Patterns of nausea and vomiting in first pregnancies

One component of this study was to describe patterns of nausea and vomiting reported by primigravidas women. Since nausea and vomiting are so widely experience by pregnant women and since surprisingly little is know about he cause of these symptoms as evidence by the wide rage of theories, the study of nausea and vomiting in pregnancy presents problems of definition and diagnosis. The second aspect was to begin to develop a tool for further research related to nausea and vomiting in pregnancy to enable the practitioner to offer better support to the mother and recommend treatment based individually on evaluation of specific symptoms. This was an inferential study with a one group design utilizing a survey as the primary tool. The survey instrument was composed of two parts, one developed by the investigator and the second developed by Sullivan for use in a previous study on pregnancy symptoms at the University of Utah. Sixty-one primigravidas women voluntarily completed the survey from at the time of their scheduled prenatal visits. The following four patterns of symptoms became apparent in the analysis of the data: (1) no symptoms of nausea and/or vomiting; (2) symptoms of nausea and/or vomiting in the late night hours or in the morning hours; (3) symptoms of nausea and/ or vomiting occurring at varied times during a 24-hour period; and (4) symptoms of nausea and/or vomiting during late morning, afternoon, and/or evenings. The findings were both positive and negative. No significant relationships were found between the pattern of nausea and vomiting and the following variables: age, weeks of gestation at the time of the survey, onset and duration of nausea and vomiting, gastrointestinal symptoms in the second trimester, incidence of vomiting subsequent to alcohol intake, pain with menses, history of nausea while taking oral contraceptives, frequency and onset of menses, stresses related to social situation, family relationships, finances, life style, and changes in personal habits, Cornell Psychiatric Index, neuromuscular and skin symptoms in the first and second trimesters, plans for pregnancy, perception of nausea interfering with activities of daily living and plans to breast feed. Those findings that were significant are the following: Ease of pregnancy was strongly associated with symptoms of nausea and vomiting; that is, those with many hours of nausea thought their pregnancies more difficult than expected. Those with higher scores for symptom proneness and gastrointestinal and general adaptation stress symptoms in the first trimester tended to have more nausea. Those with the early day pattern felt the least improvement after vomiting, while all those with the late day pattern reported improvement after vomiting. Those women with early day pattern had less nausea after eating and more vomiting before eating than the other two groups of women experiencing nausea and vomiting in their pregnancies. The commonly used drug for nausea, Bendectin, was not highly effective in the treatment of nausea and vomiting. Minimization of nausea and vomiting through further research related to patterns and treatments can contribute greatly to the comfort and happiness of women during pregnancy. Anticipatory guidance can be provided related to findings of this study. Indiscriminate use of Bendectin is unwarranted.

PATTERNS OF NAUSEA AND VOMITING IN FIRST PREGNANCIES by Marcia Ann Strahn A thesis submitted to the faculty of The University of Utah in partial fulfillment of the requirements for the degree of Master of Science College of Nursing The University of Utah June 1979 Copyright G) Marcia Ann Strahn 1979 All Rights Reserved THE UNIVERSITY OF UTAH GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Marcia Ann Strahn I have read this thesis and have found it to be of satisfactory quality for a master's degree. Beryl pe{e;s Chairman, Supervisory Committee I have read this thesis and have found it to be of satisfactory quality for a master's degree. apt.(·l I~ 191t:; Date I have read this thesis and have found it to be of satisfactory quality for a master's degree. ~el0 AB.o&eh1m e Member, Supervisory Committee THE UNIVERSITY OF UTAH GRADUATE SCHOOL FIN AL READING APPROVAL To the Graduate Council of The University of Utah: I have read the thesis of Marcia Ann Strahn In Its final form and have found that (1) its format, citations, and bibliographic style are consistent and acceptable; (2) its illustrative materials including figures, tables, and charts are in place~ and (3) the final manuscript is satisfactory to the Supervisory Committee and is ready for submission to the Graduate School. Beryl P ers Member. Supervisory Committee Ap~roved for the Major Department Madeleine-r:<eininger Chairman; Dean Approved for the Graduate Council ./; James L. Clayton U Dean of The Graduale School ABSTRACT One component of this study was to describe patterns of nausea and vomiting reported by primigravida women. Since nausea and vomiting are so widely experienced by pregnant women and since surprisingly little is known about the cause of these symptoms as evidenced by the wide range of theories, the study of nausea and vomiting in pregnancy presents problems of definition and diagnosis. The second aspect was to begin to develop a tool for further research related to nausea and vomiting in pregnancy to enable the practitioner to offer better support to the mother and recommend treatment based individually on evaluation of specific symptoms. This was an inferential study with a one group design utilizing a survey as the primary tool. The survey instrument was composed of two parts, one developed by the investigator and the second developed by Sullivan for use in a previous study on pregnancy symptoms at the University of Utah. Sixty-one primigravida women voluntarily com­pleted the survey form at the time of their scheduled prenatal visits. The following four patterns of symptoms became apparent in the analysis of the data: (1) no symptoms of nausea and/or vomiting; (2) symptoms of nausea and/or vomiting in the late night hours or in the morning hours; (3) symptoms of nausea and/or vomiting occurring at varied times during a 24-hour period; and (4) symptoms of nausea and/or vomiting during late morning, afternoon, and/or evenings. The findings were both positive and negative. No significant relationships were found between the pattern of' nausea and vomiting and the following variables: age, weeks of gestation at the time of the survey, onset and duration of nausea and vomiting, gastrointes­tinal symptoms in the second trimester, incidence of vomiting subsequent to alcohol intake, pain with menses, history of allergies, selected variables associated with mealtime sickness, history of nausea while taking oral contraceptives, frequency and onset of menses, stresses related to social situation, family relationships, finances, life style, and changes in personal habits, Cornell Psychiatric Index, neuromuscular and skin symptoms in the first and second trimesters, plans for pregnancy, perception of nausea inter­fering with activities of daily living, and plans to breast feed. Those findings that were significant are the following: Ease of pregnancy was strongly associated with symptoms of nausea and vomiting; that is, those with less nausea thought their pregnancies easier than expected, and those with many hours of nausea thought their pregnancies more difficult than expected: Those with higher scores for symptom proneness and gastrointestinal and general adaptational stress symptoms in the first trimester tended to have more nausea. Those with the early day pattern felt the least improvement after vomiting, while all those with the late day pattern reported improvement after vomiting. Those WOlnen with the early day pattern had less nausea after eating and more vomiting before eating than the other two groups of women experiencing nausea and vomiting v in their pregnancies. The commonly used drug for nausea, ~en4~ct~n, was not highly effective in the treatment of nausea and vomiting. Minimization of nausea and vomiting through further research related to patterns and treatments can contribute greatly to the comfort and happiness of women during pregnancy. Anticipatory guidance can be provided related to findings of this study. Indiscriminate use of Bendectin is unwarranted. vi CONTENTS ABSTRACT •.. LIST OF TABLES . . ACKNOWLEDGMENTS CHAPTER I. INTRODUCTION • Review of Literature Sunnnary .... I I. METHODOLOGY III. RESULTS ~~ DISCUSSION Characteristics of the Sample Analysis of Variables . IV. SUMMARY AND RECOMMENDATIONS APPENDICES Recommendations for Nursing and Nurse-Midwifery . . . • . Recommendations for Future Research . A. CONSENT FORM . B. QUESTIONNAIRE Part I Part II . C. LISTING OF ITEMS FOR DETERMINATION OF CATEGORICAL SCORES ON PART II OF QUESTIONNAIRE . D. MEDICAL RECORD ABSTRACT REFERENCES . VITA . . . • . iv viii ix 1 2 9 10 13 13 15 36 39 40 42 44 45 49 63 66 68 71 LIST OF TABLES Table 1. General Characteristics of the Sample . . . • • . 2. Daily Pattern Report for Nausea and Vomiting 3. One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Age and Onset, Duration and Severity of Symptoms . . • • . . • . . 4. One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Gastrointestinal and Reproductive Systems . • • . . . . . . • 5. Chi-Square Analysis: Daily Patterns of Nausea and Vomiting by Subject's Perception of Improve­ment after Vomiting, Nausea after Meals, and Page 14 16 17 19 Vomiting before Meals . . . • . • . . . . . • • . 22 6. Chi-Square Analysis: Daily Patterns of Nausea and Vomiting by Mealtime E~periences and Symptoms . . 25 7. One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Menstrual History 26 8. 9. 10. 11. 