Med. J. Cairo Univ., Vol. 80, No.
2, March: 161-168, 2012
www.medicaljournalofcairouniversity.com
Prevalence and Risk Factors of Hyperemesis Graviderum Among
Egyptian Pregnant Woman at the Woman's Health Center
GHADAH A. MAHMOUD, D.N.Sc.
The Departments of Obstetrics and Gynecological Nursing, Faculty of Nursing, Assiut University, Egypt
Abstract
Nausea and vomiting may occur in as many as 90% of
pregnancies, whereas hyperemesis gravidarum (HG) repre-
sents a more severe condition and is potentially lethal if not
treated. HG affects 0.5-2% of all pregnancies, and is defined
as persisting nausea and vomiting leading to dehydration,
weight loss and nutritional deficiencies starting before the
22 nd week of gestation. The aim of the study was to identify
the prevalence and risk factors of hyperemesis gravidarum
among pregnant women at the Woman's Health Center, Assiut
University, Egypt. A cross sectional research was used in
carrying out this study. The sample consisted of 94 pregnant
women with Hyperemesis Gravidarum who were admitted
to the Antenatal Inpatient Wards at the Woman's Health Center
for one year. The results of this study explored that the
prevalence of Hyperemesis Gravidarum at the Egyptian
Womans Health Center was 4.5%. As regards the current
antenatal risk factors that aggravate hyperemesis gravidarum,
the highest percentage (26.6%) of women had gastrointestinal
diseases. Moreover, (19.1%) had more than one factors and
more than one sixth (16%) had urinary tract infection. Three
quarters of women diagnosed with hyperemesis gravidarum
admitted to the hospital for the first time and 94.6% of them
admitted at the first trimester. In the light of the present study
findings, it can be concluded that the overall hospital rate of
hyperemesis gravidarum at the Womans Health Center, Assiut
University, Egypt was 4.5% which was considered a high
prevalence in relation to the universal prevalence of hypere-
mesis gravidarum. The most common risk factors of hypere-
mesis gravidarum were gastrointestinal diseases, urinary tract
infection and multiple pregnancy. A larger study is needed
to establish the different prevalence and risk factors of
Hyperemesis Gravidarum on large number of population
among different Maternity Health Care Setting. An exploration
of high prevalence of Hyperemesis Gravidarum recommended
that the physicians and maternity nurses should pay more
attention to these women who were diagnosed with Hypere-
mesis Gravidarum.
Key Words: Hyperemesis Gravidarum HG Prevalence
Risk factors.
Correspondence to: Dr. Ghadah A. Mahmoud,
E-mail: Ghadah_omar2008@yahoo.com
161
Introduction
NAUSEA and vomiting are common symptoms
during early pregnancy, affecting as many as 80%
of pregnant women. The condition of hyperemesis
gravidarum represents an extreme form of these
symptoms and affects approximately 0.3 to 2.0%
of pregnancies [1] . The definition of this condition
in the literature, hyperemesis is most often charac-
terized by severe nausea and vomiting that inter-
feres with nutritional intake and metabolism, causes
fluid and electrolyte imbalances, and commonly
requires hospital management [2] . Hyperemesis
gravidarum (HG) represents a more severe condi-
tion and is potentially lethal if not treated [3] .
Hyperemesis Gravidarum (HG), hospitalizes more
than 59,000 pregnant women in the U.S. annually,
with most authors reporting an incidence of 0.5%
[4] . Estimates of severe nausea and vomiting of
pregnancy vary greatly and range from 0.3% in a
Swedish registry to as high as 10.8% in a Chinese
registry of pregnant women [5] . Recent large pop-
ulation studies support ethnic variation in the
incidence of HG. A Norwegian study of the Medical
Birth Registry of Norway from 1967-2005, revealed
an overall prevalence of 0.9% [6] . A study of Cal-
ifornia birth and death certificates linked to neonatal
hospital discharge data found an incidence of
hyperemesis gravidarum is 0.5% [7] . A Canadian
study found 0.8% of women have HG between
1988 and 2002. This rate was confirmed in a second
Canadian study during the same timeframe of the
population-based Nova Scotia Atlee Perinatal Da-
tabase of deliveries found 0.8% pregnancies have
HG [8] . Asian populations tend to have higher
incidence rates. For example, a Malaysian study
identified that the prevalence of HG is 3.9% [9] .
Additionally, a study in an Eastern Asian population
observed HG in 3.6% of the population [10] . As
mentioned, a study revealed the highest rate of
162 Prevalence & Risk Factors of Hyperemesis Graviderum Among
severe nausea and vomiting of pregnancy in Shang-
hai, China, with an incidence of 10.8%. However,
unlike the other studies mentioned, this study was
based on a clinical record of severe vomiting on
prenatal care cards, rather than hospitalization for
HG, did not limit itself to a primary diagnosis of
HG and included, for example, women with chronic
liver disease, chronic hypertension, chronic renal
illness, and preeclampsia [5] . The etiology is un-
known. Earlier studies have shown that HG can
lead to an increased risk of low birth weight,
preterm birth and lower 5min Apgar scores [11] .
Moreover, HG affects a womans quality of life
and daily functioning, and is the most common
reason for hospitalization during early pregnancy
[12] . Hyperemesis gravidarum is sufficiently per-
nicious to produce weight loss, dehydration, aci-
dosis from starvation, alkalosis from loss of hydro-
chloric acid in vomitus, and hypokalaemia. All
these symptoms are not absolutely necessary for
the diagnosis. Mild to moderate ketonuria may be
seen in urinary analysis. High or rapidly rising
steroids seem to play a part in aetiology, and raised
liver enzymes are seen in 15%-25% of women
who are hospitalized [13] . Risk factors vary among
different populations and female sex of the off-
spring, several previous pregnancies, and a high
daily intake of primarily saturated fat before preg-
nancy are reported to cause a higher risk [14] . The
incidence of hyperemesis gravidarum increases
with multiple gestation, molar pregnancy, trisomy
gestation and hydrop fetalis [15] . The diagnosis of
HG is also associated with low birth weight, in-
trauterine growth restriction, preterm delivery, and
fetal and neonatal death. Treatment is generally
supportive, occurring through maintenance of
hydration and electrolyte status and management
of symptoms [16] . A number of risk factors associ-
ated with hyperemesis have been reported, includ-
ing nulliparity, low maternal age, multiple gestation,
fetal anomalies, a previous pregnancy complicated
by hyperemesis, female sex, psychiatric conditions,
and both high and low maternal prepregnancy
weight [17] . According to the HER Foundation
(2006), there are common risk factors for hypere-
mesis such as women being less than 20 years of
age, nonsmokers, food aversions before pregnancy,
high saturated fat diet, posttraumatic stress disorder,
