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8
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d
v
o
m
itin
g
is
m
u
ltifa
cto
r
ial,
s
u
ch
as
h
o
r
m
o
n
al
ch
an
g
es,
p
s
y
ch
o
l
o
g
ical
ten
d
en
cies,
ev
o
lu
tio
n
ar
y
ad
ap
tatio
n
s
(
f
o
o
d
av
o
id
an
ce
)
,
an
d
g
e
n
etic
r
is
k
f
ac
to
r
s
,
b
u
t th
e
m
ain
ca
u
s
e
is
ca
u
s
ed
b
y
h
o
r
m
o
n
al
ch
an
g
es,
esp
ec
ially
in
cr
ea
s
ed
lev
els
o
f
h
u
m
an
ch
o
r
i
o
n
ic
g
o
n
ad
o
tr
o
p
in
(
h
C
G)
,
estro
g
en
,
an
d
p
r
o
g
ester
o
n
e
h
o
r
m
o
n
es
[
5
]
,
[
9
]
.
Hy
p
er
e
m
esis
g
r
av
id
ar
u
m
ca
n
af
f
ec
t
8
0
%
o
f
p
r
eg
n
a
n
t
wo
m
e
n
p
s
y
c
h
o
lo
g
ically
an
d
ca
n
als
o
h
av
e
a
c
o
n
s
id
er
ab
le
ef
f
ec
t
o
n
q
u
ality
o
f
life
.
M
o
s
t
p
r
eg
n
an
t
wo
m
en
f
ee
l
th
at
n
au
s
ea
an
d
v
o
m
itin
g
ca
n
b
e
an
u
n
co
m
f
o
r
tab
le
c
o
m
p
lain
t a
n
d
ca
n
in
ter
f
er
e
with
t
h
e
ac
tiv
ities
o
f
p
r
eg
n
an
t w
o
m
e
n
[
1
0
]
.
Alth
o
u
g
h
p
h
a
r
m
ac
o
lo
g
ical
tr
ea
tm
en
ts
s
u
ch
as
a
n
ti
em
etics
(
e.
g
.
,
d
o
x
y
lam
in
e
-
p
y
r
id
o
x
in
e,
m
eto
clo
p
r
am
id
e
,
a
n
d
o
n
d
an
s
e
tr
o
n
)
ar
e
co
m
m
o
n
ly
u
s
ed
to
m
an
ag
e
h
y
p
er
em
esis
g
r
a
v
id
ar
u
m
,
th
eir
ef
f
icac
y
an
d
s
af
ety
p
r
o
f
iles
ar
e
v
a
r
iab
l
e
an
d
s
u
p
p
o
r
ted
b
y
lim
ited
h
i
g
h
-
q
u
ality
ev
i
d
en
ce
.
So
m
e
s
tu
d
ies
h
av
e
r
e
p
o
r
ted
p
o
ten
tial
co
n
ce
r
n
s
r
eg
ar
d
in
g
f
etal
r
is
k
with
ce
r
tain
ag
en
ts
,
h
ig
h
lig
h
tin
g
th
e
n
ee
d
f
o
r
c
au
tio
u
s
u
s
e
d
u
r
in
g
p
r
eg
n
a
n
cy
[
1
1
]
.
T
h
ese
lim
itatio
n
s
h
av
e
led
p
r
e
g
n
an
t
wo
m
e
n
an
d
clin
ician
s
t
o
ex
p
lo
r
e
n
o
n
-
p
h
ar
m
ac
o
lo
g
ical
alter
n
ativ
es.
Ap
p
r
o
ac
h
es
s
u
ch
as
g
in
g
e
r
s
u
p
p
lem
en
tatio
n
,
d
ietar
y
ad
ju
s
tm
en
ts
,
a
n
d
ac
u
p
r
ess
u
r
e
h
av
e
s
h
o
w
n
p
r
o
m
is
e
in
r
ed
u
cin
g
n
au
s
ea
a
n
d
v
o
m
itin
g
with
m
in
im
al
ad
v
er
s
e
ef
f
ec
ts
,
o
f
f
er
i
n
g
p
o
ten
ti
al
s
af
e
o
p
tio
n
s
to
co
m
p
lem
en
t
o
r
r
e
p
lace
d
r
u
g
t
h
er
ap
y
f
o
r
n
au
s
ea
an
d
v
o
m
itin
g
in
p
r
eg
n
a
n
cy
[
1
2
]
.