12. One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Stress Situations One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Pregnancy Symptoms Chi-Square Analysis: Daily Patterns of Nausea and Vomiting by Perception of Pregnancy as Compared with Expectations ... . . . • • • Chi-Square Analysis: Daily Patterns of Nausea and Vomiting by Psychological Indices of Adjustment to Pregnancy . . • . . • . • Percentage of Activities that Worked Best to Control Nausea . . . • . • . . . • • 28 29 32 33 35 ACKNOWLEDGMENTS I would like to acknowledge those individuals who made contri­butions toward the completion of this thesis. Appreciation is extended to the members of my supervisory committee, Chairman Beryl Peters, John Sullivan, and Tyrrel Boehme for their continued interest, guidance, and suggestions during the preparation of this study. Warm gratitude is expressed to Mary Ann Rhode for her ideas and endless enthusiasm and support of this undertaking. A special thank you is given to the staff of the two clinics utilized for data collection. Sincere appreciation is extended to my friends and colleagues for their continuous patience, understanding, and support throughout the formulation and writing of this manuscript. Sincere recognition is offered to my parents and family for their continued love and support. Special love and gratitude is expressed to Paul Steadman for his understanding, encouragement, and patience during the completion of this project. CHAPTER I INTRODUCTION During pregnancy many of the rapid physical and emotional changes that occur, though normal, can cause great anxiety and dis­comfort for the expectant couple. Through knowledge of expected changes and effective treatment, the clinician can offer support, education and relief to the couple, making the pregnancy a more enjoyable life event. Nausea and vomiting are perhaps the most frequent discomforts of pregnancy. It has been estimated that approximately 50 to 75 percent of all pregnant women are troubled by nausea of some sever­ity and duration (Fairweather, 1968; Netter-Munkelt, Mau & Konig, 1972; Sullivan, 1978). The clinical experience of practitioners involved in the care of pregnant women shows that women experience different degrees of nausea and vomiting, and they experience these symptoms at different times during the day and during pregnancy (David & Doyle, 1976). Current treatment of nausea and vomiting in pregnancy is not based on specific symptoms and has not proven effective for all women. There is little discussion in the medical and nursing literature of the variability of symptoms, possibly because the incidence of nausea and vomiting is high and its importance is dis­regarded. 1~e medical literature does reveal a wide range of theories about and treatments for nausea and vomiting, but few authors give any consideration to individual differences in the degree or pattern experienced, and no one theory has yet been accepted. The purpose of this study, then, is to describe the patterns of nausea and vomiting--or their absence--as presented by pregnant primigravida women and to develop a tool to be utilized for further investigation into nausea and vomiting in pregnancy. Since nausea and vomiting are so widely experienced by pregnant women, greater definition of their discomforts is required. 2 Further research in this area may allow the practitioner to offer better support to the expectant mother, and to base treatment on evaluation of specific symptoms. This information, once docu­mented, may be valuable in further research in the etiology of nausea and vomiting in pregnancy as well as in treatment of and advise to women experiencing these symptoms. Review of Literature The literature contains five major areas of theory related to the etiology of nausea and vomiting: (1) physiologic factors; (2) allergenic factors; (3) metabolic factors; (4) endocrinologic factors; and (5) psychologic factors. The wide range of theories about nausea and vomiting during pregnancy serves to emphasize the confusion and disagreement that practitioners encounter. A review of these theories serves to provide a background for study of patterns of nausea and vomiting in pregnancy. Physiologic Factors Altered physiology appeared to be the basis for early theories of nausea and vomiting in pregnancy. Alvarez (1922) postulated a relationship between the genital and gastrointestinal tracts, based on the observation that during menstruation there is frequently a change in bowel habits. He believed that, during pregnancy, pelvic engorgement leads to intestinal irritability, reverse peristalsis, and subsequent nausea and vomiting. 3 Gardiner (1928) stated that during menstruation the gastro­intestinal system is stimulated, evidenced by the fact that many women who need laxatives most of the time must refrain from taking them during menstruation. During pregnancy, some protective substance arises from the zygote or chorionic villi, causing the involuntary muscles of the intestinal tract to quiet, even to the point of creating an intestinal obstruction, leading to reverse peristalsis and nausea and vomiting. This protects the ovum from peristaltic waves that could dislodge it until it is firmly implanted in the uterus. These theories were thought to explain why some women experience nausea only curing the first trimester. However, they did not explain why some women have nausea and vomiting continuing into the second and third trimesters. Allergenic Factors It was postulated by Finch (1938) that the nausea and vomiting accompanying pregnancy results from an allergic sensitivity to the secretions of the corpus luteum. The woman becomes sensitized to the secretion during her menstrual cycle or previous pregnancy. Corpus luteum correlates with the onset of nausea and vomiting in early pregnancy, and retrogression of the corpus luteum occurs at about the same time nausea and vomiting usually subside. It has also been hypothesized that during the time of rapid development of the placenta, a protein substance is released into the maternal circulation causing an incompatibility and a toxic reaction triggering the vomiting center and creating nausea and vomiting in some women (Johnson, 1940). Many of these women were found to have a history of allergies, leading to consideration of a relationship. 4 Peckham (1929) theorized that ~ragments of the chorionic villi or detached masses of chorionic epithelium gain entrance to the maternal circulation, and the "normal" mother can dispose of such foreign material satisfactorily. When the nervous system is upset, the mechanism for neutralization of these particles fails, and nausea and vomiting are produced by the toxic action of the substances on the vomiting center of the brain. This theory combines an allergenic/ toxic approach with a psychological basis and could provide an explanation of ind~vidual symptoms in women, but remains unsupported. Metabolic Factors Altered metabolism has been a basis for theories about nausea and vomiting in pregnancy. It has been proposed that nausea and vomiting occur due to a deficiency of glycogen in the maternal liver (Harding, 1921; Titus & Dodds, 1928). The mother suffers from a carbohydrate deficiency due to the sudden demand for glucose by the developing fetus. If the maternal diet is deficient in glucose, the needs of the embryo are met by depletion of the glycogen stores of 5 the maternal liver. If not corrected, maternal breakdown of proteins and fats in the tissues occurs, leading to ketosis and negative nitrogen balance, precipitating nausea and vomiting. If severe, the glycogen storing cells of the liver are replaced by fatty infiltra­tions and the condition worsens. This theory most logically explains "morning sickness" or nausea and vomiting experienced by mothers following fasting or in those who demonstrate poor glycogen reserves. It may also account for continued severity of nausea and vomiting as pregnancy progresses .. It does not, however, explain why many women experience a decrease in symptoms after the first trimester, nor why glucose replacement or a high carbohydrate diet do not correct or prevent nausea in every case. McGanity, McHenry, van Wyck and Watt (1944) proposed that altered metabolism in pregnancy is due to a deficiency of pyridoxine (Vitamin B 6 ). This deficiency leads to a decreased ability to process some proteins and abnormal urea levels result. This relationship leads to nausea and vomiting. Reinken and Gant (1974) found that women with hyperemesis gravidarum have the same deficiency of Vitamin B6 in early pregnancy as other women have in later pregnancy. Wheatley (1936) discovered a high degree of relief of symptoms of pregnancy sickness with the use of pyridoxine combined with an anticholinergic 6 and an antihistamine (Bendectin). Endocrinologic Factors Way (1945) noted that high levels of an anterior-pituitary-like hormone were responsible for low secretion of acid in the gastric juices. This leads to faulty digestion and nausea and vomiting. Evidence has also been presented that high levels of human chorionic gonadotropin (HeG) correspond with the occurrence of nausea and vomiting (Schoeneck, 1942). Possibly those women who experience nausea and vomiting are unduly sensitive to HeG or have excessive amounts of RCG. Moreover, in cases of hydatidiform mole and multiple pregnancy, in which levels of ReG are found to be higher than in single or normal pregnancy, the occurrence of nausea and vomiting is often more prominent (Pritchard & MacDonald, 1976). A study con­ducted by Fairweather and Loraine (1962) contradicted these findings, and they proposed that ReG was significantly lower than normal in women who eA~erienced hyperemesis. Because of this discrepancy, support of these theories is tenuous. Kemp (1932) was first to suggest adrenocortical insufficiency as the cause of nausea and vomiting. The adrenal cortex hypertrophies during pregnancy and the first symptoms of adrenal insufficiency are often nausea and vomiting. Support for this relationship came from Wells (1935), who found that nausea and vomiting frequently occurred during the first trimester when the maintenance of the pregnancy is dependent upon the anterior pituitary. In some patients a deficiency in ACTH developed secondary to overstimulation of the anterior 7 pituitary, leading to nausea and vomiting. Vomiting ceases when the placenta assumes principal hormone control in pregnancy. Carreras (1945) outlined a similar hypothesis. During the first weeks of pregnancy, pituitary gonadotropin increases and other pituitary hormones decrease, including ACTH, resulting in adrenal insufficiency. Hormones produced by the placenta later in pregnancy cause a reflex decrease in pituitary gonadotropin, ACTH production rises to normal, and nausea and vomiting decrease. It has been proposed that nausea and vomiting in late pregnancy were due to the effects of progesterone (Midwinter, 1971). Proges­terone relaxes smooth muscle, including the cardiac sphincter and gastric musculature. In late pregnancy, particularly, the increase in intra-abdominal pressure causes gastric reflux and vomiting. Astwood (1970) reported that the exact cause is unknown, but nausea and vomiting are probably due to some substance in excess during pregnancy. He theorized the substance was estrogen, since similar side effects were observed as a result of taking estrogen-containing oral contraceptives. Psychological Factors Nausea and vomiting have been considered to be unconscious manifestations of oral rejection of the fetus (Weiss & English, 1943; Chertock, Mandzain & Bonnaud, 1963), repudiation of femininity and punishment of the father (Nenninger, 1939). The symptoms have been thought to spring from anxiety and fear (Walser, 1948; Fitzpatrick, Reeder & Mastroianni, 1971) or from societal expectation (Mead, 1947). McCammon's study (1951) of pregnant American Indian women showed the incidence of nausea and vomiting to be only 14 percent. He noted that 85 percent of women with these symptoms were English-speaking