Depression in Hyperemesis Gravidarum: Determinants and Extent in Al-Nasiriyah, Across Sectional Study - Open Journal ...
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1532 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7
Depression in Hyperemesis Gravidarum: Determinants and
Extent in Al-Nasiriyah, Across Sectional Study
Alaa Hussein Ali Al Nasir
Assistant Prof. Department of Obstetrics and Gynecology, College of Medicine, University of Thi-Qar, Iraq
Abstract
Objective of this study was to assess depression extent among hyperemesis gravidarum pregnant women in
Thi-Qar. A cross sectional, hospital based, analytical study was carried out in two teaching hospitals Bent
Al Huda and Al Habobi teaching hospitals in period from September 2015 to July 2016. In this study, all of
pregnant participated are suffered from HG to obstetric outpatients. Based on Iraqi previous study 37.2%
of depressive symptoms prevalence in pregnant women. Sample size had been calculated such prevalence
rate with precision of 5%, confidence level of 95%, and added extra sample of 10%, to reach to 322. Beck
depression inventory-II Arabic version BDI –II score of > 20 depression was considered used as a specialized
questionnaire to achieve aim of study. Results showed 37.1%. of HG pregnant women was depressed, which
was significantly affected by previous history of hyperemesis P = 0.03, high socioeconomic status P = 0.009,
increased gravidity P = 0.03 increased gestational age P=0.003 and unwanted pregnancy P = 0.03. Re-
inforce mental health care of pregnant women through antenatal care services at primary health care level,
with strengthening mental and social rehabilitation methods used for diagnosed women with depression.
Keywords: hyperemesis gravidarum, Pregnant, Depression
Introduction conditions6. Actually, different etiological theories of
HG are suggested, but in fact only few of these theories
Nausea and vomiting are earliest symptoms at
are tested7. Such theories include role of infection with
pregnancy first trimester, start as soon as at 4th week of
helicobacter pylori HP8, pregnancy specific factors
gestation with a peak at week 9–12 of pregnancy and
such as fetal gender, multiple pregnancy, and molar
fade at end of 1st trimester1. It is varying in severity
pregnancies9, genetic factors, and ethnic factors,
between pregnant women, being mild to moderate in
immunological changes during pregnancy10 and finally
approximately 80%of pregnant women and known as
hormonal changes in early pregnancy11. Different
morning sickness, and severe in 0.5% - 2% of them
studies reported that HG is associated with different
and known as hyperemesis gravidarum HG, remain
risk factors12. In early pregnancy, changes in maternal
18%have no symptoms of nausea and vomiting2. It may
circulatory levels of reproductive hormones especially
stay continue for whole pregnancy period in 20% of
human chorionic-gonado-tropin HCG are considered
pregnant women3. Nausea and vomiting in severe form
as a triggering factor for development of HG. This is
intractable in early pregnancy is known as hyperemesis
because pattern of HCG secretion matches with onset,
gravidarum4. Hyperemesis gravidarum is still vague
peak and relief from hyperemesis gravidarum, and
and not completely understood5. It is believed that HG
association of high HCG levels with multiple gestation
is a multi-factorial complex health event attributed
and molar pregnancy that are associated with higher
to combination of different unrelated conditions such
risk of hyperemesis gravidarum13. Epidemiologically,
as genetic, environmental, hormonal and psychiatric
rates of HG are different from each other among
different countries, being higher in Asian countries
Corresponding author: than European14. HG is strongly associated with
Alaa Hussein Ali Al Nasir adverse outcomes on both fetal and maternal levels.
dr.hassan198366@yahoo.com As a longterm outcome, high rate of depression andIndian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 1533
serious neurological disorders were reported among HG was nearly two million 1979561, 4% 79182 represents
suffered women15. Depression, Globally, depression annual pregnancy target at 2015. Since incidence of HG
represents a public health importance due to its higher is 2% worldwide 79182˟0.02=1583.6~1584, 2,3,35 so it
rate during pregnancy. Its strong effects on development was estimated that 1584 of these pregnant women will
of postpartum depression and its impact on mother and suffer from hyperemesis gravidarum. estimated sample
fetus health16. Females have double risk of experiencing size is adjusted for estimated pregnant women who is
depression than male and at childbearing ages had expected to suffer from HGN=1584 by using following
higher tendency to develop depression than any other equation: Nadjusted = N˟n / N+n 36 = N= population
time in their lives17. Different theories explained size 1584
pathophysiology of depression especially among
n= sample size for infinite population
pregnancy; including neurotransmitter theory and
neuroendocrine system theory18. Mental illness among n = adjusted = 1584˟359 / 1584+359 = 292.6 ~ 293
pregnant women in Arabic World is highly stigmatized
health issue19. Nationally, scarce published information researcher adds extra 10% 29 of sample to cover
was related to depression prevalence among pregnant refusal or incomplete questionnaire so final sample size
especially with hyperemesis gravidarum women. Aim is 322.
