, such as the EPDS [37] or PHQ-9 [38] to screen for depression and/or GAD-7 [39] to further screen for anxiety, may also prove useful If psychological and emotional difficulties are identified, it is worth asking the patient, ‘is this something you feel you need help with?’ (the ‘Arrol’ question) After discussing this with the patient you may 13:56:46 Assessment and Management of Women with Nausea and Vomiting during Pregnancy consider that a referral to a clinical psychologist or psychiatrist is warranted It is very important when working with a patient with NVP, and particularly when discussing issues around mental health, that it is done sensitively, and that one makes an active attempt to carefully listen and empathize with the patient If a patient is treated unsympathetically it risks worsening her psychological and emotional well-being [40] If she is found to be experiencing mental health difficulties, where possible try to help normalize what she is experiencing and reassure her (e.g let her know that such problems are common) and try to instil hope that something can be done to help ameliorate and manage her difficulties Social Assessing whether the patient has adequate social support and is aware of sources of help is an important part of the assessment process Women with NVP and HG, just like everyone, are members of dynamic social systems (e.g families, workplaces, medical teams) and are influenced by these cognitively, emotionally and behaviourally – that is, the individuals affect the systems they are in and these systems affect the individuals The impact on the individual can be positive (e.g she feels supported) or negative (e.g the person experiences low mood because of how she is treated by others) One needs to be mindful when working with a patient with NVP/HG to consider her social context, the systems she inhabits NVP and particularly HG can negatively impact on the woman’s well-being, functioning and her social support system [26] How well a woman is supported may in turn affect her general well-being, how well she copes and manages with nausea and vomiting and adapts to pregnancy [27] A number of questionnaires have been developed to assess social functioning and/or the social support needs of pregnant women; for example, the Social Functioning Questionnaire [41] assesses social functioning in a number of situations (e.g functioning at work and home, financially and in relationships) The Short Form Social Support Questionnaire assesses perceived social support [42], and a brief Maternity Social Support Scale has also been developed [43] These measures have their advantages; for example, they can give a quick snapshot of social functioning and/or social support needs, and they are often quicker to administer and score than conducting a verbal assessment 22 However, there are a number of shortcomings; for instance, they lack specificity and may miss out on details that can emerge during a conversation between the doctor and patient – with these details, tailored follow-up questions can then be asked to highlight specific unmet needs which can be addressed Asking patients questions about their social support and functioning should help gain an insight into their present circumstances and enable an assessment of whether they require input regarding this (e.g having additional social support put in place) Aspects of social support and functioning that may be helpful to ask about include (1) they feel that they are getting the support that they need from others (e.g partner/family); (2) is there anyone in particular that they can rely on when they need practical help; (3) is there anyone who provides them with emotional support; (4) are they having any difficulties at home (e.g with partner, children, finances); (5) if they are working, are they having any problems at work and they feel well supported by colleagues and/or management; and (6) how satisfied are they with the support that they are receiving from others It is important to be mindful that some women might find talking about such issues to be irrelevant to their symptoms and/or distressing to talk about Providing the woman with a brief rationale as to why you are asking such questions, being warm and empathic, and tailoring the questions to make them relevant to her situation may diffuse such problems and lead to a meaningful and useful conversation Formulation of the Assessment After carrying out a biopsychosocial assessment the doctor should be in a position to formulate what the main difficulties are and to have ascertained what is likely contributing to the nausea and vomiting and/ or making it particularly challenging to cope with (e.g if secondary psychological distress is present and/or there is insufficient social support) Sharing this formulation with patients increases the likelihood that they will feel heard and understood and it also provides an opportunity to see what their views are Any differences of opinion can then be discussed and ideally, a shared understanding of what has caused and is maintaining/contributing to the symptoms can be reached This is an important step before moving on to agreeing to a management 13:56:46 181 Section Gynaecology BOX 21.1 Regime of Antiemetic Therapies Recommended by the Royal College of Obstetricians and Gynaecologists [48] First Line Cyclizine 50 mg PO, IM or IV hourly Prochlorperazine 5–10 mg 6–8 hourly PO; 12.5 mg hourly IM/IV; 25 mg PR daily Promethazine 12.5–25 mg 4–8 hourly PO, IM, IV or PR Chlorpromazine 10–25 mg 4–6 hourly PO, IV or IM; or 50–100 mg 6–8 hourly PR Second Line Metoclopramide 5–10 mg hourly PO, IV or IM (maximum days’ duration) Domperidone 10 mg hourly PO; 30–60 mg hourly PR Ondansetron 4–8 mg 6–8 hourly PO; mg over 15 minutes 12 hourly IV Third Line Corticosteroids: hydrocortisone 100 mg twice daily IV and once clinical improvement occurs, convert to prednisolone 40–50 mg daily PO, with the dose gradually tapered until the lowest maintenance dose that controls the symptoms is reached IM intramuscular; IV intravenous; PO by mouth; PR by rectum plan because if the