and influenced heavily by Western culture. Several authors have indicated that nausea and vomiting appear to be more severe in women predisposed to neuroses (Atlee, 1943; Uddenberg, Nilsson & Almgran, 1971; Semmens, 1971; Netter-Munke1t, 8 et a1., 1972); conversely, Brown (1964) and Palmer (1973) found no such relationship in their research. In many of the studies relating neurosis to nausea and vomiting, data were collected at the time that the subjects were experiencing the symptoms. The question can be raised whether nausea and vomiting might cause lowered self image, decreased sexual responsiveness, and dislike or rejection of the coming infant, rather than result from such factors. Additional doubt may be cast on psychological causation by the finding that in 20 percent of patients suffering nausea and vomiting, the symptoms occur before the patient realizes she is pregnant (Midwinter, 1971). Stone (1956) suggested nausea and the reactions of the woman to her pregnancy could provide clues to interpersonal distress resulting from the pregnancy. He stressed that the care provider needed to identify women with excessive nausea and tendencies to make pregnancy into an illness beyond practical limits and supply them with special attention and guidance. Rosen (1955) found the severity of nausea and vomiting to be commensurate with the level of stress to which the woman has been subjected. This could be related to findings that nausea and vomi~ are more severe, last longer, and occur earlier in primiparas (Hawkinson, 1936; Sterk, Prywes, Davies, Ever-Hadani & Lilos, (1971) and that nausea and vomiting decrease with maternal age (Sterk, et al., 1971). Sullivan, on the other hand, found no relationship between stress during pregnancy and symptoms of nausea and vomiting. Summary In general, the etiologic factors proposed as causing nausea and vomiting in pregnancy might include: 1. Physiologic factors--reverse peristalsis, decrease in gastric motility, and gastroesophageal reflux. 9 2. Allergenic factors--sensitivity to secretions of the corpus luteum, sensitivity to fragments of the chorionic villi or epithelium. 3. Metabolic factors--altered carbohydrate metabolism leading to disturbed usage and increased production of ketones, and lowering of vitamin B 6 • 4. Endocrinologic factors--active secretion of corpus luteum and increased levels of HCG, estrogen, progesterone; decreased secretion of ACTH. 5. Psychologic factors--stress, anxiety, fear, ambivalence, apprehension; personality organization, ability to cope with stress in past and present, and acceptance of femininity and the pregnancy. CHAPTER II METHODOLOGY Sixty-one primi.gravida women in the 20th to 28th week of pregnancy were selected seriatim from clinic settings at Hill Air Force Base, Utah and OB-GYN Associates, Rockford, Illinois. This gestational period was chosen because it was assumed most women would remember their particular patterns of nausea and/or vomiting more clearly if surveyed near the end of their pregnancies or after delivery. In addition, pregnancy was advanced enough so that most women, if they were going to, would have experienced nausea and vomiting. These particular sites were chosen because their patient populations were essentially normal and because they were geographi­cally accessible for the research. The medical charts of the subjects were reviewed to determine parity and gestational period of the pregnancy. The gestational period was based on calculation of the estimated date of confinement from the first day of the last menstrual period and its confirmation by the care provider through physical examination. Women having previous pregnancies which terminated spontaneously or artificially were not included in the study due to possible influence of the earlier pregnancy on the existing pattern of nausea and/or vomiting. Each subject was required to complete a survey. Informed written consent (Appendix A) was obtained from each subject after verbal explanation of the purpose of the study and data collection methods. Confidentiality was ensured through use of a numerical identification system. 11 The administered survey was a combination of a survey designed specifically for this study (Part I) and the Utah Test Appraising Health (UTN1-IV), developed by Sullivan (Part II). Part I investigated more precisely the individual's pattern of nausea and/or vomiting during the current pregnancy. The UTAH-IV has been used in a number of validation studies and the reliabilities were established in the Pregnancy-Illness Proneness and Stress (PIPAS) research con­ducted at the University of Utah. The UTAH-IV survey involves three areas: (1) demographic data; (2) physical symptoms; and (3) common problems confronting normal persons. The survey is located in Appendix B. Scores were determined for various sections of the UTAH-IV following procedures developed by Sullivan. Specific items were categorized, counted and the total coded for statistical analysis. Appendix C contains the listing of items as they related to specific categorical scores. Data collection was conducted from July through November, 1978. Each subject was approached by clinic personnel to determine interest in participation and to explain the study. The survey form was com­pleted by subjects without help and was returned while the subject was at the clinic for her scheduled prenatal visit. Completion of the survey took approximately 30 minutes. A medical record abstract, Appendix D, was completed by the investigator from data in the 12 subject's clinical record. These data augmented those obtained from the survey_ Permission for chart audit was included on the consent form, and the audit was completed after the survey form was returned by the subject. CHAPTER III RESULTS AND DISCUSSION Data gathered through the survey were analyzed using the following Statistical Package for the Social Sciences (SPSS) pro­cedures: FREQUENCIES, CHI-SQUARE, and ONE-WAY ANALYSIS OF VARIANCE. Since this was essentially an exploratory study, significance levels for relationships were set at the 0.05 level. Since many tests were performed, it was difficult to know whether some of the results reported as significant were due to chance. Characteristics of the Sample The sample population for this inferential study consisted of 61 primagravida women in the 20th to the 28th week of pregnancy. Since 82% of the subjects were obtained from Hill Air Force Base, Utah and the remaining 18% of the subjects were obtained from OB-GYN Associates in Rockford, Illinois, the majority of the women were Air Force dependents. Their ages ranged from 17 to 35 years with a mean age of 22 years. Table 1 details information about the char­acteristics of the sample population, including marital status, income, educational level, and feelings about the pregnancy. Seventy-seven percent of the subjects in the sample population reported symptoms of nausea and/or vomiting. This is consistent with the findings of Fairweather (1968), Netter-Munkelt et ale (1972), and Table 1 General Characteristics of the Sample Variable Age Weeks of Gestation at Time of Survey Variable Level'S Marital Status Single Manied Separated Divorced Income None $1-2.999 3-4,999 5-6.999 7-8,999 9-10,999 11-12,999 13-14.999 15-16.999 17-18.999 19-20.999 21-22,999 23,000 or more Educational Level 0-6 Grades 7-9 Grades 10-11 Grades High School Graduate 1 year College College Graduate Postgraduate Plans for Pregnancy Planned Unplanned Father's Opinion Happy of the Pregnancy Unhappy Undecided Unknown Perception of the Easier Pregnancy as As Expected Compared ·.rith More Difficult Expectations Mean 22.0 23.5 N(%) 8 (13.1) 52 (85.2) 1 (1.6) 0 0 0 2 (3.9) 8 (15.4) 8 (15.4) 6 (11.5) 6 (11.5) 8 (15.4) 2 (3.9) 3 (5.8) 3 (5.8) 1 (1.9) 5 (9.6) a 1 (1. 7) 5 (8.6) 28 (48.3) 18 (31.0) 5 (8.6) 1 (1. 7) 34 (57.6) 25 (42.4) 55 (90.2) 1 (1.6) 4 (6.6) 1 (1.6) 26 (43.3) 23 (38.3) 11 (18.3) 14 Range 17-35 20-28 Total N 61 52 58 59 61 60 15 Sullivan (1978). Subjects were divided into four groups according to the daily temporal pattern of nausea and/or vomiting reported (Table 2). Variables, such as age and onset, severity and duration of symptoms, believed to be related to daily patterns of nausea and vomiting were analyzed using the one-way analysis of variance procedure between the groups (Table 3). Only the number of hours of nausea per day showed a significant difference between groups (P < 0.001). Those with the irregular pattern of nausea and vomiting showed the highest mean number of hours of nausea per day (15.29), the early pattern second highest (4.28), and the late pattern the least (3.67). Age was not significant but a tendency towards a difference between groups (P < 0.065) was demonstrated. Those with the irregular pattern had a mean age of 23.79. Those with the late pattern had a mean age of 20.67, and the early pattern had a mean age of 20.67. This result may have been significant had the sample size been larger. Netter-Munkelt, et ale (1972) and Uddenberg, et ale (1971) did not find age to be a significant factor in relation to nausea and vomiting. Analysis of Variables Variables from the survey were analyzed as they related to the etiologies of nausea and vomiting in pregnancy presented in the review of literature. Physiologic Factors Alvarez as well as Gardiner believed some relationship exists Pattern Symptoms Absent Early Pattern Irregular Pattern Late Pattern Total Table 2 Daily Pattern Report for Nausea and Vomiting N of Cases 14 18 14 15 61 % of Total Cases 23.0 29.5 23.0 24.5 100% Description No Symptoms of Nausea and/or Vomiting Symptoms of Nausea and/or Vomiting in the Late Night Hours or Early Morning Hours (11 p.m. to 12 noon) Symptoms of Nausea and/or Vomiting at Varied Times During a 24 Hour Period Symptoms of Nausea and/or Vomiting During Late Morning, Afternoon, and/or Evenings (10 a.m. to 11 p.m.) ....... '" Table 3 One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Age and Onset, Duration and Severity of Symptoms Variable Homogeneity of Groups df Variance between Groups Bartlett Box F (P) F Ratio Probability Age 0.101 3 2.544 0.064 Weeks of Gestation at Time of Survey 0.691 3 0.938 0.430 Month Nausea Began 0.708 2 0.913 0.411 Month Nausea Ended 0.879 2 1.185 0.318 Month Vomiting Ended 0.823 2 1.919 0.168 Number of Days per Week the Subject Vomited 0.819 2 1.296 0.289 Number of Hours Nauseated Per Day 0.117 2 20.273 0.001* *Significant < 0.05 level I-' ....... 