Sy
m
p
t
o
m
s
o
f
n
a
u
s
ea
an
d
v
o
m
itin
g
in
p
r
eg
n
an
t
wo
m
en
ca
n
b
e
tr
ea
ted
b
y
p
h
ar
m
ac
o
lo
g
ical
an
d
n
o
n
-
p
h
ar
m
ac
o
lo
g
ica
l
m
ea
n
s
,
t
h
e
aim
is
to
p
r
ev
en
t
a
m
o
r
e
s
ev
er
e
c
o
n
d
itio
n
o
r
to
r
e
d
u
ce
ex
is
tin
g
s
y
m
p
to
m
s
[
1
3
]
.
Ph
ar
m
ac
o
l
o
g
ica
l
tr
ea
tm
en
t
co
n
s
is
ts
o
f
v
itam
in
a
d
m
in
is
tr
atio
n
(
v
itam
in
B
co
m
p
lex
,
m
ed
iam
er
B
6
as
a
v
itam
in
,
a
n
d
an
tiem
etic
)
an
d
m
il
d
s
ed
ativ
e
tr
ea
tm
en
t.
No
n
-
p
h
ar
m
ac
o
lo
g
i
ca
l
tr
ea
tm
en
ts
f
o
r
n
au
s
ea
an
d
v
o
m
itin
g
ca
n
u
s
e
h
er
b
al
in
g
r
ed
ien
ts
ar
o
u
n
d
th
e
m
o
th
er
,
s
u
c
h
as h
o
n
e
y
an
d
g
in
g
er
.
Gin
g
er
h
as p
h
a
r
m
ac
o
lo
g
i
ca
l e
f
f
ec
ts
as a
n
an
tiem
etic
[
1
4
]
.
Hy
p
er
em
esis
g
r
av
id
ar
u
m
is
ex
ce
s
s
iv
e
o
r
u
n
c
o
n
tr
o
llab
le
n
au
s
ea
an
d
v
o
m
itin
g
d
u
r
i
n
g
p
r
e
g
n
an
cy
.
T
h
e
m
ain
ca
u
s
e
o
f
h
y
p
er
e
m
esis
g
r
av
id
ar
u
m
is
u
n
k
n
o
wn
,
b
u
t
it
i
s
lik
ely
to
b
e
a
c
o
m
b
in
atio
n
o
f
h
o
r
m
o
n
al
ch
an
g
es
an
d
p
s
y
ch
o
lo
g
ical
f
ac
to
r
s
[
1
5
]
.
Nau
s
ea
an
d
v
o
m
itin
g
b
e
g
in
at
a
r
o
u
n
d
6
-
8
wee
k
s
,
p
e
ak
s
at
n
in
e
we
ek
s
'
g
estatio
n
,
an
d
p
er
s
is
ts
f
o
r
ar
o
u
n
d
1
2
wee
k
s
.
A
s
m
all
p
r
o
p
o
r
tio
n
o
f
p
r
eg
n
a
n
t
wo
m
en
s
till
f
ee
l
n
au
s
ea
an
d
v
o
m
itin
g
at
2
0
wee
k
s
o
f
g
estatio
n
[
1
6
]
.
Gin
g
er
(
Zin
g
ib
er
o
fficin
a
le
)
h
as
b
ee
n
wid
ely
r
ec
o
g
n
ized
as
a
n
atu
r
al
an
tiem
etic
ag
en
t.
I
ts
b
io
ac
tiv
e
co
m
p
o
u
n
d
s
,
in
clu
d
i
n
g
g
in
g
er
o
ls
an
d
s
h
o
g
ao
ls
,
h
a
v
e
b
ee
n
s
h
o
wn
to
r
ed
u
ce
n
au
s
ea
an
d
v
o
m
itin
g
b
y
m
o
d
u
latin
g
g
astro
in
test
in
al
m
o
ti
lity
an
d
in
h
ib
itin
g
s
er
o
to
n
in
(
5
-
HT
3
)
r
ec
ep
to
r
s
in
v
o
lv
ed
in
th
e
em
etic
p
ath
wa
y
.
I
n
ad
d
itio
n
,
g
in
g
e
r
e
x
h
ib
its
an
ti
-
in
f
lam
m
ato
r
y
p
r
o
p
e
r
ties
th
at
m
ay
co
n
tr
i
b
u
te
to
g
astro
in
test
in
al
co
m
f
o
r
t
[
1
7
]
.