woman and her doctor have a shared understanding of the illness it should hopefully improve her satisfaction with the care provided [44] This then will facilitate development of a comprehensive mutually-agreed management plan that should address the woman’s symptoms and any secondary difficulties Management The management of NVP and HG should be guided and informed by the assessment In line with the biopsychosocial approach we will describe both the medical treatment of NVP/HG, and how to manage psychosocial aspects Medical Management NVP – Mild to Moderate Symptoms Most women with mild to moderate NVP should be able to be cared for in the community by primary care teams Pharmacological treatments include antiemetics, such as promethazine or cyclizine, as there is some evidence that these are both safe and effective [45–47] Cyclizine is both an anticholinergic drug and an antihistamine (H1 receptor blocker) The phenothiazines (promethazine, prochlorperazine) are dopamine receptor antagonists Promethazine is also an antihistamine Metoclopramide is a dopamine receptor antagonist but also has a direct action on the gastrointestinal 22 tract Drug-induced extrapyramidal symptoms and oculogyric crises can occur with the use of phenothiazines and metoclopramide If this occurs, there should be prompt cessation of the medications To minimize this risk, high-dose treatment should be avoided Metoclopramide should not be prescribed for more than five days Combinations of different drugs should be used in women who not respond to a single antiemetic A recommended regime of antiemetic therapy is reproduced in Box 21.1 Regarding non-pharmacological treatments, there is also some equivocal evidence that ginger and acupuncture/acupressure may be beneficial [45] Some women may also find that dietary and lifestyle modifications and avoidance of triggers may help (see Box 21.2) Some general advice in this regard may include that the woman tries eating bland food little and often until she can tolerate a normal well-balanced diet, that she remembers to stay hydrated, take rest when it is necessary, and if required temporarily avoid triggers, such as foods and odours For women with persistent or severe HG who are unable to tolerate oral medication, the parenteral or rectal route may be necessary Inpatient care should be considered when primary/outpatient care has failed, when symptoms are severe and persistent and/or ketonuria and weight loss greater than 5% of body weight occurs and/or when severe abdominal pain is present 13:56:46 Assessment and Management of Women with Nausea and Vomiting during Pregnancy BOX 21.2 Triggers of NVP/HG Environmental Stuffy room; humidity Perfume, food, smoke and other odours Noise and other abrasive auditory stimuli Flickering lights and similar visual challenges Excessively stressful situations Mealtime Habits and Diet Spicy, high-fat and acidic foods Lying down soon after eating and lying on the left side (both of which delay gastric emptying) Foods with a strong odour HG – Severe and Persistent Symptoms Those with severe and persistent symptoms will require more care and monitoring Nonetheless where possible even a woman with HG should be provided with care in the community particularly when suitable outpatient services are available, as this will avoid the inconvenience of hospital admission Treatment should include vitamin supplements (thiamine, folic acid) and antiemetics as well as careful assessment and close monitoring When dehydration, significant weight loss or electrolyte imbalance is detected, hospital admission is required If inpatient care is required treatment should commence by promptly addressing any signs of dehydration and electrolyte imbalance Treatment should start with intravenous fluid (normal saline or Hartmann’s solution) and electrolyte replacement [49] and include first-line antiemetics and ondansetron (a serotonin antagonist) The overall risk of birth defects associated with ondansetron exposure appears to be low, but there may be a small increase in the incidence of cardiac abnormalities, so ondansetron should be used as a second-line treatment [50] Corticosteroids should be considered only if symptoms not respond to standard treatment, and should be avoided in the first trimester [51] Some women with HG will develop a transient hyperthyroidism, due to the thyroid-stimulating activity of hCG This is a self-limiting condition, and treatment should not be offered unless there is other evidence (goitre or thyroid autoantibodies) of thyroid disease The patient should be carefully monitored and, when suitable for discharge, they should be provided 22 with symptom management advice (e.g continue with medications and basic advice regarding diet and lifestyle modifications) Before the woman is discharged if any additional specialist support is required she should be appropriately referred/signposted to services (e.g if a social work or a clinical psychology/psychiatry referral is required) Psychosocial Management Whether NVP symptoms are mild to moderate or severe and persistent, as in the case with HG, one should be mindful of the impact that symptoms can have on a woman’s well-being and quality of life After carrying out the psychosocial assessment and sharing a formulation of the assessment (see the assessment section earlier in this chapter), it should be clear to what extent nausea and vomiting are impacting on psychological and social functioning and the role that these may be playing in contributing to symptoms If the patient is found to have any psychological and emotional difficulties and/or insufficient social support (e.g the relationship with her partner is strained as a result of the symptoms), then this should guide where psychosocial interventions are targeted For example, if anxiety problems seem to be contributing to the symptoms or making them more challenging to manage and cope with, then these should be addressed by providing evidence-based interventions, such as, cognitive behavioural therapy for anxiety secondary to medical problems [52] If insufficient social