Large variation in management of nausea and vomiting in pregnancy

An observational study from researchers at the University of Warwick focusing on the health economy within one NHS CCG indicates that there is currently considerable variation in the management of nausea and vomiting in pregnancy in general practice and the financial impact is high (Br J Gen Pract 2018; DOI: https://doi.org/10.3399/bjgp18X700745).

The study authors note that nausea and vomiting affects up to 80% of pregnant women, and can range from mild symptoms to the more serious condition hyperemesis gravidarum. The Royal College of Obstetricians and Gynaecologists (RCOG) published its first guideline on the management of nausea and vomiting in pregnancy in 2016, in which they recommend a range of interventions beginning with conservative management, followed by antiemetics such as antihistamines and phenothiazines first-line if medication is needed. Currently, there is only one licensed treatment for nausea and vomiting in pregnancy in the UK – Xonvea (doxylamine/pyridoxine), a combined antihistamine/vitamin B6 preparation authorised in July 2018 – although many other treatments are used off-label.

The study collected data from eight GP practices within Newcastle Gateshead CCG over one year (2014–2015). Of the 804 pregnant women in the GP practice study population, 15.2% presented with nausea and vomiting. Of those that had treatments recorded, 51% were offered conservative management, 22% first-line pharmacotherapy and 4% second-line pharmacotherapy; 17% were issued with medicines not featured in the 2016 RCOG guideline. There was a substantial variation in the management of nausea and vomiting between GP practices, with treatment recommendations not uniformly prescribed across all practices in the study. There was also a high frequency of repeat visits, with 33.6% of women presenting to their GP with nausea and vomiting on more than one occasion in the same pregnancy and some women visiting up to seven times.

The study authors also reported a year-on-year increase in the number of patients admitted to hospital for nausea and vomiting symptoms over a three-year period (2013–16) within the same CCG, with the mean length of stay being approximately 1.3 days. Over a 12-month period, 44.6% of 999 or 111 calls from pregnant women experiencing nausea and vomiting symptoms resulted in an ambulance being dispatched; a substantial resource use that could potentially have been avoided by earlier intervention.

In terms of economic burden, the study authors extrapolated data from the Newcastle Gateshead CCG health economy to the whole of the UK, and estimated that the cost impact of nausea and vomiting in pregnancy to the NHS could be up to £62 million annually. The authors concluded that “the costs of NVP for the NHS are considerable, and any effective improvements in treatment and management will benefit sufferers, and potentially reduce the economic burden of the condition”.

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