Gastroözofageal Reflüsü Olan Gebelerde Hemşirelik Eğitiminin Uyku ve Yaşam Kalitesine Etkisi

Amaç: Araştırma gastroözofageal reflü hastalığı (GÖRH) olan gebelerde hemşirelik eğitiminin uyku ve yaşam kalitesine etkisini incelemek amacıyla topluma dayalı, müdahale tipi (kontrol gruplu) ve longitudinal bir çalışma olarak planlandı.

Gereç ve Yöntem: 82 gebe kadın randomize olarak iki gruba ayrıldı. Deney grubuna GÖRH semptomlarının yönetimi hakkında eğitim ve bu konuda yazılı materyal verildi, kontrol grubundaki gebelere ise sağlık kurumlarında var olan bakım uygulandı.

Bulgular: İlk görüşmede deney grubundaki gebelerin %97.6'sında, kontrol grubunda ise %90.2'sinde GÖRH semptomlarının bulunduğu saptandı. Son görüşmede deney grubundaki gebelerin %63.4'ü, kontrol grubundaki gebelerin %97.6'sında GÖRH semptomları saptandı.

Sonuç: Araştırmanın sonuçlarında GÖRH semptomlarının yönetimi hakkında verilen eğitimin semptom sıklığı ve şiddetini azalttığı, yaşam ve uyku kalitesini arttırdığı belirlendi.

Objective: This study, which was planned population-based, randomized, and prospective, aims to evaluate the effect of education frequency and severity of gastro-oesophageal reflux disease (GERD) symptoms, on sleep and quality of life among pregnant women with (GERD).

Material and Methods: Eighty two pregnant women were randomly divided into two groups; experimental group had education intervention and written material about GERD symptoms management whereas the control group did not receive any intervention beyond standard prenatal care.

Results: In the first interview GERD was found in 97.6% of the experimental group and in 90.2% of the control group. In the final interview, GERD was reported by 63.4% of the experimental group versus 97.6% of the control group.

Conclusions: The results obtained from our research show that education for pregnant women for management of GERD symptoms was found to decrease symptom frequency and severity and improvement in quality of life and sleep quality.

Introduction

Prevalence of gastro-oesophageal reflux disease (GERD) increases during pregnancy and is seen in 40-80% of all pregnant women. The two major factors that promote GERD in pregnant women are changes in hormones and the growing fetus. Changes in levels of estrogen and progesterone result in a decrease in the lower esophageal sphincter pressure thereby increasing acid reflux. Additionally, the growing fetus causes an increase in intra-abdominal pressure, resulting in an increase in the development of reflux[1-4]. Reported risk factors for GERD during pregnancy include women’s age, obesity, weight gain during pregnancy, history of GERD symptoms, gestational age, and multiparity[1,5,6].

Pregnant women suffering from GERD at some time during gestation something that is in turn associated with deterioration in quality of life (QoL)[7-14]. Sleep disturbance also is remarkably prevalent in GERD. Pregnant women report sleep disorders frequently and increasingly as their pregnancies progress. They complain about poor sleep quality (SQ), shorter sleep duration, awakenings, trouble falling asleep and lower sleep efficiency[15,16]. Sleep problems at night caused by GERD symptoms can lead to daytime tiredness, which disrupts daily functioning and productivity[17].

Although a number of studies suggest that the QoL is significantly reduced in patient with GERD, no published studies have evaluated the impact of GERD on QoL and SQ in a pregnant population. We conducted a prospective survey of GERD symptoms during pregnancy in experimental (EG) and control group (CG), and evaluated nursing education about diet and lifestyle measures for GERD during pregnancy their impact on frequency and severity of GERD symptoms, QoL and SQ in Turkish sample.

Material and Method

The research which was planned as a randomized, prospective and experimental-control group was performed in Manisa, Turkey between November 1, 2008 and May 1, 2009. The sample of the study included 168 pregnant women who were at a gestational age between 20 and 24 weeks and applied at the outpatient clinic in Manisa Maternity and Child Hospital. Gestational age at recruitment was based on the last menstrual period and ultrasound assessment. Among the 168 pregnant women, we found 102 to have GERD symptoms and four women who did not agree to participate. 98 pregnant women with GERD symtoms were included in the study. Overall, 8 pregnant in both groups did not complete follow-up data, thus 41 pregnant women in both groups were available for the study (Figure 1).

The EG and CG were randomized according to previous study results, which found the risk factors associated with GERD symptoms: GERD symptoms prior to pregnancy, cumulative weight gain, gestational age, history of GERD symtoms, women’s education, age and parity[1-3,5,6].