Ho
n
e
y
,
o
n
th
e
o
th
e
r
h
a
n
d
,
s
er
v
es
as
a
r
ea
d
ily
av
ailab
le
s
o
u
r
ce
o
f
en
e
r
g
y
an
d
co
n
tain
s
b
io
ac
tiv
e
co
m
p
o
u
n
d
s
with
an
tio
x
i
d
a
n
t,
a
n
ti
-
in
f
lam
m
ato
r
y
,
an
d
p
r
eb
io
tic
p
r
o
p
er
ties
.
T
h
ese
co
m
p
o
n
en
ts
m
ay
h
el
p
p
r
o
tect
th
e
g
astric
m
u
c
o
s
a,
im
p
r
o
v
e
g
astro
in
test
in
al
co
m
f
o
r
t,
an
d
s
u
p
p
o
r
t
n
u
tr
itio
n
al
in
tak
e,
wh
ich
is
o
f
ten
c
o
m
p
r
o
m
is
ed
in
p
r
eg
n
an
t
wo
m
e
n
e
x
p
er
ien
cin
g
h
y
p
er
em
esis
g
r
a
v
id
ar
u
m
[
1
8
]
.
T
h
e
co
m
b
in
atio
n
o
f
g
in
g
er
an
d
h
o
n
ey
is
th
er
ef
o
r
e
h
y
p
o
th
esized
to
p
r
o
d
u
ce
a
s
y
n
er
g
is
tic
ef
f
ec
t,
in
wh
ich
g
in
g
e
r
p
r
im
ar
ily
allev
iates
n
au
s
ea
an
d
v
o
m
itin
g
wh
ile
h
o
n
ey
en
h
an
ce
s
g
astro
i
n
test
in
al
to
ler
an
ce
an
d
e
n
er
g
y
r
ep
len
is
h
m
en
t.
T
h
is
co
m
p
lem
en
tar
y
m
ec
h
an
is
m
p
r
o
v
id
es
a
s
tr
o
n
g
th
eo
r
etica
l
b
asis
f
o
r
t
h
e
u
s
e
o
f
g
in
g
e
r
an
d
h
o
n
ey
d
ec
o
ctio
n
as
a
s
im
p
le,
s
af
e,
an
d
n
o
n
-
p
h
ar
m
ac
o
l
o
g
ical
in
ter
v
e
n
tio
n
f
o
r
m
an
ag
in
g
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
in
p
r
e
g
n
an
t
wo
m
en
[
1
9
]
.
Gin
g
er
an
d
h
o
n
e
y
b
o
iled
wate
r
ar
e
o
n
e
o
f
th
e
ef
f
ec
tiv
e
way
s
as
an
in
itial
tr
ea
tm
en
t
to
r
e
d
u
ce
n
a
u
s
ea
an
d
v
o
m
itin
g
in
f
ir
s
t
tr
i
m
ester
p
r
eg
n
a
n
cy
a
n
d
i
n
p
r
e
g
n
an
t
wo
m
e
n
with
h
y
p
er
em
esis
g
r
av
id
ar
u
m
[
2
0
]
.
T
h
e
ad
v
an
tag
es
o
f
g
in
g
er
ar
e
th
at
it
co
n
tain
s
es
s
en
tial
o
ils
th
at
r
ef
r
esh
an
d
b
lo
ck
th
e
v
o
m
itin
g
r
ef
le
x
,
g
in
g
er
o
l
ca
n
im
p
r
o
v
e
b
l
o
o
d
cir
c
u
latio
n
,
an
d
n
er
v
es
wo
r
k
well
[
2
1
]
.
W
h
ile
h
o
n
e
y
co
n
tain
s
m
in
er
als,
v
itam
in
s
B
1
,
B
2
,
B
6
,
an
d
o
th
e
r
s
th
a
t
ca
n
r
ed
u
ce
n
a
u
s
ea
an
d
v
o
m
itin
g
[
2
2
]
.
