The Role of Helicobacter Pylori Infection in Occurrence and Severity and Outcome of Hyperemesis Gravidarum: Prospective Cohort study

Introduction

Helicobacter pylori is a bacteria that inhabits the human stomach. H. pylori has been identified as a primary etiological factor for a range of gastrointestinal disorders, like peptic ulcers, gastritis, and even stomach tumor. This bacterium, which belongs to the gram-negative group, possesses a distinct capability to flourish in the acidic conditions of the stomach while avoiding the body's innate immune system.^1,2

1. pylori infection is influenced by various risk factors, such as inadequate sanitation, densely populated living environments, and disadvan-taged socioeconomic level. Moreover, it is widely considered that the main method of transmission is through the fecal-oral route, emphasizing the crucial role of hygiene in preventing infection. Consequently, groups that have greater exposure to these risk factors are more likely to have a greater occurrence of H. pylori infection. Comprehending these aspects is essential for evaluating the possible influence of H. pylori on the well-being of particular populations, such as expectant mothers.^3,4

Hyperemesis gravidarum (HG) is an intense manifestation of vomiting and nausea that occurs during pregnancy, frequently resulting in dehydration, reduction in body weight, and deficiencies in essential nutrients. Although nausea and vomiting are frequently experi-enced during pregnancy, Hyperemesis Gravidarum (HG) stands out due to its intense severity and prolonged duration. The precise cause of HG is not completely comprehended; however, investigations have been conducted on hormonal changes, dietary variables, and a possible association with Helicobacter pylori infection. Examining the frequency of H. pylori in pregnant females had hyperemesis gravidarum is especially important because of the physiological changes that occur during pregnancy and the possible effects of infections on the health of both the mother and the fetus.^5,6

Potential risk factors for hyperemesis gravidarum (HG) encompass a prior occurrence of HG in a previous pregnancy, pregnancies that are occurring for the first time, the presence of multiple gestations (such as twins or more), and the existence of trophoblastic diseases. Moreover, women who have prior gastroint-estinal disorders or are susceptible to motion sickness may face an elevated risk. Studying the frequency of H. pylori infection in pregnant women with hyperemesis gravidarum is crucial for understanding any connections between this bacterium and the severity of pregnancy-nausea and vomiting that are connected or associated.⁷  

The goal of this work was to estimate the role of infection with helicobacter pylori in occurrence and severity and outcome of hyperemesis gravidarum.

Patients and methods

This prospective cohort investigation has been performed at Obstetrics and Gynecology clinics of minia University Hospitals, for one year from March 2024 to February 2025. Included 70 patients were selected from attendee of Obstetrics and Gynecology clinics of minia University Hospitals

Inclusion criteria: Age of females varied from eighteen to forty years old, hyperemesis Gravidarum before gestational age 12 weeks,

pregnant Women with HG, hyperemesis gravidarum is a severe form of vomiting and nausea throughout pregnancy that may result in electrolyte imbalances, weight loss, and dehydration. It is diagnosed based on certain criteria, which include: experiencing severe vomiting (occurring more than three times per day without any other apparent reason), weight loss exceeding three kilograms, and the presence of at least one positive ketonuria and criteria for H. Pylori: unintended weight loss, nausea, stomach pain, vomiting, bloating, and loss of appetite.^8,9

Exclusion criteria: History of gastrointestinal surgery and diseases, multiple gestations (twins or more), use of antibiotics, refusal to participate, a history of thyroid disorders, gestational trophoblastic disease, and a past history of resolved H. pylori infection.

Methods

All patients were subjected to: Complete history taking, Physical examinations, Investigational studies for H. pylori in pregnant females had hyperemesis gravidarum include both invasive and non-invasive methods. Routine laboratory tests like blood sugar concentrations and complete blood count (CBC) are conducted. Invasive tests involve venous blood collection to detect H Pylori IgG antibodies, rapid urease test (RUT) for active infection, and PCR analysis for genetic identification. Non-invasive techniques involve the urea breath test (UBT), stool antigen tests, and molecular diagnostics. Ultrasound was performed to rule out obstetric factors like twin pregnancy. The UBT, considered the gold standard, detects H. pylori through changes in CO₂ levels. ELISA technology was used for antibody detection, with classifications into positive, negative, or borderline cases requiring follow-up. Borderline cases were re-evaluated after two weeks, while severe cases were referred to a gastrointestinal specialist for further management.

Ethical Consideration

The protocol will be utilized to obtain permi-ssion from the Research Ethics Committee, and prior to enrolling in the trial, patients will be required to provide informed consent. The confidentiality of all data will be maintained,

and all participants will have the right to withdraw from the research without any impact on their management.

Statistical Analysis

The gathered data was encoded, processed, and analyzed utilizing the SPSS software (Version 25) designed for the Windows operating system. We calculated descriptive statistics, which involved medians, ranges, means, standard deviations, and percentages. For continuous variables, independent t-tests were conducted to compare the means of data that follow a normal distribution. In cases where the information isn’t normally distributed, Mann-Whitney U tests will be utilized to analyze the variances in medians. For categorical information, a chi-square test will be carried out. The t-test and Wilcoxon test were employed for paired samples. A p-value below 0.05 deemed statistically significant.

Results

Table (1) illustrates that, mean age of the examined women was 29.11±5.07 years and ranged from 18 to 38 years, mean of gravidity was 3.2±1.2, mean of parity was 1.9±1.2, mean of gestational age was 8.73±1.8 weeks and ranged from 4 to 12 weeks.