18 between the genital and gastrointestinal tracts. Variables believed by the investigator to be related to the physiologic theories explaining nausea and vomiting in pregnancy were analyzed using Chi­square and one-way analysis of variance statistical procedures. Those variables were gastrointestinal symptoms in the first and in the second trimesters and reproductive symptoms in the first and second trimesters. Gastrointestinal symptoms, including loss of appetite, consti­pation, he~rtburn, stomach cramps and food cravings as well as nausea and vomiting, occurring in the first trimester of pregnancy were found to be significantly related (P < 0.001) to reported time of nausea and/or vomiting (Table 4). Subjects who did not experience nausea and vomiting reported the least number of gastrointestinal symptoms (mean 1.79; range 0-5). Those with irregular patterns of nausea and vomiting generally reported the highest number of gastro­intestinal symptoms (mean 4.29; range 1-9). Those experiencing the early pattern (mean 3.83; range 1-9) and the late pattern (mean 4.0; range 1-7) were relatively close to those experiencing the irregular pattern in the number of symptoms they reported. These results indicate a general gastrointestinal system upset in women who experience nausea and vomiting. The relationship between gastrointestinal symptoms and patterns of nausea and vomiting was not as clear in the second trimester, and there was no significant difference between groups. This may indi­cate a change in adaptation of the body to the pregnancy as a subsequent decrease in gastrointestinal somatization occurred in Table 4 One-\~ay Analysis of Variance: Daily Patterns of Nausea and Vomiting by Gastrointestinal and Reproductive Symptoms --,.--- -------- Variable Pattern Mean Homogeneity Bartlett B of Groups ox F (P) Gastrointestinal Symptoms Absent 1. 79 0.30 Symptoms 1** Early Pattern 3.83 Irregular 4.29 Late Pattern 4.00 Gastrointestinal Symptoms Absent 1.64 0.34 Symptoms 2** Early Pattern 2.78 Irregular 3.43 I,ate Pattern 2.93 Reproductive Symptoms Absent 2.50 0.63 Symptoms 1** Early Pattern 2.56 Irregular 2.93 Late Pattern 3.93 Reproductive Symptoms Absent 3.07 0.13 Symptoms 2** Early Pattern 4.44 Irregular 3.79 Late Pattern 4.27 * = Significant < 0.05 level ** 1 = First trimester; 2 = second trimester 9 = One-tailed ] 6 2 7 df Variance between Groups F Ratio Probability9 3 6.108 0.001* 3 1.340 0.185 ] 1.966 0.064 3 1.540 0.107 t-' 1.0 20 those who had many symptoms in the first trimester. Response to alcohol and a history of motion sickness were con­sidered by the investigator to be indicative of the lability of the gastrointestinal system in the individual and were tested using the Chi-square for any relationship to symptoms of nausea and vomiting in pregnancy. Neither the incidence of vomiting subsequent to alcohol intake nor the subject's experience of motion sickness was found to differ significantly in relation to symptoms during pregnancy. The nausea and vomiting of pregnancy, then, may be related to a hormonal or placental influence rather than gastrointestinal system stability. Pain with menstruation was tested among the four groups utilizing the Chi-square statistical test with the following result: X2 = 4.027 with 3 d.f. and P < 0.259. This result along with one-way analysis of variance comparisons of reported reproductive symptoms in the first and second trimesters of pregnancy (Table 4) demonstrated a lack of significant difference in the groups of women tested. Repro­ductive symptoms in the first trimester were approaching significance (P < 0.064) and may have been significant if the sample size had been larger. There did not appear to be the same difference between groups in the degree of somatization related. to the reproductive system as there was in that related to the gastrointestinal system. These women may find reproductive symptoms more acceptable and expected, and have less awareness of them than of the gastrointestinal symptoms, which are generally socially unacceptable in this culture. 21 Allergenic Factors Johnson's toxic/allergic theory suggested a relationship between history of allergies and symptoms of nausea and vomiting in pregnancy. Data gathered on history of allergies in the subjects of this study showed the absence of such a relationship with the result of the corrected Chi-square being 0.002 with 1 d.f. and P < 0.968. Metabolic Factors Variables believed by the investigator to show a relationship to the metabolic theories explaining nausea and vomiting in pregnancy were analyzed using the Chi-square statistical procedure. The subject's perception of how she felt after vomiting was found to have a significant relationship (P < 0.014) to the reported pattern of nausea and vomiting. Only 25% of those women with the early pattern of symptoms felt improvement after vomiting. Fifty percent of those with an irregular pattern and 100% of those with the late pattern stated they felt improvement after vomiting (Table 5). Fifty-eight percent of the early pattern and 50% of the irregular pattern felt worse after vomiting while none of the late pattern felt worse after vomiting. One can only speculate about the reason so few women with the early pattern felt relief from and so many felt worse after vomiting. One factor to be considered, however, is the individual's psychological response to vomiting. Perhaps those who felt no improvement believed vomiting to be a very negative experi­ence, or having vomited, believed themselves to be even more ill. These factors were not tested in this study. Table 5 Chi-Square Analysis: Daily Patterns of Nausea and Vomiting by Subject's Perception of Improvement after Vomi.ting, Nausea after Meals, and Vomiting before Meals Variable Levels % N X2 df Probability Early Irregular Late Pattern Pattern Pattern Subject's Perception Better 25 50 100 of How She Felt Same 16.7 0 0 30 12.55 4 0.014* After Vomiting Worse 58.3 50 0 MNaeuaslse a After YNoe s 2790..46 2755 6345..73 43 6.53 2 0.038* MVoemalist ing Before YNoe s 5445..55 8181..91 1854..73 27 9.08 2 0.011* *Significant < 0.05 level N N 23 Temporal occurrence of nausea and/or vomiting was tested in relation to nausea and vomiting at mealtimes and was found to be significantly different between the groups for two variables (Table 5): (1) nausea after meals, and (2) vomiting before meals. Those with the irregular pattern represented the highest percentage of women who experienced nausea after meals (75%) as well as the highest percentage of those who vomited before meals (88.9%). The early pattern had the lowest percentage (29.4%) of women with nausea after meals and 45.5% of those who vomited before meals. The late pattern contained 35.7% who were nauseated after meals and had the lowest percentage (14.3%) of women who vomited before meals. It is possible that the women experiencing the early pattern reported less nausea after meals because their particular pattern of nausea and vomiting was during hours of the day frequently not associated with meals. On the other hand, those with the late pattern did not have a high percentage of women with nausea and vomiting at mealtimes, and that pattern was during hours generally associated with mealtimes. Altered metabolism leading to a ketosis is believed to precipi­tate nausea and vomiting (Harding, 1921; Titus & Dodds, 1928). Fewer women with the early pattern had nausea after eating, at which time available glucose increases and ketone production is reduced. Fur­thermore, nearly half of these women vomited prior to meals when ketones would probably be higher. Since meals did not seem to help sufficiently to reduce the nausea for those with the irregular pattern of symptoms, other 24 factors seemed to enter into the etiology of their nausea and vomiting. Similarly, since few (14.3%) of those with the late pattern vomited prior to their meals, they also seemed to have other influences. Analysis of other variables related to meals, Table 6, demon­strated no significant differences among the three groups of women with symptoms of nausea and vomiting. Vitamin B6 was taken in some form by 96% of the subjects. Therefore, the relationship of Vitamin B6 in the control of nausea and vomiting in pregnancy as proposed by McGanity, McHenry, van Wyck and Watt (1949) could not be analyzed. Endocrinologic Factors Reports of nausea experienced during use of oral contraceptives were tested using Chi-square to determine the relationship to presence of nausea during pregnancy. The result, X2 = 0.233 with 1 d.f. and P < 0.629, was not signifitant. This finding does not support Astwood's postulation that those who experienced nausea and vomiting when taking oral contraceptives, due to their hormonal influences, may experience a similar response in pregnancy. This discrepancy may be due to the reduction of the amount of estrogen in oral contraceptives since his study was done. Neither frequency of menstruation (days) nor onset of menstrua­tion (years), Table 7, were found to have a significant relationship to the pattern of nausea and vomiting. The incidence in the sample of other endocrinological disorders including thyroid disorders, Table 6 Chi-Square Analysis: Daily Patterns of Nausea and Vomiting by Mealtime Experiences of Symptoms Variable Levels N X2 df Probability Nausea During Meal Yes Preparation No 43 2.42 2 0.297 Nausea Before Yes 43 3.79 2 0.150 Meals No Nausea During Yes Meals No 43 3.44 2 0.178 Vomiting on an Yes 33 3.08 2 0.213 Empty Stomach No Vomiting on a Yes 43 4.49 2 0.106 Full Stomach No Vomiting During Meal Yes 27 1.33 2 0.513 Preparation No Vomiting During Yes 27 1.92 2 0.383 Heals No Vomiting After Yes 27 3.71 2 0.157 Heals No N VI Table 7 One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Menstrual History Variable Homogeneity of Groups df Variance between Groups Bartlett Box F (P) F Ratio Probability Frequency of Menstruation 0.0158 (II of days) 3 3.425 0.025 Onset of Menstruation (Age in Years) 0.374 3 0.064 0.973 - . 