T
h
e
co
m
b
in
atio
n
o
f
g
in
g
er
an
d
h
o
n
ey
is
p
r
esu
m
e
d
to
p
r
o
v
i
d
e
a
s
y
n
er
g
is
tic
ef
f
ec
t,
wh
e
r
e
g
in
g
er
ac
ts
as
an
an
tiem
etic
ag
en
t
wh
ile
h
o
n
e
y
co
n
tr
ib
u
tes
to
en
er
g
y
r
e
p
len
i
s
h
m
en
t
an
d
g
astro
in
test
in
al
c
o
m
f
o
r
t,
p
o
ten
tially
en
h
an
cin
g
th
e
o
v
er
all
ef
f
ec
ti
v
en
ess
in
r
ed
u
cin
g
n
au
s
ea
an
d
v
o
m
itin
g
d
u
r
in
g
p
r
e
g
n
an
c
y
[
2
3
]
.
T
h
is
s
tu
d
y
is
ex
p
ec
ted
to
co
n
tr
ib
u
te
n
o
v
el
e
v
id
en
ce
r
eg
a
r
d
in
g
t
h
e
ef
f
ec
tiv
en
ess
o
f
g
in
g
er
an
d
h
o
n
ey
d
ec
o
ctio
n
as
a
s
im
p
le,
af
f
o
r
d
a
b
le,
a
n
d
lo
ca
ll
y
av
aila
b
le
n
o
n
-
p
h
ar
m
ac
o
lo
g
ical
in
ter
v
en
tio
n
f
o
r
h
y
p
er
em
esis
g
r
av
i
d
ar
u
m
in
p
r
eg
n
a
n
t
wo
m
en
.
Fro
m
a
p
u
b
lic
h
ea
lth
p
er
s
p
ec
tiv
e,
th
e
u
s
e
o
f
h
er
b
a
l
-
b
ased
in
ter
v
en
tio
n
s
s
u
ch
as
g
in
g
er
a
n
d
h
o
n
ey
m
ay
s
u
p
p
o
r
t
m
ater
n
al
h
ea
lth
p
r
o
m
o
tio
n
s
tr
ateg
ies
b
y
r
ed
u
cin
g
d
ep
en
d
en
cy
o
n
p
h
ar
m
ac
o
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[
2
4
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s
aid
p
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a
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wo
m
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wh
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d
id
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p
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alwa
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Gin
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[
2
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co
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ly
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with
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.
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g
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ased
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alu
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q
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asi
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ex
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im
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tal
d
esig
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s
in
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s
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B
a
s
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th
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at
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v
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g
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ey
,
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e
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ter
ested
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ex
am
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in
g
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f
f
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t
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Gr
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Evaluation Warning : The document was created with Spire.PDF for Python.
I
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I
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15
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2
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20
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m
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ig
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ated
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1
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%
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(
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(
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4
(
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4
.
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6
±
0
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2
3
5
7
0
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
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B
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r
a
vid
a
r
u
m
(
N
u
r
s
ya
h
id
S
ir
eg
a
)
441
4.
DIS
CU
SS
I
O
N
4
.
1
.
Cha
r
a
ct
er
is
t
ics
o
f
re
s
po
nd
ent
s
in
t
he
f
o
rm
o
f
a
g
e,
educa
t
io
n,
o
cc
up
a
t
io
n,
pa
rit
y
,
a
nd
preg
na
ncy
a
g
e
o
f
re
s
po
nd
ent
s
T
ab
le
1
p
r
esen
ts
th
e
d
em
o
g
r
ap
h
ic
an
d
o
b
s
tetr
ic
ch
ar
ac
ter
i
s
tics
o
f
th
e
r
esp
o
n
d
en
ts
,
in
cl
u
d
in
g
a
g
e,
ed
u
ca
tio
n
al
lev
el,
o
cc
u
p
atio
n
,
p
ar
ity
,
an
d
g
estatio
n
al
ag
e.
T
h
e
m
ajo
r
ity
o
f
r
esp
o
n
d
en
ts
wer
e
ag
ed
2
0
–
3
5
y
ea
r
s
(
8
3
.
3
%),
wh
ich
r
e
p
r
esen
ts
th
e
o
p
tim
al
r
ep
r
o
d
u
ctiv
e
ag
e
r
an
g
e.
T
h
is
f
in
d
in
g
is
co
n
s
is
ten
t
with
p
r
ev
i
o
u
s
s
tu
d
ies,
Pu
tr
i
[
2
6
]
r
e
p
o
r
tin
g
t
h
at
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
m
o
s
t
co
m
m
o
n
l
y
o
cc
u
r
s
am
o
n
g
wo
m
en
with
in
t
h
is
ag
e
g
r
o
u
p
.
