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Need of medical care due to hyperemesis gravidarum in different pregnancy outcomes

Miina Nurmi, 10.10.2019

Results from a nation-wide register study, 2005–2017

We aimed at evaluating the ”burden of illness” caused by HG

1. In terms of the number of hospitalizations and outpatient visits

2. And in different pregnancy outcomes

• Deliveries (live births and stillbirths)

• Gestational trophoblastic disease (molar pregnancies)

• Ectopic pregnancies

• Spontaneous abortions

• Pregnancy terminations

Objective


• Data of women with HG diagnosis (N=9,315) between 2005 and

2017 were retrieved from Finnish health care registers

• Finnish Hospital Discharge Register: diagnoses (HG, spontaneous

abortion, gestational trophoblastic disease, ectopic pregnancy)

• N.B. the name of the register – officially Care Register for Health Care

• Inpatient and outpatient data from hospitals, specialized health care

clinics and emergency wards administratively associated with specialized

clinics

• Finnish Medical Birth Register: deliveries

• Finnish Register of Induced Abortions: pregnancy terminations

Methods/Registers


• Hyperemesis gravidarum, HG

• All O21 diagnoses in the ICD-10 classification (WHO 2004)

• O21 Excessive vomiting in pregnancy

• O21.0 Mild hyperemesis gravidarum (starting before the end of the 22nd week of gestation)

• O21.1 Hyperemesis gravidarum with metabolic disturbance (starting before the end of the 22nd week of

gestation)

• O21.2 Late vomiting of pregnancy (starting after 22 completed weeks of gestation)

• O21.8 Other vomiting complicating pregnancy

• O21.9 Vomiting of pregnancy, unspecified

• Diagnoses given by physicians in the health care services

• Admission: Diagnosis date

• Readmission: More than diagnosis date during the same pregnancy

Methods/Definitions


We should

include all of

these ladies!


Flowchart

9,315 women

with O21 diagnoses in the Finnish Hospital Discharge Register;

all women diagnosed between 2005 and 2017

Other causes of vomiting:

5 pregnancies excluded

Readmission

5,720

pregnancies

Pregnancies ending in delivery

9,354

No readmission

3,634

pregnancies

Pregnancies not ending in delivery

843

Readmission

202 pregnancies

No readmission

641 pregnancies

Eligible pregnancies with HG diagnosis during the study period

10,197 pregnancies

All pregnancies with HG diagnosis during the study period

10,202 pregnancies

• Primary outcome measure: total number of outpatient visits and

hospitalizations

• Dates calculated from the health care system’s point of view: one woman’s

one outpatient visit + hospitalization on the same day are calculated as two

• Secondary outcome measures

• Readmissions due to HG in live births, stillbirths, gestational trophoblastic

disease, ectopic pregnancies, spontaneous abortions and pregnancy

terminations

• Pregnancy-specific

• Dates calculated from the women’s point of view: one woman’s one

outpatient visit + hospitalization on the same day are calculated as one

Outcome measures


One outpatient

resource plus one

hospital resource

have been used.

”I’m ill today,

please just

help me,

anywhere!”

Results: hospitalizations & outpatient visits


Hospitalizations decreasing,

outpatient visits increasing;

Did we just observe an

ongoing shift in treatment

policies?

0

200

400

600

800

1000

1200

1400

1600

1800

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Hospitalizations Outpatient visits

Results: Readmission rates


HG pregnancies,

total

HG pregnancies,

readmission Readmission rate

Live birth 9,324 5,701 61 %

Stillbirth 30 19 63 %

Spontaneous abortion 310 69 22 %

Gestational trophoblastic disease 8 3 38 %

Ectopic pregnancy 16 4 25 %

Pregnancy termination 509 126 25 %

Total 10,197 5,922 58 %

Results: hospitalizations & outpatient visits in pregnanciesending in delivery, 2005–2017


The majority of

patients are treated

both as outpatients

and in hospitals.

• Always to be remembered with registers: you can only find cases which have

been entered in the register

• Interpretation!

• Example 1, one woman in our data

• HG pregnancy terminated in 2005, in pregnancy week 14

• HG pregnancy ending in delivery in 2008

• Pregnancy terminated in 2014, in pregnancy week 5 (with no HG diagnosis)

• Without a diagnosis it is not possible to know whether the third pregnancy was or wasn't an HG

pregnancy (or would have been at later weeks)

• Example 2, readmission rate in pregnancy terminations

• In the first analysis, pregnancy termination appeared to be associated with very high readmission

rate, but corrected analysis showed a lower rate

• Double checking & manual checking!

• Cases with HG diagnosis and pregnancy termination on the same date

• Time limits between diagnoses; date formats; pregnancy week at termination

Discussion/methodological issues


At least

so many!

”Thus, these results

should be considered

as the lower limit of the

real number of cases.”

• Analyzing background factors to find out if or how

pregnancies involving repeated admissions due to

HG differ from pregnancies involving only one

admission due to HG

• Unfortunately this can only be done with pregnancies

ending in delivery, so the other pregnancy outcomes

still remain less well characterized

Next steps


But at least

we’ve tried

our best!

Acknowledgements

Working on the register data:

Miina Nurmi, MSc, PhD student/University of Turku

Päivi Polo, MD, PhD, Professor (Obstetrics and Gynaecology)/University of Turku

Päivi Rautava, MD, PhD, Professor (Public Health)/University of Turku

Mika Gissler, PhD, Research Professor/THL National Institute of Health and Welfare

Tero Vahlberg, MSc, biostatistician/University of Turku

Working on our other datasets:

Linda Laitinen, MD, PhD student/University of Turku

Nina Kulovuori, MD, PhD student/University of Turku

Data extraction, anonymization and data provision:

Jouni Meriläinen, Senior Planning Officer/THL National Institute of Health and Welfare

Jouni Rasilainen, Senior Planning Officer/THL National Institute of Health and Welfare

Backup support:

Friends and families

Thank you for your attention


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