8 = Homogeneity not established; si.gnificance of F Ratio cannot be accepted. N Q'\ infertility, and diabetes mellitus were so low that relationships could not be determined. Psychologic Factors 27 Stresses related to social situation, family relationships, finances, life style, and changes in personal habits were tested using one-way analysis of variance for their relationship to patterns of nausea and vomiting. The results as reported in Table 8 show that significant differences were not detected at or below the 0.05 level. Symptom proneness (based on symptoms reported in the last ten years) was tested to determine the degree of symptom reporting for each of the women. The scores were compared by patterns of nausea and vomiting, and the result, P < 0.031 (Table 9), demonstrates that women who report many illness symptoms describe more nausea and vomiting in pregnancy. Those with irregular patterns had the highest mean number of symptoms (9.29) in the last ten years. Those with the late pattern had a mean number of 6.07, the early pattern had a mean number of 6.00, and those with symptoms absent had a mean number of 5.14 for s)~ptoms in the past ten years. General adaptational stress symptoms, such as frightening dreams, ill health affecting work, fatigue, excessive weight gain, changes in sleep patterns, and headaches, in the first trimester were significantly different between patterns of nausea and vomiting (P < 0.004; Table 9). Those with the irregular pattern tended to have most symptoms of general adaptational stress (mean 4.57); the late pattern was second (mean 4.00); the early pattern was third {mean 28 Table 8 One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Stress Situations Variable Homogeneity of Groups df Variance between Groups Bartlett Box F (P) F Ratio One-Tailed Probability Social Stress 1* 0.861 3 1.139 0.171 Social Stress 2* 0.953 3 0.364 0.391 Work Stress 1* 0.789 3 0.046 0.368 Work Stress 2* 0.676 3 1.479 0.115 Family Stress 1* 0.818 3 0.353 0.395 Family Stress 2* 0.912 3 0.912 0.222 Financial Stress 1* 0.766 3 1.606 0.099 Financial Stress 2* 0.,409 3 0.846 0.237 Life Style Stress 1* 0.399 3 0.183 0.453 Life Style Stress 2* 0.939 3 0.066 0.486 Personal Habits Changes Stress 1* 0.464 3 0.028 0.495 Personal Habits Changes Stress 2* 0.111 3 0.604 0.320 *(1 = first trimester; 2 = second trimester) 29 Table 9 One-Way Analysis of Variance: Daily Patterns of Nausea and Vomiting by Pregnancy Symptoms Variable Homogeneity of Groups df Variance Bartlett Box F (P) F Ratio Symptom Proneness 0.191 3 2.580 General Adaptational Stress Symptoms 1* 0.260 3 4.461 General Adaptational Stress Symptoms 2* 0.537 3 1.726 Cornell Psychiatric Inventory 1* 0.513 3 0.705 Cornell Psychiatric Inventory 2* 0.716 3 0.752 Neuromuscular Symptoms 1* 0.584 3 0.267 Neuromuscular Symptoms 2* 0.817 3 1.328 Skin Symptoms 1* 0.160 3 1.360 Skin Symptoms 2* 0.775 3 1.160 Cardiac/ Respiratory Symptoms 1* 0.359 3 2.076 Cardiac/ Respiratory Symptoms 2* 0.445 3 1.729 *(1 - first trimester; 2 = second trimester) **Significant < 0.05 level between Groups One-Tailed Probability 0.031** 0.004** 0.085 0.278 0.265 0.425 0.137 0.132 0.460 0.056 0.085 30 3.61); and those with absence of symptoms of nausea and vomiting reported the fewest (mean 2.00). This suggests that degree or pattern of nausea and vomiting in pregnancy may provide clues to the woman's response or adaptation to the pregnancy in general. The reverse may be true also which would enable the practitioner to provide anticipatory guidance to the client. This relationship was not significant in the second trimester indicating greater equality in adaptation to pregnancy between groups. Cardiovascular and respiratory symptoms in the first trimester, which included heart pounding, varicose veins, shortness of breath, frequent colds or cough, frequent dizzy spells, fainting, and swelling of extremities, approached significant differences (P < 0.056) between groups of women previously defined (Table 9). This may have been significant if the sample size were larger. Those in the early pattern had the least mean number of cardiovascular and respiratory symptoms (0.667), and those with the late pattern had the highest mean number (1.267). Possibly those women with the fewer number of symptoms were in better physical condition prior to pregnancy. In the second trimester the significance was P < 0.085 demonstrating less of a relationship between cardiovascular and respiratory symptoms and pattern of nausea and vomiting. One-way analysis of variance on the Cornell Psychiatric Inven­tory, scores for neuromuscular symptoms, and skin symptoms in the first and second trimesters did not demonstrate significant differ­ences between groups of women (Table 9). Uddenberg et al. (1971) reported similar findings on stresses 31 and other indices of pregnancy discussed above and pointed to nausea and vomiting as being aspects of pregnancy which may be modified in either direction by such factors. They concluded that subjects with moderate nausea seemed to be best adjusted. A woman's pattern of nausea and vomiting may provide a useful early clue to her adjustment to the pregnancy in general. Further­more, her symptom proneness and general adaptational stress score in the first trimester may give clues to her expected pattern of nausea and vomiting. The subject's perception of the pregnancy as compared with expectations was tested using Chi-square to determine significant differences between groups defined previously. The result, Table 10, was significant (P < 0.016). Reasonably, the group with irregular nausea and vomiting patterns, who generally had more hours of nausea per day, contained the highest percentage (42.8%) of women who con­sidered their pregnancies to be more difficult than expected. Seventy-seven percent of those without nausea and vomiting thought their pregnancies were easier than expected. The ease of pregnancy, then, is strongly associated with symptoms of nausea and vomiting. Plans for the pregnancy, perception of nausea interfering with activities of daily living, and plans to breast feed the infant were not significantly different between groups (Table 11). Uddenberg et al. (197l) found the lowest rate of unwanted pregnancies in the moderately nauseated women and indicated this was because they were well adjusted to the pregnancy. Palmer (1973) did not find a sig­nificant relationship existed between desire for the pregnancy and Table 10 Chi-Square Analysis: Daily Patterns of Nausea and Vomiting by Perception of Pregnancy as Compared with Expectations - Variable Levels % N X2 Symptoms Early Irregular Late Absent Pattern Pattern Pattern Perception of Easier 77 33.3 14.3 53.3 Pregnancy as Compared with Expectations Same 23 50.0 42.8 33.3 60 15.681 More Difficult 0 16.7 42.8 13.3 -_.- - *Significant < 0.05 level df 6 Probability 0.016* W N Table 11 Chi-Square Analysis: Daily Patterns of Nausea and Vomiting by Psychological Indices of Adjustment to Pregnancy Variable Levels N X2 df Probability Plans for Pregnancy Planned 59 2.800 3 0.424 Unplanned PInetrecrefpetrioinng o wf iNtha usea Yes ADacitliyv i1t.i.eivsi nog f No 45 1.800 2 0.406 Yes Plans to Breast Feed 58 2.824 3 0.419 No w w nausea and vomiting experienced in his study of 138 primigravida women. Table 12 contains an itemization of activities that subjects reported helped to control their nausea. No specific relationships have been defined; however, eating seemed to be the most helpful in each group. The use of Bendectin did not seem to be consistently helpful, but was most helpful for those in the early pattern. Five out of ten persons with the early pattern and who used Bendectin thought it was most helpful in the relief of nausea and vomiting, while only one out of six in the irregular pattern and two out of seven in the late pattern thought it most helpful. 34 Table 12 Percentage of Activities that Worked Best to Control Nausea Activities Eating Bendectin Rest Vomiting Discontinuance of Iron Keeping Busy Nothing helpful Total N = Early Pattern 8 (42.1) 5 (26.3) 4 (21.1) 1 (5.3) o o 4 (21.1) 19 N (%) Irregular Pattern 7 (53.8) 1 (7. 7) 3 (23.0) 3 (23.0) o 1 (7 . 7) 3 (23.0) 13 Late Pattern 5 (35.7) 2 (14.3) 5 (35.7) o 1 (7.1) 1 (7 .1) 1 (7 .1) 14 35 CHAPTER IV SUMMARY AND RECOMMENDATIONS One component of this study was to describe the patterns of nausea and vomiting reported by primigravida women. Since nausea and vomiting are so widely experienced by pregnant women and since surprisingly little is known about the cause of these symptoms as evidenced by the wide range of theories, the study of nausea and vomiting in pregnancy presents problems of definition and diagnosis. The second aspect was to begin to develop a tool for further research related to nausea and vomiting in pregnancy to enable the practitioner to offer better support to the mother and recommend treatment based individually on evaluation of specific symptoms. This was an inferential study with a one group design utilizing a survey as the primary tool. The survey instrument was composed of two parts, one developed by the investigator and the second developed by Sullivan (1978) for use in a previous study on pregnancy symptoms at the University of Utah. Sixty-one primigravida women voluntarily completed the survey form at the time of their scheduled prenatal visits. The following four patterns of symptoms became apparent in the analysis of the data: (1) no symptoms of nausea and/or vomiting; (2) symp~oms of nausea and/or vomiting in the late night hours or in the morning hours; (3) symptoms of nausea and/or vomiting occuring at various times during a 24 hour period; and (4) symptoms of nausea and/or vomiting during late morning, afternoon, and/or evenings. 37 The findings were both positive and negative. No significant relationships were found between the pattern of nausea and vomiting and the following variables: age, weeks of gestation at the time of the survey, onset and duration of nausea and vomiting, gastroin­testinal symptoms in the second trimester, incidence of vomiting subsequent to alcohol intake, pain with menses, history of allergies, selected variables associated with mealtime sickness, history of nausea while taking oral contraceptives, frequency and onset of menses, stresses related to social situation, family relationships, finances, life style, and changes in personal habits, Cornell Psychiatric index, neuromuscular and skin symptoms in the first and second trimesters, plans for pregnancy, perception of nausea inter­ferirtg with activities of daily living, and plans to breast feed. Those findings that were significant are the following: (1) There was a significant difference (P < 0.016) between groups pertaining to the subject's perception of the pregnancy as com­pared with expectation. Those with the irregular pattern of nausea and vomiting, and generally the most number of hours of nausea per day, had the highest percentage (42.8%) of women who considered their pregnancies to be more difficult than expected. Of those without symptoms of nausea and vomiting, 77% thought their pregnancies were easier. (2) The number of gastrointestinal symptoms reported by subjects in the first trimester differed significantly (P < 0.001) 38 between the groups as defined by reported time of nausea and vomitin~ Those without nausea and vomiting generally reported the least number of symptoms, and those with the irregular pattern reported the most. (3) Symptom proneness (based on symptoms reported in the last ten years) was significantly different (P < 0.031) between groups. Those women with the irregular pattern of nausea and vomiting generally reported more symptoms in the last ten years than those in the other groups. (4) General adaptational stress symptoms reported by subjects in the first trimester differed significantly (P < 0.004) between defined patterns of nausea and vomiting. Those with the irregular pattern tended to have the highest number of symptoms in this category, and those without nausea and vomiting the fewest. It is impossible to determine causal relationships from this data. For example, one can question whether nausea and vomiting have contributed to a woman's fatigue and sleep disturbances, or whether the fatigue and sleep disturbances make her subject to more nausea and vomiting. (5) The subject's perception of how she felt after vomiting was found to have a significant relationship (P < 0.014) to the patterns defined. Of those women with the early pattern only 25% felt improve­ment after vomiting, while 100% of those with the late pattern felt better after vomiting. (6) Nausea after meals and vomiting before meals were found to be significantly different at P < 0.038 and P < 0.011, respectively. 