of this study was to assess depression extent among
Sampling Method
hyperemesis gravidarum pregnant women in Thi-Qar /
Iraq All HG suffered pregnant who attend obstetric
outpatient clinic in nominated hospitals were included
Subjects & Methods depending on inclusion and exclusion criteria.
Study design & settings
Data collection data was collected by researcher by
A cross sectional, hospital based, analytical study direct interview and filling two special questionnaires
was carried out in two teaching hospitals Bent Al Huda forms after signing the consent form. Objectives of
and Al Habobi teaching hospitals from first week of study were explained and required ethics approvals were
September /2015 to end of July 2016. All eligible obtained. Data collected in groups of questionnaires.
pregnant women who were suffering from severe 1st is Arabic version of standard Beck depression
vomiting > 3 times/day without any other obvious inventory questionnaire- 37 , and 2nd is a special
underlying cause and were unable to maintain oral questionnaire. Beck Depression Inventory scale BDI
uptake with >3 Kg weight loss, and positive ketone screening instrument for detecting symptoms and
urea, and who were attending obstetric outpatient of two severity of depression consists of 21questions with a
hospitals were recruited for this study. scoring ranging from 0-3 for each question and total
score range from 0 to 63 . 2nd questionnaire includes
Exclusion criteria different variables that are suspected to associated with
Pregnant women with evidence of antenatal bleeding, depression among enrolled participants. These variables
with mild to moderate nausea and vomiting morning are titled under three main categories: demographic
sickness, preexisting medical or psychiatric comorbid variables, socio-economic socio-economic scoring had
conditions, physical or psychological disabilities, patient been done according to Saadoon et al study 38 variables,
refused to participate, and those using antibiotic, proton and obstetric variables.
pump inhibitor, and H2 blocker at time of inclusion were
Statistical Analysis
excluded from the study.
A computerized statistical software; Statistical
Sample size calculation Package for Social Sciences SPSS version 23 was used.
Descriptive statistics are presented as mean ± standard
An appropriate sample size and according to national
deviation. In all statistical analysis level of significance
demographic figures of Thi-Qar province at 2015 which
p value ≤ 0.05.
was supplied by Ministry of Health Thi-Qar population1534 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7
Results
Mean BDI score of HG women was 20±12.Approximately 11.5%, 9.9% ,15.7% , 19.5% and 23% of participants
suffered from extreme, severe, moderate depression, borderline clinical depression and mild mood disturbances
respectively.Generally,depression prevalence among pregnant women with HG was 37.1%, as shown in figure 1.
Fig 1: Extent of depression in hyperemesis pregnant
As shown in figure2,3 there was no significant statistical association between depression and sociodemographic characteristics
of studied women except for socio-economic character.
Fig 2: A. Distribution of age characteristics of HG women according to depression status P value=0.063. B. Distribution of age
characteristics of HG women according to depression P value=0.228.
Fig 3: Distribution of socioeconomic characteristics of HG women.Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 1535
As it is shown in figure 4, HG women with high socioeconomic status had higher depression prevalence p=0.00.
Fig 4: Distribution of occupations of HG according to depression P value=0.18 0.27.
Table 1 show significant association was observed between previous history of HG and depression prevalence
p=0.03. No significant association was observed between depression and multiple pregnancy p=0.8. Women with
HG who did not want this pregnancy had significantly higher depression p=0.03.
Table 1: A. Distribution of obstetric history of HG women according to depression status, B. Distribution
of determinants means of HG according to depression Mean ±SD
A. Distribution of obstetric history of HG women according to depression status
Depression No depression
Variable χ² P
No. % No. %
History of HG
Yes 72 42.4 98 57.6 4.4 0.03
No 44 30.8 99 69.2
Multiple pregnancy
Yes 7 38.9 11 61.1 0.2 0.8
No 109 36.9 186 63.1
Wanted pregnancy
Yes 88 34.4 168 65.6 4.3 0.03
No 28 49.1 29 50.91536 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7
Cont... Table 1: A. Distribution of obstetric history of HG women according to depression status, B.