multiple gestation, history of motion sickness,
sensitivity to oral contraceptives, migraine head-
aches, allergies, ulcers, mother or sister with HG,
high blood pressure, liver disease, kidney disease,
and poor diet [18] . Hyperemesis gravidarum can
be responsible for increased health care use hospi-
talization; time lost from work, and reduced quality
of life during pregnancy [19] . Both relatively benign
and pernicious complications may be caused by
hyperemesis gravidarum.Weight loss, dehydration,
acidosis from malnutrition, alkalosis from vomiting,
hypokalaemia, muscle weakness, electrocardio-
graphic abnormalities, tetany, and psychological
disturbances may be included in the benign
group. Life threatening complications include
oesophageal rupture due to severe vomiting, Wer-
nickes encephalopathy, central pontine myelinol-
ysis, retinal haemorrhage, renal damage, spontane-
ous pneumomediastinum, intrauterine growth
retardation, and fetal death [20] . Hyperemesis Gravi-
darum is the most common cause of hospitalization
in the first half of pregnancy and is second only
to preterm labor for pregnancy overall. HG can be
associated with serious maternal and fetal morbidity
such as Wernickes encephalopathy, fetal growth
restriction, and even maternal and fetal death [21] .
Besides these factors, gestational trophoblastic
disease, multiple pregnancy, and psychology of
the patient are other major concerns [22] . Hypere-
mesis is a potentially life-threatening complication
of pregnancy [23] . With mild-to-moderate vomiting,
the patient and the fetus are unlikely to experience
any increased morbidity or mortality. Before the
advent of intravenous hydration, hyperemesis was
a major cause of maternal death. Currently, mor-
tality is exceedingly rare, but maternal morbidities
may include Wernicke encephalopathy from vita-
min B-1 deficiency, Mallory-Weiss tears, esoph-
ageal rupture, pneumothorax, and acute tubular
necrosis [24-25] . Additionally, many women expe-
rience significant psychosocial morbidity, occa-
sionally interfering with assumption of the maternal
role and rarely leading to termination of the preg-
nancy [26] .
Aim of the study:
The aim of the study was to identify the prev-
alence and risk factors of hyperemesis gravidarum
among pregnant women at the Woman's Health
Center, Assiut University, Egypt.
Research questions:
What is the prevalence of hyperemesis gravidarum
among pregnant women at the Womens Health
Center, Assiut University, Egypt?
What are the risk factors predispose hyperemesis
gravidarum among these pregnant women?
Subjects and Methods
Research design:
A cross sectional descriptive research was used
in carrying out this study.
Ghadah A. Mahmoud
Setting:
The study was conducted in the Antenatal In-
patient Wards at the Woman's Health Center, Assiut
University, Egypt, which received the high risk
pregnancy cases.
Sample:
The convenient sample consisted of 94 pregnant
women with Hyperemesis Gravidarum who were
admitted to the Antenatal psychosocial morbidity,
occasionally interfering with assumption of the
maternal role and rarely leading to termination of
the pregnancy [26] .
Inpatient Wards at the Woman's Health Center
for one year.
Tools:
A Structured Interviewing sheet was designed
by the investigator to be filled from each pregnant
woman with Hyperemesis Gravidarum who was
admitted to the Antenatal Inpatient Ward for one
year.
The data was collected in the sheet included the
following data:
- Part 1: Sociodemographic characteristics:
(Name, age, address, educational level, resi-
dence and occupation)
- Part 2: Obstetric history:
(Number of Gravidity, Parity, abortions, and
number of living children)
Outcomes of previous deliveries if present:
(Number of Normal Vaginal Deliveries, Abnor-
mal Vaginal Deliveries, Cesarean Sections)
- Part 3: Current antenatal history:
Gestational age/weeks
The current antenatal risk factors predispose
to or aggrevate Hyperemesis Graviderum if
present:
(Multiple pregnancy, Molar pregnancy, Previous
hyperemesis graviderum, Preexisting eating
disorders, Dyspepsia, Gastrointestinal diseases,
Urinary tractinfection, Hepatitis, Pyelonephritis,
Helicobacter pylori, Cholelithiasis, Depression,
Inflammatory bowel diseases and Others).
- Part 4: The investigations done for the patients
with hyperemesis gravidarum. (Sodium and Po-
tassium, Complete Blood Count, Urea and Crea-
tinine, Random blood Glucose, Complete liver
enzymes, Urine analysis, TFTs (T3, T4, TSH),
Calcium if persistent vomiting, Serum amylase,
Pelvic ultrasound and others).
163
Methods:
Before implementation of the study, an official
permission was obtained from the Dean of the
Faculty of Nursing, Assiut University directed to
the chairman of the Woman's Health Center, Assiut
University, Egypt. The investigator interviewed
the pregnant women with Hyperemesis Gravidarum
in the Antenatal Inpatient Ward at the Woman's
Health Center. All ethical considerations were
clarified to each woman before explaining the
nature of the study. The investigator asked the
women about their sociodemographic data, the
Obstetric history and the current antenatal risk
factor predisposes hyperemesis gravidarum and
the investigations done for these patients and its
results by using the patients hospital record. Each
pregnant woman was interviewed individually by
the researcher at the antenatal ward. The number
interviewed per week was 1-3 patients. The average
time taken for filling each sheet was around 10-
15 minutes depending on the response of the pa-
tients. Each patient was reassured that information
obtained would be confidential and used only for
the purpose of the study. The pilot study was
applied on 10 pregnant women with Hyperemesis
Gravidarum to modify the questionnaire and test
the validity and reliability of the study. The neces-
sary modifications were done based on the results
of the pilot study. The data were collected over 12
months, from October 2009 to September 2010.
Statistical analysis:
Statistical analysis was done by using SPSS
version 16 statistical software package. Data were
presented using descriptive statistics in the form
of frequencies and percentages for categorical
variables and means and standard deviation for
quantitative variables.
Ethical consideration:
There were no risks can affect the patients during
the application of the study.
Informed consent was obtained from patients
before their participation in the study.
Results
Table (1) shows that more than half of the
sample (53.2%) was in the age group 21-25 years
old, with the mean age 24.85 3.75 years. As regards
education, more than one third of women were
illiterate and had secondary school (41.5% and
40.4%) respectively. The highest percentages of
women were living in rural areas and were house-
wives (84% and 87.2%) respectively.
164 Prevalence & Risk Factors of Hyperemesis Graviderum Among