Data were collected using the questionnaire which consisted of four parts as follows: prenatal characteristics questionnaire (PCQ), GERD questionnaire, Short Form- 36 (SF-36) and The Pittsburgh Sleep Quality Index (PSQI). The first part included prenatal characteristics questionnaire (PCQ), which evaluated the pregnant women’s socio-demographic and reproductive characteristics, including age, education level, health insurance, employment status, parity, and body mass index (BMI).

The second part included GERD questionnaire which was developed by Locke et al.[18] and adapted for the Turkish population by Kitapcıoglu et al.[19] in 2004. It was previously defined by Locke et al that the group with frequent symptoms defined as heartburn and/or regurgitation occurring at least once a week or common, was accepted as having GERD. The group with occasional symptoms was defined of an episode of one of the major symptoms less than once a week during the pregnancy. We evaluated also the GERD cardinal symptoms in the last visit of women[18,19].

Thirdly, health-related QoL was measured using the Short Form-36 (SF-36) which was validated by Koçyiğit et al.[20]. The form includes 36 items, is based on a 5- point scale and eight dimensions as follows: physical function, social function, role limitations (physical and emotional), mental health, vitality, pain and general health perception. Higher scores indicated better functioning or well-being[20].

Lastly, SQ was assessed using The Pittsburgh Sleep Quality Index (PSQI) which was validated by Buysse et al in 1989 and the validity and reliability of the PSQI Turkish version was made by Agargun et al.[21] in 1996. PSQI measures quality and patterns of sleep with 19 individual items which generate seven “component” scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. The sum of seven components yields one global score. A global PSQI score of 5 or greater indicate “poor” SQ[21,22].

The research purpose was explained to the pregnant women in the hospital. The researcher interviewed pregnant women who agreed to participate in this research at their homes by face-to face interview. After formal permission was obtained the data were collected from CG in two stages and from the EG in three stages. In the first stage PCQ, GERD questionnaire, SF-36 and PSQI were measured. The pregnant women in the CG received standard nursing care by health institution and after four weeks a researcher visited these pregnant women at their home and GERD symptoms, QoL and PSQI were evaluated again.

Pregnant women in EG were visited by a researcher at their home and the researcher applied “education about diet and lifestyle measures for pregnants with GERD” which was prepared using the available literature[23-28] (Table 1). After four weeks the researcher visited the pregnant women in EG at their home again and GERD symptoms, QoL and SQ were evaluated again. At the end of the study, education was given to the CG.

The study was approved by the Ege University Ethic Committee of Nursing in Izmir. Each pregnant woman was informed about the study and gave a written consent to participate.

The primary outcome variables were GERD symptoms, QoL and SQ were evaluated two times. We compared socio-demographic and some variable which could affect GERD symptoms between CG and EG using χ² statistics. We compared the QoL and PSQI scores by using the t-test. Two sided p values less than 0.05 were considered to be significant

Results

The mean age of the pregnant women was 26.1±5.0 (min=18, max=40) years. Overall, in the EG, 41.4% of the pregnant women had graduated from primary school, 7.3% were smoking, 22.0% were obese, 90.2% had health insurance, and 7.3% were employed. There were not found statistically significant differences for women’s age, education, body mass index (BMI), employment status, health insurance, smoking, parity, and gestational week between the CG and the EG (p>0.05).

Overall, 14.6% of women in the EG and 17.1% women in the CG had suffered from heartburn; 22.0% of women stated that they had had regurgitation before pregnancy. Most of the women (82.9%) reported heartburn and 80.5% of the women reported regurgitation during pregnancy in the EG. The ratio was found respectively 68.3% and 92.7% in the CG (p>0.05).

In the first interview, frequent GERD symptoms were found 97.6% in the EG, 90.2% in the CG (p>0.05). In the last interview, 63.4% of the pregnant women in EG and 97.6% of the pregnant women in CG described frequent GERD symptoms (p<0.00001) (Table 2).

In the first stage, except vitality, no statistically significant difference was found between the seven dimensions of quality of life (p>0.05). After nursing education, we found statistically significant differences of SF-36 scores between the two groups. There was a significant statistical difference between the first and last visit measurements of six dimensions of quality of life: physical functioning, role-physical, physical pain, mental health, vitality, and role-emotional in both groups (p<0.05). There were no statistical differences between the groups in regard to general health and social functioning point in the last interview (p>0.05) (Table 3).