Ap
r
ilas
ar
i
et
a
l
.
[
2
7
]
also
d
em
o
n
s
tr
ated
a
s
ig
n
i
f
ican
t
ass
o
ciatio
n
b
etwe
en
m
ater
n
al
ag
e
an
d
th
e
in
cid
en
ce
o
f
h
y
p
er
e
m
esis
g
r
av
id
ar
u
m
,
with
a
m
o
d
e
r
ate
co
r
r
elatio
n
s
tr
en
g
th
(
r
=
0
.
4
2
6
)
,
in
d
icatin
g
th
at
ag
e
m
ay
in
f
lu
e
n
ce
th
e
o
c
cu
r
r
e
n
ce
o
f
p
r
e
g
n
an
c
y
-
r
elate
d
n
au
s
ea
a
n
d
v
o
m
itin
g
.
Pre
g
n
an
cies
o
cc
u
r
r
in
g
at
m
ate
r
n
al
ag
es
b
elo
w
2
0
y
ea
r
s
o
r
a
b
o
v
e
3
5
y
ea
r
s
h
a
v
e
b
ee
n
ass
o
ciate
d
with
an
in
cr
ea
s
ed
r
is
k
o
f
h
y
p
e
r
em
e
s
is
g
r
av
id
ar
u
m
d
u
e
to
b
io
lo
g
i
ca
l
an
d
p
s
y
ch
o
lo
g
ical
f
ac
to
r
s
.
Yo
u
n
g
er
p
r
eg
n
a
n
t
wo
m
en
m
a
y
e
x
p
er
ien
ce
em
o
ti
o
n
al
in
s
tab
ilit
y
a
n
d
i
n
ad
eq
u
at
e
n
u
tr
itio
n
al
ad
a
p
tatio
n
,
wh
ile
ad
v
a
n
ce
d
m
ater
n
al
ag
e
is
o
f
ten
ass
o
ciate
d
w
ith
d
ec
r
ea
s
ed
p
h
y
s
io
lo
g
ical
r
esil
ien
ce
an
d
in
cr
ea
s
ed
p
r
eg
n
an
cy
-
r
elate
d
co
m
p
licatio
n
s
[
2
8
]
.
Ho
we
v
er
,
in
th
e
p
r
esen
t
s
tu
d
y
,
m
o
s
t
r
e
s
p
o
n
d
en
ts
wer
e
with
in
t
h
e
o
p
tim
al
r
ep
r
o
d
u
ctiv
e
ag
e,
s
u
g
g
esti
n
g
th
at
f
ac
to
r
s
o
th
er
th
an
ag
e,
s
u
ch
as
p
s
y
c
h
o
lo
g
ical
s
tr
ess
,
g
r
av
id
ity
,
o
r
p
ar
ity
,
m
a
y
h
av
e
co
n
tr
ib
u
ted
to
th
e
o
cc
u
r
r
e
n
ce
o
f
h
y
p
er
em
esis
g
r
av
id
a
r
u
m
.
Re
g
ar
d
in
g
ed
u
ca
tio
n
al
b
ac
k
g
r
o
u
n
d
,
m
o
s
t
r
esp
o
n
d
e
n
ts
h
ad
co
m
p
leted
s
ec
o
n
d
a
r
y
ed
u
ca
tio
n
(
6
1
.
1
%).
Similar
f
in
d
in
g
s
wer
e
r
e
p
o
r
te
d
b
y
R
en
i
et
a
l
.
[
2
9
]
wh
o
o
b
s
er
v
ed
t
h
at
h
y
p
er
em
esis
g
r
a
v
id
ar
u
m
was
m
o
s
t
p
r
ev
alen
t
am
o
n
g
p
r
eg
n
a
n
t
wo
m
en
with
a
h
ig
h
s
ch
o
o
l
ed
u
ca
tio
n
lev
el
.
Hijr
awa
ti
et
a
l
.
[
3
0
]
,
f
u
r
th
e
r
r
ep
o
r
ted
a
s
tatis
t
ically
s
ig
n
if
ican
t
r
elati
o
n
s
h
ip
b
etwe
en
ed
u
ca
tio
n
lev
el
an
d
h
y
p
er
e
m
esis
g
r
av
id
ar
u
m
in
cid
e
n
ce
(p
<
0
.