Table (1): Distribution of pregnant women with Hyperemesis Table (3) illustrates the mean of gestational
Gravidarum according to sociodemographic char-
acteristics. weeks was 9.53 2.26 weeks. As regards the current
antenatal risk factors, the highest percentage
Sociodemographic Frequency Percentage
characteristics (N) (%) (26.6%) of women had gastrointestinal diseases.
Moreover, (19.1 %) had more than one factors and
Age (Mean+SD) 24.853.756 more than one sixth (16%) had urinary tract infec-
<=20 year 12 12.8
21-25 years 50 53.2 tion.
26-30 years 27 28.7
30+ years 5 5.3 Table (3): Distribution of pregnant women with Hyperemesis
Total 94 100.0 Gravidarum according to their current antenatal
Education: condition.
Illiterate 39 41.5
Read & write 6 6.4 Frequency Percentage
Current antenatal condition (%)
Basic Education 4 4.3 (No.)
Secondary school 38 40.4
(complete/higher) 1- Gestational weeks (Mean SD) 9.532.26
University 7 7.4
Total 94 100.0 2- Current antenatal risk factors:
Residence: 1- Multiple pregnancy 12 12.8
Urban 15 16.0
Rural 79 84.0 2- Previous hyperemesis 9 9.6
Total 94 100.0 graviderum
Occupation: 3- Gastrointestinal diseases 25 26.6
Housewives 82 87.2
Employer 12 12.8 4- Urinary tract infection 15 16.0
Total 94 100.0 5- Hepatitis 3 3.2
6- Pyelonephritis 1 1.1
Concerning Obstetric history, Table (2) indicates 7- Depression 1 1.1
that more than one third of women (36.2%) were 8- Appendicitis 2 2.1
primigravida, while more than two thirds of women
9- Others 8 8.5
were multipara and had previous 1-2 previous
abortion (74.1% and 78.9%) respectively. 10- More than one risk factors 18 19.1