In the first stage, the mean of PSQI point in the EG was found 5.63±2.80, and 5.73±3.16 for the CG (p>0.05). In the last stage, the mean of PSQI point was found 4.78±2.36 for the EG and 9.10±3.67 for the CG (p<0.05). Better SQ points were encountered in EG than the CG and there was a significant statistical difference between the two groups for subscale of PSQI except habitual sleep efficiency (Table 4).

Discussion

Although GERD is commonly seen by primary care, no study has examined the effect of education about GERD during pregnancy on QoL and SQ. In this research, pregnant women educated with GERD symptoms and the women’s GERD symptom frequency and severity decreased and QoL and SQ scores improved. According to our findings, another important point is that pregnant who were relieved of symptoms QoL and SQ, was impaired at baseline and improved significantly after nursing education. Improving pregnantnurse communication by using home visit and addressing unmet pregnant needs is very important for public health.

As pregnant education in GERD has previously been poorly studied, considering the available results of patient education in other gastro-intestinal diseases is relevant. Urnes et al.[29] study did not show any effects of patient education in GERD, with regard to QoL or to health-research use. In our study patient education has been show to decrease symptoms and has shown significant improvement of QoL and SQ. A critical point in the evaluation of patient education is largely theoretical. In other words, we can not know whether the patient education programs have been adequately constructed and performed. The most carefully performed study on patient education in GERD during pregnancy we followed the pregnancy at home and we applied education for GERD symptoms during pregnancy and written patientinformation material, guided self-management plans. Also, researcher who followed the pregnancy in their home trained professionals in a patient-centred approach.

GERD is common in pregnancy with an important negative impact on the QoL. GERD in pregnancy deserves more attention and better therapeutic management. Health related QoL is becoming increasingly important as an outcome measure of treatment response, because neither questioning of symptoms alone nor the assessment of “objective” findings, such as endoscope evaluation, oesophageal sphincter manometer or PH monitoring seems to adequately reflect patients’ subjective well-being[30]. Until now, only scant data have been published on the QoL in pregnant with GERD. In the present study, we examined the impact of GERD on QoL and observed that QoL was significantly impaired in CG with GERD than EG. The presence of GERD symptoms was found to have a negative impact on the QoL and SQ. In our study pregnant in the CG had substantially impaired QoL in terms of both physical and psychosocial aspects of wellbeing compared with the EG. Similar findings were observed in other large scale population survey. Findings show that subjects with untreated GERD have lower QoL than the general population[8,11,16,30]. Assesing and education about the GERD symptoms by using prenatal visit are important for pregnant women with GERD to ensure improvement in pregnant health status, QoL and SQ. After education, pregnant women in EG reported better means bodily pain, physical function, role-physical, mental health, role-emotional and vitality scale scores compared with CG. Clinical trial patients experiencing complete resolution of heartburn reported improved psychosocial well-being, vitality, general health perceptions and reduced pain measured by SF-36[9,10].

Night-time heartburn is common in GERD patients and is associated with reduced well-being and have negative effects on SQ. The Montreal definition stated that serious sleep disturbances with GERD were level II evidence. Patients with GERD frequently wake up at night or are unable to get to sleep because of their symptoms[16]. Symptoms can be worse when patients lie down[17]. Some patients will eat only one meal a day because of intense postprandial symptoms and others will need to sleep upright in a chair[3]. In our study, SQ scores were improved in the EG. In previous research, respondents with night-time GERD symptoms were more likely to experience sleep difficulties and difficulties with induction and maintenance of sleep[31]. The study was not conducted in pregnant women but these findings were similar to our study findings. Considering the health benefits of good sleep, pregnant women are an important target group to improve sleep, yet the challenge lies in finding an adequate and safe treatment, because pharmacological treatment is not recommended for pregnant women[15].

In conclusions, the frequency of GERD symptoms during pregnancy impacted directly on women’s SQ and QoL. Our study results suggest that nursing education for GERD during pregnancy had a significant positive impact on QoL and SQ. Further studies are needed to determine whether the assessment and treatment of GERD symptoms in pregnancy can reduce GERD symptoms later in pregnancy. Future studies also might prospectively evaluate the effect of GERD symptoms on postpartum period.

Acknowledgments
The authors wish to thank Serhat Bor (Professor, PhD, Ege University, Gastroenterology department), Ümran Sevil (Professor, PhD, Ege University, Obstetric and gynaecology nursing department), Gülten Kaplan (Professor, PhD, Maltepe University, Internal disease nursing department), and Gül Kitapçıoğlu (MD, Ege University, Biostatistics department) for advisor guided my study of cognitive science and designed the study.

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