0
5
)
.
E
d
u
ca
tio
n
is
g
e
n
er
ally
ass
o
ciate
d
with
k
n
o
wled
g
e
ac
q
u
is
itio
n
an
d
h
ea
lth
-
s
ee
k
in
g
b
e
h
av
io
r
;
h
o
wev
er
,
k
n
o
wled
g
e
r
elate
d
to
p
r
eg
n
a
n
cy
h
ea
lth
is
n
o
t
e
x
clu
s
iv
ely
o
b
tain
e
d
th
r
o
u
g
h
f
o
r
m
al
ed
u
ca
tio
n
.
I
n
f
o
r
m
al
s
o
u
r
ce
s
s
u
ch
as
p
er
s
o
n
al
ex
p
er
ie
n
ce
,
h
ea
lth
c
o
u
n
s
elin
g
,
m
ed
ia
ex
p
o
s
u
r
e,
a
n
d
s
o
cial
in
ter
ac
tio
n
s
also
p
lay
a
cr
itical
r
o
le
in
s
h
ap
in
g
m
ater
n
al
h
ea
lth
awa
r
en
ess
[
2
6
]
.
I
n
t
h
is
s
tu
d
y
,
th
e
o
cc
u
r
r
en
ce
o
f
h
y
p
er
em
esis
g
r
av
id
ar
u
m
am
o
n
g
wo
m
en
w
ith
r
elativ
ely
h
ig
h
er
ed
u
ca
tio
n
al
b
ac
k
g
r
o
u
n
d
s
s
u
g
g
ests
th
at
ed
u
ca
tio
n
al
lev
el
alo
n
e
m
ay
n
o
t b
e
a
p
r
o
tectiv
e
f
ac
to
r
ag
ain
s
t p
r
eg
n
a
n
cy
-
r
elat
ed
n
au
s
ea
an
d
v
o
m
itin
g
.
I
n
t
e
r
m
s
o
f
o
c
c
u
p
a
t
i
o
n
,
t
h
e
m
a
j
o
r
i
t
y
o
f
r
e
s
p
o
n
d
e
n
t
s
w
e
r
e
h
o
u
s
e
w
i
v
es
(
8
8
.
9
%
)
.
P
r
e
v
i
o
u
s
s
tu
d
i
e
s
h
a
v
e
s
h
o
w
n
m
i
x
e
d
f
i
n
d
i
n
g
s
r
e
g
a
r
d
in
g
t
h
e
r
e
l
a
t
i
o
n
s
h
i
p
b
e
t
w
e
e
n
m
a
t
e
r
n
a
l
e
m
p
l
o
y
m
e
n
t
a
n
d
h
y
p
e
r
e
m
e
s
is
g
r
a
v
i
d
a
r
u
m
.
F
a
u
z
i
a
h
a
n
d
S
u
r
y
a
n
i
[3
1
]
r
e
p
o
r
t
e
d
t
h
a
t
n
o
n
-
w
o
r
k
i
n
g
p
r
e
g
n
a
n
t
w
o
m
e
n
h
a
d
a
s
i
g
n
i
f
i
ca
n
t
l
y
h
i
g
h
e
r
r
i
s
k
o
f
e
x
p
e
r
i
e
n
c
i
n
g
h
y
p
e
r
e
m
e
s
is
g
r
a
v
i
d
a
r
u
m
c
o
m
p
a
r
e
d
t
o
w
o
r
k
i
n
g
w
o
m
e
n
(
O
R
=
2
.
8
4
2
)
.
C
o
n
v
er
s
e
l
y
,
o
t
h
e
r
s
t
u
d
i
e
s
s
u
g
g
e
s
t
t
h
a
t
w
o
r
k
i
n
g
w
o
m
e
n
m
a
y
e
x
p
e
r
i
e
n
c
e
i
n
c
r
e
as
e
d
p
s
y
ch
o
l
o
g
i
c
a
l
s
t
r
es
s
d
u
e
t
o
d
u
a
l
r
o
le
s
as
e
m
p
l
o
y
e
e
s
a
n
d
h
o
m
e
m
a
k
e
r
s
,
w
h
i
c
h
m
a
y
e
x
a
ce
r
b
a
t
e
p
r
e
g
n
a
n
c
y
-
r
e
l
a
t
e
d
s
y
m
p
t
o
m
s
[
2
9
]
.