11- Total 94 100

Table (2): Distribution of pregnant women with Hyperemesis
Gravidarum according to their obstetric history.

Obstetrics history No. (%) Table (4) reveals the frequency of readmission
Number of gravidity: to the hospital. More than three quarters of women
None 34 36.2 (75.5%) had no readmission to the hospital, while
1-3 44 73.3 18.1% had once readmission to the hospital. The
4 16 26.7
Total 60 100.0 mean duration of the hospital stay was 3.86 1.99
days.
Number of parity:
1-3 43 74.1
4 15 25.9 Table (4): Distribution of pregnant women with Hyperemesis
Total 58 100.0 Gravidarum according to the previous admission
Number of abortion: to the hospital.
1-2 22 78.6
3 6 21.4 The previous admission Frequency Percentage
Total 28 100.0 to the hospital (No.) (%)
Number of living childern:
Males: None 71 75.5
0 54 57.4 Once 17 18.1
1-3 40 42.6
Females: Twice 2 2.1
0 60 63.8 Triple 4 4.3
1-3 33 36.1
The duration of hospital stay 3.86 1.99
Number of normal vaginal deliveries: (Mean SD)
1-3 41 87.2
4 6 12.8
Total 47 100.0
Table (5) shows that there is no significant
Number of cesearean section:
1-3 7 7.4 difference between the risk factors of Hyperemesis
4 1 1.1 Gravidarum and previous admission to the hospital.
Ghadah A. Mahmoud 165

Table (5): The relationship between risk factors of Hyperemesis Gravidarum and previous
admission to the hospital.
Previous admission to the hospital
Current antenatal risk factors
None Once Twice Triple Total p-value
1- Multiple pregnancy 7 3 0 2 12
2- Previous hyperemesis graviderum 8 1 0 0 9
3- Gastrointestinal diseases 21 2 1 1 25
4- Urinary tract infection 12 1 1 1 15
5- Hepatitis 2 1 0 0 3 0.376
6- Pyelonephritis 1 0 0 0 1
7- Depression 0 1 0 0 1
8- Appendicitis 0 2 0 0 2
9- Others 7 1 0 0 8
10- More than one risk factors 13 5 0 0 18
11- Total 71 17 2 4 94