1bose women with the early pattern had less nausea after eating and more vomiting before eating than the other two groups of women 39 experiencing nausea and vomiting in their pregnancies. Possibly the nausea of those women with the early pattern is due to low levels of available glucose making them prone to ketosis. (7) Cardiovascular and respiratory symptoms in the first trimester approached significance (P < 0.031 and P < 0.064, respec­tively). Those with the early pattern had the least cardiovascular and respiratory symptoms, and those with the late pattern had the most. Those with symptoms absent had the least reproductive symp­toms, and those with the late pattern had the most. (8) The commonly used drug for nausea, Bendectin, was not consistently effective in the treatment of nausea and vomiting in those women. These significant findings plus the awareness of the lack of significant differences in the many other variables of this study fail to substantiate anyone theory on etiology of nausea and vomiting. Recommendations for Nursing and Nurse-Midwifery The following recommendations for nursing and nurse-midwifery are based on the findings of this study: (1) Since ease of pregnancy is so strongly related to symptoms of nausea and vomiting, minimization of these symptoms will contri­bute greatly to the comfort and happiness of the expectant mother. Thorough investigation of the client's pattern of nausea and vomiting should be undertaken by the nurse or the nurse-midwife. Any. recommendations for treatment should be based on her reported pattern. 40 These recommendations should be accompanied by an explanation of patterns of nausea and vomiting and the interventions that have been found to work best for others experiencing her particular pattern. (2) Anticipatory guidance can be provided for women who experience nausea and vomiting, particularly those with the irregular pattern. For example, those with the irregular pattern could be counseled to expect other gastrointestinal and general adaptational stress symptoms, such as constipation, heartburn, fatigue and sleep disturbances. They could be encouraged by nurses to take action to prevent these symptoms through diet modification, exercise, and increased rest. (3) Indiscriminate use of Bendectin is unwarranted and not effective. Since Bendectin worked best for those experiencing the early pattern of nausea and vomiting, it is recommended that its prescription be based on patterns of nausea and vomiting and be given to those women who seem to benefit from its use. Attempts to provide diet counseling are highly recommended to nurses since this seemed to be most effective for all patterns of nausea and vomiting. Recommendations for Further Research The following recommendations for future research are based on recognition of the limitations of this study. (1) The study should be repeated obtaining a much larger £ample with subjects from a greater variety of races, locales, and socio­economic status. This study sample was one of convenience due to the time and financial constraints of the situation. 41 (2) The subject often could not (a) identify the trimester of pregnancy to complete correctly all sections of Part II of the survey; (b) correctly interpret questions and sections to be completed; and (c) supply adequate information about corrective measures taken to relieve the nausea and vomiting and their usefulness to the subject. An interview or assistance by the investigator to complete the survey may be beneficial. (3) That all of the women were not investigated at the same time in the pregnancy may be a source of error and could be more carefully controlled in a repeat study. On the other hand, no association was found between the period of gestation of the subjects at the time of investigation and the pattern of reported nausea and vomiting during pregnancy. (4) An alternate approach to the same information would be to have the subject keep records of her nausea, times, length, relief measures, medications, etc., during her pregnancy and perform a regression analysis on the factors to detect their influence on the pattern of nausea and vomiting presented. Follow-up by obtaining more precise physical data, blood sugar levels, and urinary ketone levels could be performed on individuals, particularly those with the early pattern of nausea and vomiting, to correlate these data with the pattern exhibited. Furthermore, control of individuals using Vitamin B6 is recommended to determine its effects on the pattern of nausea and vomiting. APPENDIX A CONSENT FORM 43 The following questionnaire was compiled by the research section of the University of Utah College of Nursing and by this author as a part of research for a master's degree in nursing. If you are willing to cooperate in this research, please read carefully and sign below. Please feel free to ask questions of the person who gave you these forms at any time before or during your completion of the questionnaire. I herewith agree to serve as a subject in the study Patterns of Nausea and vomiting in First Pregnancies under the supervision of Marcia Strahn, R.N. The study aims to develop deeper understanding of the nausea and/or vomiting women experience in their first preg-nancy. I will be given a questionnaire which will involve approximately 30 minutes of my time. I will also authorize inspection of my chart to determine specific information related to my health that will supplement the questionnaire. There are no expected risks. My participation and cooperation in filling out this survey will help to advance the understanding of the processes involved in health of pregnant women and of their babies. I understand that confidentiality will be protected, and that I am free to withdraw from participation in the study at any time without prejudice to my care. I have read and fully understand the above information. Date Signature Subject Number ---------- APPENDIX B QUESTIONNAIRE 45 Part I Please fill in the blank or circle the answer that applies. 1. What is your age? __________ years 2. What is your marital status? Single Married Widowed Divorced Separated 3. With whom are you living? 4. How does the baby's father feel about the pregnancy? Happy Unhappy Undecided 5. Have you ever taken birth control pills? Yes No 6. If yes, did you have nausea while taking the "pill"? Yes No . did you have vomiting while taking the "pill"? Yes No Please name or describe the type(s) of birth control pills you were taking while experiencing the nausea and/or vomiting. Have you had motion sickness? Yes No If yes, how often? Rarely Occasionally Frequently how severe? Mild Moderate Severe Do you take medication for the motion sickness? Yes No If yes, give name (if known) COMPLETE THIS SECTION ONLY IF YOU HAVE HAD ANY NAUSEA IN THIS PREGNANCY. Please be as specific as possible. Circle the month in which your nausea began and ended. 1. Month began 1 '..-., 3 4 5 6 7 8 9 2. Month ended 1 2 3 4 5 6 7 8 9 presently continues 3. How many hours per day were you/are you nauseated? 4. What times of day were you/are you nauseated? 5. What times of day do you normally eat meals and snacks? 46 6. Did you/do you have nausea associated with meals? Yes No If yes, while preparing food? Yes No before meals? Yes No during meals? Yes No after meals? Yes No with certain foods? Yes No Identify -------- 7. What did you/do you do to try to control your nausea? 8. What seemed/seems to work best to relieve your nausea? ----- 9. If you took/are taking medicines for the nausea, what are they? (Please give the name of the drug or its description.) (a) Month began 1 2 3 4 5 6 7 8 9 Month ended 1 2 3 4 5 6 7 8 9 Still taking (b) Month began 1 2 3 4 5 6 7 8 9 Month ended 1 2 3 4 5 6 7 8 9 Still taking (c) Month began 1 2 3 4 5 6 7 8 9 Month ended 1 2 3 4 5 6 7 8 9 Still taking (d) Month began 1 2 3 4 5 6 7 8 9 Month ended 1 2 3 4 5 6 7 8 9 Still taking 10. Did you/do you take prenatal vitamins? Yes No If yes, brand or type (if known) 11. Did/does the nausea interfere with your daily routine? Yes No If yes, how? CO~~LETE THIS SECTION ONLY IF YOU HAVE HAD ANY VOMITING IN THIS PREGNANCY. Please be as specific as possible. Circle the month in which your vomiting began and ended. 1. Month began 1 2 3 4 5 6 7 8 9 2. Month ended 1 2 3 4 5 6 7 8 9 presently continues 3. How many times per day did you/do you vomit? 4. How many days per week did you/do you vomit? t; What times of day did you/do you vomit? oJ. 6. Did you/do you vomit on a full stomach? Yes No 7. Did you/do you vomit on an empty stomach? Yes No 8. Was your/is your vomiting associated with meals? Yes No If yes, while preparing food? Yes No before meals? Yes No during meals? after meals? with certain foods? Yes No Yes No Yes No Identify 47 -------- 9. What did/do you do to try to control your vomiting? 10. What seemed/seems to work best to relieve your vomiting? 11. Was your vomiting during your pregnancy due to flu or other illness? Yes No If yes, what illness? 12. How did you feel after you vomited? Better Worse Same 48 13. What are your feelings about vomiting during your pregnancy and at other times in your life? ----------------------------------- 14. How does your husband/family feel about you being nauseated and/or vomiting? Concerned Indifferent Annoyed Unknown PLEASE COMPLETE THIS SECTION REGARDLESS OF WHETHER YOU HAD NAUSEA OR VOMITING IN YOUR PREGNANCY. 