Distribution of determinants means of HG according to depression Mean ±SD
B. Distribution of determinants means of HG according to depression Mean ±SD
Variable Depression No depression t-test P
Gravida 3.6±2.4 3.1±1.7 2.08 0.038
Parity 2.2±2.05 1.8±1.6 1.8 0.07
GA at time of review interviewweeks 9.6±2.2 9.4±3.2 0.6 0.5
GA at appearance of HG HGweeks 6.6±1.9 6.07±2.5 2.04 0.06
Miscarriage number 1±2 1±1 1.6 0.09
Table 2 show significant association was observed between increased gravida mean and depression p=0.03.
No significant differences were observed between depressed and non-depressed women regarding age, parity,
miscarriage number, and GA at time of interview and at appearance of HG p>0.05.
Performing logistic regression of these significantly associated variables revealed that only high Socioeconomic
state SES previous history of hyperemesis gravidarum, and unwanted current pregnancy were significantly associated
with depression among pregnant women, as shown in Table 2.
Table 2: Logistic regressing analysis
95%CI for expected B
Significance Variable Β p-value Expected B
Lower Upper
High SES 1.158 0.031 3.182 1.112 9.103
Significant History of HG 0.499 0.043 1.647 1.016 2.672
Unwanted this pregnancy 0.680 0.023 1.973 1.099 3.544
Moderate SES 0.432 0.394 1.540 0.571 4.156
Insignificant
Gestational age at interview
0.477 0.168 1.612 0.966 2.688
>8 weeks
Discussion (21)
. In this study, depression prevalence among HG is
37.1%. This prevalence is lower than that reported by
Many authors indicate that HG is main reason for
a previous study in Turkey which found that 53.9%
increased maternal hospitalization (8, 20). HG is reported
of those with HG had moderate to severe depression.
in 0.3% of all pregnancies (20). However, a few researches
Depression prevalence which was reported by current
estimated the prevalence and explore relations of
study is higher than what estimated by Malaysian study
psychopathological factors which accompany pregnancy
(22)
and an Omani study (23) 19% and 24.3% respectively.Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 1537
These differences in depression prevalence among HG HG in early pregnancy and high socioeconomic status of
pregnant women might be attributed to discrepancies pregnant women and clarified that those women with high
in lifestyle and cultural habits, socioeconomic status socioeconomic status might be more sensitive and might
and general mental health in the community in addition complain more than low socioeconomic status women.
to differences in study designs and depression scores second explanation was stated by Japanese study which
among studies. Mean BDI score of HG in this study is reported that employed pregnant women had lower rate
20±12. This finding is close to results of Turkey study of depression in early pregnancy and showed significant
(24) which stated that mean BDI score of pregnant with
of social support in lowering depressive scores during
HG was 20.9. present study showed that 19.5% of pregnancy. In general, in our community and our study
pregnant women with HG had borderline depression, most of women are unemployed especially those living
15.7% of them had moderate depression and 21.4% of in moderate to high socioeconomic status families.
them had severe and extreme depression. These findings
are relatively lower than those reported by a previous Conclusion
Iranian study (25) except for severe rank which revealed one-third of pregnant with HG had depression
that 19% of HG pregnant women had mild depression, which was high on provincial level SES, history of HG
46% of them had moderate depression and 7% of them and unwanted pregnancy was the main determinants.
had severe depression. This difference might be due to For that reason, it is recommended to: Implement mental
the use of BDI-SF Beck Depression Inventory-Short health care programs targeting pregnant women through
Form score by Iranian study. Etiology of HG is still antenatal care services provided at primary health care
unknown; however, many literatures demonstrate many level. awareness of medical Personal about depression
mechanisms for HG like human chorionic gonadotropins among pregnant women should be raised. family
effect, estrogen and progesterone effect, pregnancy Planning activities to mitigate unwanted Pregnancy
thyrotoxicosis, H-pylori effect and other hormonal must be reinforced
effects (26). Although this psychosomatic theory is
considered a controversial topic, and it is dealt with by Conflict of Interest: None
authors as the main cause of HG in early pregnancy which
Funding: Self
needs intensive mental health care (27). Many literatures
from multiple countries document direct relationship Ethical Clearance: Not required.
between psychopathology of pregnant women and HG.
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