Table (6) indicates that the majority of the the hospital for the first time while 16.8% had
women (94.6%) had Hyperemesis Gravidarum at previous history of one admission to the hospital
the first trimester. with highly significance differences between weeks
of gestation and the previous admission to the
This table describes the prevalence of Hypere- hospital.
mesis Gravidarum at the Womans Health Center
for one year, 4.5% of pregnant women who were Table (9) illustrates that more than two thirds
admitted to the Womans Health Center had Hype- of women at the first trimester (71.9%) stayed at
remesis Gravidarum. he hospital for (1-4 days) while 28.1% at he hospital
for (5-9 days) with significance differences between
Table (8) shows that more than two thirds of weeks of gestation and the duration of hospital
women at the first trimester (77.6%) admitted to stay.
Table (6): Distribution of pregnant women with Hyperemesis Table (7): Statistical data related to the prevalence of Hyper-
Gravidarum according to their weeks of gestation. emesis Gravidarum for one year.
Frequency Percentage The prevalence of Frequency Percentage
Weeks of gestation
(No.) (%) Hyperemesis Gravidarum (No.) (%)
First trimester (6-12 weeks) 89 94.6 Total high risk pregnancies 2075 95.5
Second trimester (13-16 weeks) 5 5.4
Total no of pregnant women with 94 4.5
Total 94 100 Hyperemesis Graviderum

Table (8): The relationship between weeks of gestation and previous admission to the
hospital.

Weeks of The previous admission to the hospital

gestation None Once Twice Triple Total % p-value
(6-12 weeks) 69 (77.6%) 15 (16.9%) 2 (2.2%) 3 (3.3%) 89 94.6
(13-16 weeks) 2 (40%) 2 (40%) 0 1 (20%) 5 5.4 0.007

Total 71 17 2 4 94 100

Table (9): The relationship between weeks of gestation and the duration of hospital stay.

Weeks of The duration of hospital stay

gestation (1-4 days) (5-9 days) Total Percentage (%) p -value
First trimester 64 (71.9%) 25 (28.1%) 89 (100%) 94.6 0.030
(6-12 weeks)
Second trimester 1 (20%) 4 (80%) 5 (100%) 5.4
(13-16 weeks)