1. Did you have vomiting at times other than associated with your pregnancy (before you were pregnant or as a child)? Yes No If yes, due to what? 2. Do you find that you vomit when you are feeling tired? Yes angry? Yes frustrated? Yes helpless? Yes 3. Do you vomit after drinking alcohol? Yes No If yes, No No No No after excess? Always Frequently OccaSionally Rarely after moderate amount? Always Frequently Occasionally after small amount? Always Frequently Occasionally 4. Have you ever tried to make yourself vomit? Yes No If yes, under what circumstances? Rarely Rarely 5. Can you remember your mother vomiting when you were a child? Yes No If yes, how did you feel at that time? Concerned Indifferent Annoyed Unknown PLEASE ADD ANY OTHER COMMENTS ABOUT YOUR NAUSEA AND/OR VOMITING THAT YOU FEEL MAY BE HELPFUL TO OUR UNDERSTANDING: 49 Part II Please Circle the Illnesses or Symptoms You Have Had Within the Past Ten Years 1. Gas 2. Stomach cramps 3. Gallbladder trouble 4. Hemorrhoids (piles) 5. Crampy pain in abdomen 6. Trouble with teeth/gums 7. Loss of appetite for more than a day 8. Burning sensation in stomach 9. Sensitive to particular foods 10. Earaches 11. Trouble with eyes 12. Prolonged stuffy nose 13. Severe headaches 14. Hay fever 15. Tonsillitis 16. Pneumonia 17. Persistent cold in chest 18. Urinary tract infections 19. Bladder infections 20. Blood in urine 21. High or low blood pressure 22. Anemia 23. Bleeding tendency 24. Allergies 25. Chest pains 26. Persistent cough 27. Feeling of general weakness 28. Gain or loss of weight (more than 10 pounds) 29. Severe menstrual cramps 30. Stiff sore joints 31. Specific muscle weakness 32. Many skin infections 33. Cuts or wounds which healed slowly 34. Bruise easily Please Circle the Trimester(s) During THIS Pregnancy in Which you OFTEN Have Had or Are Having Any of the Following Symptoms When 1-3 Hhen 4-6 When 7-9 Months Months Months Pregnant Pregnant Pregnant 35. Loss of appetite for some time Yes Yes Yes 50 When 1-3 When 4-6 When 7-9 Months Months Months Pregnant Pregnant Pregnant 36. Frequent dry mouth--bad breath Yes Yes Yes 37. Persistently bleeding gums Yes Yes Yes 38. Frequent constipation Yes Yes Yes 39. Certain foods bother you Yes Yes Yes 40. Troubled by nausea or morning sickness Yes Yes Yes 41. Troubled by vomiting (other than No. 40) Yes Yes Yes 42. Bothered by diarrhea if not taking "iron pills" Yes Yes Yes 43. Heartburn Yes Yes Yes 44. Gas Yes Yes Yes 45. Stomach cramps Yes Yes Yes 46. Crave certain foods Yes Yes Yes 47. Frequent frightening dreams Yes Yes Yes 48. III health frequently affecting your work Yes Yes Yes 49. Felt persistently tired Yes Yes Yes 50. Not much energy Yes Yes Yes 51. Frequently need more sleep than usual Yes Yes Yes 52. Gained more weight than you wanted to Yes Yes Yes 53. Increase in neryous irritability Yes Yes Yes 54. More sensitive to light, sounds, smell Yes Yes Yes 55. Trouble getting to sleep Yes Yes Yes 56. Trouble staying asleep 57. Tired when you get up in the morning 58. Headaches 59. Persistent increase in vaginal discharge without itching or burning 60. Discharge of fluid from breasts (colostrum) 61. Painful breasts 62. Tingling in breasts 63. Vaginal bleeding (more than spotting) 64. Vaginal bleeding (spotting) 65. Increased breast size 66. Contraction of uterus, sometimes associated with discomfort, pain 67. Excessive movement of baby 68. Sharp pains in lower abdomen on either side when you suddenly change positions 69. Baby too big or too small for your dates 70. Do you feel stretched out of shape? 71. Need to pass urine (water) frequently 72. Pain or burining feeling during/following urination (passing water) 51 When 1-3 When 4-6 When 7-9 Months Months Months Pregnant Pregnant Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 73. Muscle cramps especially at night 74. Low backache 75. Stiff or sore joints 76. Joints of body feel loose 77. Aching arms/legs 78. Numbness arms/legs 79. Weakness arms/legs 80. Have a tendency to drop things 81. Pains in rib cage 82. Have difficulty walking 83. Hands often sweaty 84. Definite rashes 85. Itchy skin 86. Perspire a great deal 87. Skin blotches 88. Marked changes in hair 89. Skin infections 90. Bruise easily 91. Stretch marks on breasts, abdomen, hips 92. Frequently feel heart pounding 93. Have problems with varicose veins 94. Have problems with hemorrhoids 52 When 1-3 When 4-6 When 7-9 Months Months Months Pregnant Pregnant Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 95. Frequently feel short of breath 96. Need to sleep on two or more pillows 97. Get "colds" frequently 98. Troubled by stuffy nose 99. Frequently cough day or night 100. Frequent dizzy spells 101. Often felt like fainting 102. Swelling in ankles and legs 103. Swelling of hands/face late in the day 104. Frequently feel hot and flushed 105. Did/do you get nervous and shaky when approached by someone you consider to be important? 106. Did/do you usually feel unhappy and depressed? 107. Did/does life look entirely hopeless? 108. Did/do you suffer from severe nervous exhaustion? 109. Did/does every little thing get on your nerves lately and wear you out? 110. Did/do you often become suddenly scared for no good reason? 111. Did/do you often wish you were dead and away from it all? 53 When 1-3 When 4-6 When 7-9 Months Months Months Pregnant Pregnant Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 112. Did/does your thinking get completely mixed up when you have to do things quickly? 113. Were/are you constantly keyed up and jittery? 114. Did/do frightening thoughts keep coming back in your mind? 115. Did/do you often get spells of complete exhaustion of fatigue? 116. Were/are you often bothered by thumping of the heart? 117. Did/do you wear yourself out worrying about your health? 118. Did/does your heart often race like mad? 119. Did/does pressure or pain in the head often make life miserable for you? 120. Did/do you wish you always had someone at your side to advise you? 121. Did/do you go to pieces if you don't constantly control yourself? 122. Did/do you often shake or tremble? 123. Did/does worrying continually get you down? 124. Were/are you considered to be a nervous person? 54 When 1-3 When 4-6 When 7-9 Months Months Months Pregnant Pregnant Pregnant Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 55 Please Answer "Yes" to the Following Questions if They Apply to You During One or Both of the Two Periods in the Last Year 125. Have you been in an automobile accident in which the major fault was yours? 126. Have you changed to a different line of work? 127. Have you had a change in your role as wife or mother? 128. Do you have a mortgage over $10,0007 129. Have you had a change in living conditions? 130. Have you changed some of your personal habits? 131. Have you been arrested for a minor violation? 132. Have you had a change in responsibilities at work? 133. Have you experienced a marital reconciliation? 134. Do you have a mortgage under $10,000? 135. Have you had a change in residence? 136. Have you changed some of your eating habits? 137. Have you had a fight with a close friend? 138. Have you had trouble with your boss? 139. Have you had a change in the number of family get-togethers? 140. Do you have monthly car payments? 141. Have you begun or finished school? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 142. Have you changed some of your sleeping habits? 143. Have you been either drunk or disorderly? 144. Have you had a change in attitude towards your job? 145. Have you gotten married? 146. Do you have a bank loan (other than education, house, or car loan)? 147. Have you had a change in your usual social activities? 148. Have you changed some of your exercise habits? 149. Have you left home for a pericd of hours or longer because of a dispute? 150. Have you had a change in your boss? 151. Have you had trouble with your in-laws? 152. Do you have any outstanding medical bills? 153. Have you had a change in your usual church activities? 154. Have you changed your recreational activities? 155. Have you changed marital partners? 156. Have you had a change in your co-workers? 157. Have you had more or fewer arguments with your spouse? 158. Have you had a reduction in family income? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 56 During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 159. Have you started or stopped any social activities? 160. Have you been a vegetarian? 161. Have you been abandoned by your family? 162. Have you had a change in your physical conditions at work? 163. Have you had difficulties in your sexual relationship? 164. Have you had an increase in family income? 165. Have you had a difficult time budgeting for household expenses? 166. Have you gone on or off a reducing diet? 167. Have you run away from home? 168. Have you had a change in your work due to seasonal changes? 169. Have you discussed a possible separation from your spouse? 170. Have you had a change in your financial state? 171. Have you had a change in your hobby? 172. Have you changed the time you wake up or go to bed? 173. Have you had a close friend who has been arrested or jailed? 174. Have you had a temporary change in the kind of work you do? 175. Have you had an increase or decrease in the number of people in your household? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 57 During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 176. Has recent inflation forced you to shop more carefully? 177. Have you had a change in your mode of transportation? 178. Have you had a change in the quality of your dreams? 179. Have you been planning any legal action against someone? 180. Have you had a change in work which strains your competencies? 181. Have you had religious conflicts within your household? 182. Have you recently made a major purchase (house, furniture, car, etc.)? 183. Have you h~d a change in the time (more or less) you spend by yourself? 184. Have you changed the amount of time you spend doing housework? 185. Have you occasionally used social drugs (marijuana, alcohol)? 186. Have you had a change in work which now does not make good use of your capabilities? 187. Have you had any political or religious conflicts in your family? 188. Because of inflation, have you changed your eating habits? 189. Have you felt that you never have enough time for yourself? 190. Have you increased or decreased activities in church? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 58 During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 191. Have you thought of suicide? 192. Have you changed the location of your work? 193. Have you experienced the death of a close family member? 194. If you have a checking account, have you overdrawn it? 195. Have you been spending less time in outdoors activities? 196. Have you increased or decreased social contacts? 197. Have you been a victim of a swindle or fraud? 198. Have you felt that your work has become more of a strain for . you because of your pregnancy? 199. Have you experienced a change of attitude toward your family? 200. Have you had to borrow money from your family or friends? 201. Have you watched television or read more than before your pregnancy? 202. Have you seemed to feel more optimistic? 203. Have you been a victim of a serious crime? 204. Have you changed your work hours or work conditions? 205. Have you had conflicts over who performs various tasks in your household? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 59 During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 206. Have you put money away each month in a savings account? 207. Have you changed from thinking of yourself as a pregnant woman to being the mother of an unborn baby? 208. Have you experienced considerable mood changes? 209. Have you become fearful of being alone while at home? 210. Have you strongly disliked your work? 211. Have you had arguments about family finances? 212. Have you bought major purchases on credit? 213. Have you become close to or lost some friends? 214. Have you had any personal injury or illness? 