support and/or relationship difficulties are present, some counselling could be provided to both the woman and her partner and/or additional social supports identified It may prove useful to consult with 13:56:46 183 Section Gynaecology one of the hospital clinical psychologists or social workers when psychosocial problems are present Regarding psychological treatments to treat NVP and HG symptoms directly, a number of approaches have been developed, including behavioural therapy and hypnosis [13, 19, 26] However, these treatments have not yet been subjected to sufficient rigorous scientific study (e.g randomized control trials) Given this lack of data it is not possible to recommend any specific psychosocial treatment that directly treats the symptoms of NVP and HG The use of psychological therapy for directly treating nausea and vomiting of pregnancy should be regarded as being an experimental treatment until well-conducted studies (e.g randomized control trials) find support for the efficacy of such therapies While there is insufficient evidence for the routine use of psychological interventions at present to directly treat NVP or HG, there are scenarios where psychological therapy may be indicated, for example to treat secondary anxiety and depression Effective evidencebased interventions to treat these difficulties should be used (e.g interpersonal therapy, cognitive behavioural therapy) As there is evidence that negative psychosocial effects may continue even after symptoms have resolved and into the postnatal period, close monitoring is advised, as is ensuring an adequate psychological and social support plan is in place Summary Nausea and vomiting are common symptoms experienced during pregnancy with approximately 52% having both nausea and vomiting [1] A smaller number of pregnant women, approximately 0.3 to 1.5%, will experience hyperemesis gravidarum, which is a severe and persistent form of NVP [1, 2] NVP is associated with negative physical, social and psychological effects [5,6,20] It seems likely that what causes and maintains the symptoms is multifactorial and taking a biopsychosocial approach is recommended [22, 26] Within the hypothetical model presented in this chapter the main aetiological factor is assumed to be biological (e.g rising levels of hCG), and psychological and social effects are seen as secondary to the nausea and vomiting These negative psychosocial effects may potentially play a role in maintaining and exacerbating nausea and vomiting for some women The biopsychosocial approach is a useful framework to apply in both the assessment and management of NVP After carrying out a biopsychosocial assessment it is recommended that a formulation of the assessment (i.e a synthesis of the 22 information gathered during the assessment) is shared with the woman Management should be guided and informed by assessment and adhere to clinical guidelines [22, 45, 48] Interventions should be matched to the severity of symptoms When possible care should be provided at a primary care or outpatient level, with hospital admission reserved for severe cases A parsimonious approach to psychosocial input should be applied; interventions should be evidence-based and targeted to address specific problems As negative effects may continue even after symptoms have resolved, it is recommended that an adequate psychosocial care plan should be in place for the postnatal period Key Points • The aetiology of nausea and vomiting during pregnancy (NVP) is uncertain The majority of the research supporting a psychogenic origin of NVP suffers from methodological problems • The cause of NVP is probably multifactorial, and there may be slightly different variables at play depending on the individual woman and her biological, psychological and social circumstances • NVP can negatively impact on the psychological and emotional well-being of pregnant women, and it seems theoretically plausible that psychological distress and behavioural conditioning could play a role in exacerbating symptoms for some women • Making a diagnosis of NVP involves a process of exclusion • The Pregnancy-Unique Quantification of Emesis (PUQE) is a brief validated measure which enables symptoms to be classed as mild, moderate or severe • The Social Functioning Questionnaire can be used to assess functioning at work and home, financially and in relationships The Short Form Social Support Questionnaire and the Maternity Social Support Scale assess perceived social support These measures have their advantages but they lack specificity and may miss out on details that can emerge during a conversation between the doctor and patient • If the woman and her doctor have a shared understanding of the illness, it should hopefully improve her satisfaction with the care provided 13:56:46 Assessment and Management of Women with Nausea and Vomiting during Pregnancy • Where possible women with NVP/HG should be provided with care in the community or managed as outpatients • Medical treatment comprises antiemetic drugs, acid-reducing drugs, rehydration and electrolyte replacement Antiemetic drugs include antihistamines (cyclizine), dopamine antagonists (e.g prochlorperazine, metoclopramide) and serotonin antagonist (ondansetron) • Psychotherapy, behavioural therapy and hypnosis could be beneficial, but these treatments have not yet been subjected to sufficient rigorous scientific study • While there is insufficient evidence for the routine use of psychological interventions at present to directly treat NVP or HG, there are scenarios where psychological therapy may be indicated, for example to treat secondary anxiety and depression References Gadsby R, Barnie-Adshead AM, Jagger C A prospective study of nausea and vomiting during pregnancy Br J Gen Pract Royal College of General Practitioners; 1993;43(371):245–8 Verberg MFG, Gillott DJ, Al-Fardan N, Grudzinskas JG Hyperemesis gravidarum, a literature review Hum Reprod Update 2005;11(5):527–39 Chin RK, Lao TT Low birth weight and hyperemesis gravidarum Eur J Obstet Gynecol 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