Total 65 29 94 100
166 Prevalence & Risk Factors of Hyperemesis Graviderum Among

Table (10) indicates that the majority of women that the overall hospital rate of Hyperemesis Gravi-
had almost the initial investigations should be done darum in United States of America was 0.5%.
for them to indicate the risk factors that aggravate Estimates of severe nausea and vomiting of preg-
Hyperemesis gravidarum. nancy (HG) vary greatly and range from 0.3% in
a Swedish registry to as high as 10.8% in a Chinese
Table (10): Distribution of pregnant women with Hyperemesis registry of pregnant women [5] . A Canadian study
Gravidarum according to the initial investigations. done by Dodds et al., found that HG in 1,270
Yes No (0.8%) out of 156,091 of women with deliveries
The initial investigations between 1988 and 2002 [22] . This rate was con-
No. % No. %
firmed in a second Canadian study done by Fell et
Sodium and Potassium 90 95.7 4 4.3 al., 2006 in his study about the risk factors of
Complete Blood Count 91 96.8 3 3.2
Urea and Creatinine 91 96.8 3 3.2
Hyperemesis Gravidarum during the same time-
Random blood Glucose 91 96.8 3 3.2 frame of the population-based Nova Scotia Atlee
Complete liver enzymes 91 96.8 3 3.2 Perinatal Database of deliveries at 20 weeks ges-
Urine analysis 88 93.6 6 6.4 tation, that found 1,301 (0.8%) out of 157,922
TFTs (T3, T4, TSH) 16 17.0 78 83.0 pregnancies [1] . Asian populations tend to have
Calcium if persistent vomiting 1 1.1 93 98.9
Serum amylase 4 4.3 90 95.7
higher incidence rates. For example, a Malaysian
Pelvic ultrasound 90 95.7 4 4.3 study identified 192 recorded cases (3.9%) out of
Others 87 92.6 7 7.4 4,937 maternities [14] . From the previous interna-
tional studies about Hyperemesis Gravidarum, the
present study demonstrates high prevalence of
Discussion Hyperemesis Gravidarum among Egyptian pregnant
women at the Womans Health Center, Assiut Uni-
Hyperemesis Gravidarum (HG) is a state of
versity, Egypt (2010).
excessive nausea and vomiting in early pregnancy
which usually resolves spontaneously by 16-20 In this study, it was noticed that the majority
weeks of gestation [27,28] . Hyperemesis Gravidarum of women were admitted at the first trimester which
is the most common cause of hospitalization in the is consistent with Fell et al., 2006 [1] who reported
first half of pregnancy and is second only to preterm the same results. The mean of gestational weeks
labor for pregnancy overall [24] . HG can be asso- at this study is 9.53 2.26 weeks which is consistent
ciated with serious maternal and fetal morbidity with Power, et al. [29] who mentioned in his British
[25] . The present study showed that more than half study about Hyperemesis impact of symptoms
of women were in the age group 21-25 years old questionnaire that the mean of gestational weeks
which is in agreement with Dodds, et al. [22] who are 9.80.47 weeks. The risk factors revealed at
studied the outcomes of pregnancies complicated the present study as the highest percentages were
by hyperemesis gravidarum mentioned that more gastrointestinal diseases, more than one risk factor,
than half of women (64.8%) were in the same age urinary tract infection and multiple pregnancy.
group. As regards the Obstetric history, the present (26.6%, 19%, 16%, 12.8%) respectively. These
study revealed that more than one third of women findings are inconsistent with Fell et al. [1] who
were primigravida which is consistent with Vikanes mentioned that hyperthyroid diseases, psychiatric
et al. [25] who reported in his study about Hypere- illness, previous molar pregnancy, preexisting
mesis Gravidarum in United States of America that Diabetes mellitus, gastrointestinal disorders were
34.7% of women who were diagnosed with hype- all statistically significant risk factors for Hypere-
remesis gravidarum were primigravida. According mesis Gravidarum. Concerning the duration of
to the statistical data of the present study, the hospital stay, the present study indicated that more
overall hospital admission rate of Hyperemesis than two thirds of women had from 1-4 days hos-
Gravidarum was (94/2075, 4.5%) [Hospital Data pital stay which is consistent with Tan et al. [30]
Base, Assiut University, Egypt, 2010]. After hard who reported in his Malaysian study about the
online searching, there were no available studies indicators of prolonged hospital stay in hyperemesis
about the prevalence of Hyperemesis Gravidarum gravidarum that 68 % of women had four days of
in Egypt can be obtained by the researcher. But hospital stay and considered that four days or more
this finding of the present study is consistent with are prolonged hospital stay. The routine initial
Vikanes, [25] who reported that the prevalence of investigations done for women with hyperemesis
Hyperemesis Gravidarum in Kuwait was 4.5% gravidarum at the present study were sodium and
while it is inconsistent with other authers who potassium, complete blood count, urea and creati-
study the prevalence of Hyperemesis Gravidarum nine, complete liver function, urine analysis, and
such as Verberg et al. [28] who reported in his study pelvic ultrasound which is consistent with Tan et
Ghadah A. Mahmoud
al. [30] who mentioned that full blood cell count,
pelvic ultrasound, urine microscopy, renal function
assessment and liver function test are the routine
laboratory work on admission.
Conclusion:
In the light of the present study findings, it can
be concluded that the overall hospital rate of hy-
peremesis gravidarum at the Womans Health Cen-
ter, Assiut University, Egypt was 4.5% which was
considered a high prevalence in relation to the
universal prevalence of hyperemesis gravidarum.
The most common risk factors of hyperemesis
gravidarum were gastrointestinal diseases, urinary
tract infection and multiple pregnancy.
Recommendations:
A larger study is needed to establish the different
prevalence and risk factors of Hyperemesis Gravi-
darum on large number of population among dif-
ferent Maternity Health Care Setting. An explora-
tion of high prevalence of Hyperemesis Gravidarum
recommended that the physicians and maternity
nurses should pay more attention to these women
who were diagnosed with Hyperemesis Gravi-
darum.
Acknowledgement:
We would like to express our deep appreciation
to all patients who participate in succession my
research. We would also like to thank the medical
and nursing staffs who participate in highlighting
the aims of my research.
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