Table (2) shows that, mean hemoglobin of the studied women was 10.86 ±0.66 gm and ranged from 9.33 to 12.62, mean Albumin of the studied women was 4.15 ±0.35 (mg/dl) and ranged from 3.42 to 5.23, mean Total bilirubin of the studied women was 2.03 ±0.18 (mg/dl) and ranged from 1.63 to 2.4, mean Creatinine of the studied women was 0.81 ±0.15 (mg/dl) and ranged from 0.42 to 1.07, mean Na+ of the studied women was 132.15 ±4.35 (mmol/L) and ranged from 126.3 to 146.18 and mean K+ of the studied women was 3.12 ±0.49 (mmol/L) and ranged from 2.35 to 4.74.

Table (3) shows that, 18 patients (25.72%) were nil in acetone urine test, 20patients (28.56%) were (+) in acetone urine test, 21 patients (30%) were (++) in acetone urine test and 11 patients (15.72%) were (+++) in acetone urine test.

Table (4) shows that, 61 patients (87.14%) were positive in H. Pylori antibody test, 9 patients (12.86%) were negative in H. Pylori antibody test.

Table (5) illustrates that, there was a statistically insignificant variance among examined groups according to Parity, while there was statistically significant variance among examined groups according to Age, Gravidity and Age of gestation.

Table (6) illustrates that, there was a statistically insignificant variance among examined groups according to Albumin, Total bilirubin and Creatinine, whereas there was statistically significant variance among examined groups according to Hemoglobin, Na⁺ and K⁺.

Table (7) illustrates that, there was a statistically insignificant variance among examined groups according to Urine Acetone test.

Discussion

The current research revealed that as regard general characteristic in the examined patients, mean age of the studied women was 29.11 ± 5.07 years and ranged from 18 to 38 years, mean of gravidity was 3.2±1.2, mean of parity was 1.9±1.2, mean of gestational age was 8.73±1.8 weeks and ranged from 4 to 12 weeks.

Our results in concordance with Zakaria et al.,.¹⁰ who aimed to investigate the association among Helicobacter pylori infection and hyperemesis gravidarum throughout preg-nancy. There were hundred pregnant females in the research. They found that the mean age was 26.5± 2.6 years and mean of gestational age was 8.6± 1.4weeks.

Regarding laboratory data in the studied group, we found that mean hemoglobin of the studied women was 10.86 ±0.66 gm and ranged from 9.33 to 12.62, mean albumin of the studied women was 4.15 ±0.35 (mg/dl) and ranged from 3.42 to 5.23, mean total bilirubin of the studied women was 2.03 ±0.18 (mg/dl) and ranged from 1.63 to 2.4, mean creatinine of the studied women was 0.81 ±0.15 (mg/dl) and ranged from 0.42 to 1.07, mean Na+ of the studied women was 132.15 ±4.35 (mmol/L) and ranged from 126.3 to 146.18 and mean K+ of the studied women was 3.12 ±0.49 (mmol/L) and ranged from 2.35 to 4.74.

Our results in concordance with Zakaria et al.,.¹⁰ determined that mean hemoglobin was 10.86±0.83 gm, mean Na+ was 135.74±2.95 (Millimoles per liter) and mean K+ was 3.57±0.32 (Millimoles per liter).

Similarly, our study can be supported by (Hussein et al., 2020) who aimed to evaluate the assortation among the pathogenesis of HG and H. pylori infection in this population. 45 pregnant females had Hyperemesis gravi-darum have been recruited. They revealed that mean hemoglobin was 10.56 ± 1.20 gm, mean creatinine was 0.65 ± 0.16 (mg/dl), mean Na+ was 133.09 ± 5.432 (Millimoles per liter) and mean K+ was 3.43±0.58 (Millimoles per liter).

Regarding urine acetone test, we reported that 18 patients (25.72%) were nil in acetone urine test, 20 patients (28.56%) were (+) in acetone urine test, 21 patients (30%) were (++) in acetone urine test and 11 patients (15.72%) were (+++) in acetone urine test.

Also, our findings in line with Al-Omda et al., ¹¹ stated that 30 (100%) were acetone positive.

Regarding H. Pylori antibody test, we revealed that 61 patients (87.14%) were positive in H. Pylori antibody test, 9 patients (12.86%) were negative in H. Pylori antibody test.

As well, our outcomes in concordance with Hussein et al.,.¹²  reported that thirty-eight (84.4 percent) patients examined positive for the H. pylori stool antigen (HpSA).

In our research we found that there was a statistically insignificant variance among examined groups according to parity, while there was statistically significant variance among examined groups according to age, gravidity and age of gestation.

In concordance with the present study Katta et al.,¹³  reported that there was statistically significant variance among groups according to age as the presence of H. pylori was significantly associated with younger age. While in contrast, there was a statistically insignificant variance among groups according to gestational age.

In our study we found that there was a statistically insignificant variance between studied groups regarding albumin, total bilirubin and creatinine, whereas there was statistically significant variance between studied groups according to hemoglobin, Na⁺ and K⁺.

In concordance with the present study Ahmed et al.,.¹⁴ who found that there was statistically significant variance among examined groups according to hemoglobin whereas there was an insignificant variance according to serum creatinine, serum albumin, or liver enzymes. While in contrast with our outcomes, there was an insignificant variance as regards the levels of electrolytes (Na, K, Ca).

In our investigation we found that there was a statistically insignificant variance among examined groups regarding urine acetone test.

In contrast, our findings disagreed with Al-Omda et al.,¹¹ stated that there were statistically significant differences among examined groups according to acetone.