215. Have you gotten divorced? 216. Have your co-workers generally been satisfied with their work? 217. Have you had some outstanding personal achievement? 218. Has there been a change in your financial state? 219. Have you changed your style of dressing? 220. Have you had a change in your sex life? 221. Have you exceeded the speed limit by more than 10 miles per hour? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 60 During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 222. Have you wanted to quit your present job (if you could afford not to work)? 223. Have you had a pregnancy? 224. Have you had to change your vacation plans because of financial reasons? 225. Have you changed your shopping habits? 226. Have you had a change in your daily activities? 227. Do you tend to feel physically and emotionally exhausted at the end of your working day? 228. Has your family changed in any important way? 229. Have you changed your hair style or cosmetic makeup? 230. Have you had a change in health? Six to Twelve Months Ago Yes Yes Yes Yes Yes Yes Yes Yes Yes 61 During the Past Six Months Yes Yes Yes Yes Yes Yes Yes Yes Yes 1. Who is the chief income earner in your family? (please check one) Husband ---- Wife ---- Other ---- 2. What is the yearly income for your family from all sources? (please check one) ---- None $1,000-2,999 ____ $3,000-4,999 ____ $5,000-6,999 ---- $7,000-8,999 ---- $9,000-10,999 $11,000-12,999 $13,000-14,999 ___ $15,000-16,999 ____ $17,000-18,999 ___ $19,000-20,999 ____ $21,000-22,999 ---- $23,000 or more 3. What is the highest level of education achieved by: (please check one) Male 62 Female Head Household Head Household 0-6 grades, ungraded 7-9 grades, Junior High School 10-11 grades, some High School Graduate, High School At least one year College Graduate, four years College Postgraduate, College 4. What is the occupation of the head of the household? (please check one) Student in High School, Trade School Laborer, farm laborer Other service worker Domestic worker Craftsman Salesman Clerical Proprietor, manager, business or agriculture Operator ___ Professional, including college student 5. Was this pregnancy planned? (please check one) ----- Yes ---- No 6. Do you plan to breast feed? (please check one) ---- Yes ---- 7. Has this pregnancy so far been: (please circle one) (a) easier than you expected? (b) what you expected? (c) harder than you expected? No APPENDIX C LISTING OF ITEMS FOR DETERMINATION OF CATEGORICAL SCORES ON PART II OF QUESTIONNAIRE Category Symptom Proneness Gastrointestinal Symptoms 1* Gastrointestinal Symptoms 2* General Adaptationa1 Stress Symptoms 1* General Adaptationa1 Stress Symptoms 2* Reproductive Symptoms 1* Reproductive Symptoms 2* Neuromuscular Symptoms 1* Neuromuscular Symptoms 2* Skin Symptoms 1* Skin Symptoms 2* Cardiovascular/Respiratory Symptoms 1* Cardiovascular/Respiratory Symptoms 2* Cornell Psychiatric Inventory 1* Cornell Psychiatric Inventory 2* Social Stress 1* Social Stress 2* Work Stress 1* Work Stress 2* Items /I 1-34 35-46 47-58 59-72 73-82 83-91 92-104 105-124 125, 131, 155, 161, 185, 191, 215, 221 126, 132, 156, 162, 186, 192, 216, 222, *1 = first trimester; 2 = second trimester 64 137, 143, 149 167, 173, 179 197, 203, 209 138, 144, 150 168, 174, 180 198, 204, 210 227 65 Category Items # Family Stress 1* 127, 133, 139, 145, 151 157, 163, 169, 175, 181 187, 193, 199, 205, 211 Family Stress 2* 217, 223, 228 Financial Stress 1* 128, 134, 140, 146, 152 158, 164, 170, 176, 182 188, 194, 200, 206, 212 Financial Stress 2* 218, 224 Life Style Stress 1* 129, 135, 141, 147, 153 159, 165, 171, 177, 183 189, 195, 201, 207, 213 Life Style Stress 2* 219, 225, 229 Personal Habits Changes Stress 1* 130, 136, 142, 148, 154 160, 166, 172, 178, 184 190, 196, 202, 208, 214 Personal Habits Changes Stress 2* 220, 226, 230 *1 = first trimester; 2 = second trimester - APPENDIX D MEDICAL RECORD ABSTRACT 67 (To be completed by the person administering the questionnaire. Data will be obtained from the clinical record subsequent to authorization by the subject.) Subject Number _____ __ Number of weeks pregnant by LMP -----------------------(nearest week) Is the height of the fundus consistent with the number of weeks pregnant? Yes No Onset of Menarche ---------------------- years of age Frequency of occurrence of menses every ---- days (average) Duration of menses --------------------- days (average) History of pain with menses? Yes No If yes, was it ••...•• # of days of pain during menses Mild Moderate Severe (average) History of allergies? Yes No If yes, to what substance(s)? Type of reaction Mild Moderate Severe Check conditions occurring in this subject's medical history. For those checked, please give additional information as required and available. --- Diabetes Mellitus Mild Moderate Severe (circle one) --- Thyroid disease Mild Moderate Severe (circle one) --- Hypertension ~ld Moderate Severe (circle one) Infertility Year of onset Medication(s) taken/taking '----- Year of onset Medicat ion (s) -t-a~k-e-n""'7I"'""t-a-:-k--i-n-g----- Year of onset Mecication(s) taken/taking Cause Treatment ---- REFERENCES Alvarez, W. C. A physiologic explanation for the nausea and vomiting of pregnancy. Proceedings of the Staff Meetings of the Mayo Clinic, 1929, i(24) , 181-182. Astwood, E. B. Estrogens and progestins. In L. S. Goodman & A. Gilman (Eds.), The pharmacological basis of therapeutics: A textbook of pharmacology, toxicology, and therapeutics for physicians and medical students (4th ed.). New York: The MacMillan Company, 1970. Atlee, H. B. Pernicious vomiting of pregnancy. Journal of Obstet­rics and Gynecology of the British Empire, 1924, 41, 750-759. Brown, L. B. Anxiety in pregnancy. British Journal of Medical Psychology, 1964, li, 47-58. Carreras, B. B. gravidarum. Intravenous ACTH in the treatment 'Of hyperemesis Obstetrics and Gynecology, 1954, 1, SO-52. Chertock, L., Mondzain, M. L., & Bonnaud, M. Vomiting and the wish to have a child. Psychosomatic Medicine, 1963, ~, 13-18. David, M. L., & Doyle, E. W. First trimester pregnancy. American Journal of Nursing, 1976, ~(12), 1945-1948. Fairweather, D. V. I. Nausea and vomiting in pregnancy. American Journal of Obstetrics and Gynecology, 1968, 102(1), 135-175. Fairweather, D. V. I., & Loraine, J. A. Urinary excretion of human chorionic gonadotropin in patients with hyperemesis gravidarum. British Medical Journal, 1962, 1, 666-669. Finch, J. W. The etiology of nausea and vomiting in pregnancy. Journal of the American Medical Association, 1938, 111(15), 1368-1370. Fitzpatrick, E., Reeder, S. R., & Mastroianni, L., Jr. Maternity nursing (12th ed.). Philadelphia: J. B. Lippincott Company, 1971. Gardiner, J. P. Vomiting of pregnancy. Journal of the American Medical Association, 1928, ~(25), 1937-1941. 69 Harding, V. J. Nausea and vomiting in pregnancy. The Lancet, 1921, 210, 327-331. Hawkinson, L. F. Nausea and vomiting of pregnancy. Minnesota Medicine, 1936, 19, 519-524. Johnson, H. W. Toxemias of pregnancy. Surgery, Gynecology and Obstetrics, 1940, lQ, 513-516. Kemp, W. N. The treatment of early vomiting of pregnancy with supra­renal cortex: Case reports. Endocrinology, 1932, 16, 434-436. McCammon, C. S. A study of four hundred and seventy-five pregnancies in American Indian woman. American Journal of Obstetrics and Gynecology, 1951, 61, 1159-1166. McGanity, W. J., McHenry, E. W., van Wyck, H. B., & Watt, G. L. An effect of pyridoxine on blood urea in human subjects. Journal of Biological Chemistry, 1949, 178, 511-516. Mead, M. Male and female. New York: Morrow, 1947. Menninger, K. A. Somatic correlations with the unconscious repudia­tion of femininity in women. Journal of Nervous and Mental Disease, 1939, 89, 514-527. Midwinter, A. Vomiting in pregnancy. The Practitioner, 1971, 206, 743-750. Netter-Munkelt, P., Mau, G., & Konig, B. The dimension of neuroti­cism as a modifying factor in the association between biological conditions and nausea in pregnancy. Journal of Psychosomatic Research, 1972, 16, 395-404. Palmer, R. L. A psychosomatic study of vomiting in early pregnancy. Journal of Psychosomatic Research, 1973, 12, 303-308. Peckahm, C. H. Observation on sixty cases of hyperemesis gravidarum. American Journal of Obstetrics and Gynecology, 1929, 12, 776-788. Pritchard, J. A., & MacDonald, P. C. Williams obstetrics (15th ed.), New Y~rk: Appleton-Century~Crofts, 1976. Reinken, L., & Gant, H. Vitamin B6 nutrition in women with hyper­emesis gravidarium during the first trimester of pregnancy. C1inica Chimica Acta, 1974, ~, 101-102. Rosen, S. Emotional factors in nausea and vomiting of pregnancy. Psychiatric Quarterly, 1955, ~, 621-633. Schoeneck, F. J. Gonadotropic hormone concentration in emesis gravidarum. American Journal of Obstetrics and Gynecology, 1942, 43, 308-312. 70 Semmens, J. P. Female sexuality and life situations: An etiologic psycho-socio-sexual profile of weight gain and nausea and vomiting in pregnancy. Obstetrics and Gynecology, 1971, 38(4), 555-563. Sterk, V. V., Prywes, R., Davies, A. M., Ever-Hadani, P., & Lilos, P. Vomiting during pregnancy in Jerusalem women. Israel Journal of Medical Science, 1971, l(ll) , 1248-1255. Stone, A. R. Cues to interpersonal distress due to pregnancy. American Journal of Nursing, 1965, ~(ll), 87-91. Sullivan, J. Personal communication, May, 1978. Titus, P., & Dodds, P. The etiologic significance of lowered blood sugar values in vomiting of pregnancy. American Journal of Obstetrics and Gynecology, 1928, 16, 90-96. Uddenberg, N., Nilsson, A., & Almgran, P. Psychology and psychosomatic aspects. Research, 1971, 15, 169-176. Nausea in pregnancy: Journal of Psychosomatic Walser, H. C. Fear, an important etiological factor in obstetric problems. American Journal of Obstetrics and Gynecology, 1948, ~, 799-805. Way, S. Relation between gastric acidity and the anterior-pituitary-like hormone content of urine in pregnant women. British - Medical Journal, 1945, 1, 182-184. Weiss, E., & English, o. S. Psychosomatic medicine. Philadelphia: w. B. Saunders, 1943. Wells, C. N. Treatment of hyperemesis gravidarum with cortisone. American Journal of Obstetrics and Gynecology, 1953, 66, 589-661. , \meatley, D. Meclozine and pyridoxine in pregnancy sickness. The Practitioner, 1963, 190, 251-253. Name Birthdate Birthplace High School Colleges Spring, 1970 1974-1976 Universities Fall, 1969 1975-1977 1977-1979 Degree Professional Organizations Professional Positions VITA Marcia Ann Strahn June 13, 1951 Clinton, Iowa Forreston Community High School Forreston, Illinois Highland Community College Freeport, Illinois Rock Valley College Rockford, Illinois University of Iowa Iowa City, Iowa Northern Illinois University DeKalb, Illinois University of Utah Salt Lake City, Utah B.S., Northern Illinois University DeKalb, Illinois American College of Nurse-Midwives American Nurses' Association Rockford Memorial Hospital, Rockford, Illinois, 1973-1977, staff nurse