In
t
h
e
p
r
e
s
e
n
t
s
t
u
d
y
,
t
h
e
p
r
e
d
o
m
i
n
a
n
c
e
o
f
h
o
u
s
e
w
i
v
es
a
m
o
n
g
r
es
p
o
n
d
e
n
t
s
i
n
d
i
c
a
t
es
t
h
a
t
d
o
m
e
s
ti
c
w
o
r
k
l
o
a
d
,
c
h
il
d
c
a
r
e
r
es
p
o
n
s
ib
i
l
i
t
ie
s
,
a
n
d
li
m
i
t
e
d
a
c
c
e
s
s
t
o
h
e
a
lt
h
i
n
f
o
r
m
a
t
i
o
n
m
a
y
c
o
n
t
r
i
b
u
t
e
t
o
i
n
c
r
e
as
e
d
s
u
s
ce
p
t
i
b
i
l
it
y
t
o
h
y
p
e
r
e
m
e
s
i
s
g
r
a
v
id
a
r
u
m
.
Mo
s
t
r
esp
o
n
d
e
n
ts
wer
e
m
u
ltig
r
av
id
a
(
6
1
.
1
%).
Sev
er
al
s
tu
d
ies
h
av
e
r
e
p
o
r
ted
a
s
ig
n
if
ica
n
t
a
s
s
o
ciatio
n
b
etwe
en
g
r
av
id
ity
o
r
p
a
r
ity
an
d
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
Saf
ar
i
et
a
l
.
[
2
8
]
f
o
u
n
d
a
s
ig
n
if
ican
t
r
elatio
n
s
h
ip
b
etwe
en
g
r
av
id
ity
an
d
h
y
p
e
r
e
m
esis
g
r
av
id
ar
u
m
(
p
<
0
.
0
5
)
,
wh
ile
Ap
r
ilas
ar
i
et
a
l
.
[
2
7
]
r
ep
o
r
ted
a
m
o
d
e
r
ate
co
r
r
elatio
n
b
etwe
en
p
a
r
ity
a
n
d
h
y
p
er
em
esis
g
r
av
id
ar
u
m
in
cid
en
ce
(
r
=
0
.
5
8
0
)
.
Alth
o
u
g
h
h
y
p
er
em
esis
g
r
av
id
ar
u
m
is
m
o
r
e
f
r
e
q
u
en
tl
y
r
ep
o
r
ted
am
o
n
g
p
r
im
ig
r
av
id
a
wo
m
en
d
u
e
to
h
eig
h
ten
ed
p
s
y
ch
o
lo
g
ical
s
tr
ess
an
d
f
ea
r
ass
o
ciate
d
with
f
ir
s
t
-
tim
e
p
r
eg
n
an
cy
,
th
e
p
r
esen
t
s
tu
d
y
f
o
u
n
d
a
h
i
g
h
er
p
r
o
p
o
r
ti
o
n
o
f
m
u
ltig
r
av
id
a
wo
m
en
ex
p
er
ie
n
cin
g
h
y
p
er
e
m
esis
g
r
av
id
ar
u
m
.
T
h
is
f
in
d
in
g
s
u
g
g
ests
th
at
p
s
y
ch
o
lo
g
ic
al
f
ac
to
r
s
,
p
r
ev
io
u
s
p
r
eg
n
a
n
cy
ex
p
er
ien
ce
s
,
an
d
cu
m
u
lativ
e
s
tr
ess
m
ay
p
lay
a
r
o
le
in
s
y
m
p
to
m
s
ev
e
r
ity
r
eg
a
r
d
l
ess
o
f
p
ar
ity
.
W
ith
r
esp
ec
t
to
g
estatio
n
al
ag
e,
m
o
s
t
r
esp
o
n
d
e
n
ts
wer
e
i
n
t
h
e
f
ir
s
t
tr
im
ester
(
1
–
1
2
wee
k
s
)
(
7
2
.
2
%).
T
h
is
f
in
d
in
g
alig
n
s
with
p
r
e
v
io
u
s
s
tu
d
ies
in
d
icatin
g
th
at
h
y
p
er
em
esis
g
r
av
i
d
ar
u
m
p
r
ed
o
m
in
an
tly
o
cc
u
r
s
d
u
r
in
g
ea
r
ly
p
r
eg
n
a
n
cy
[
3
2
]
.
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ically
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1
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er
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r
av
id
ar
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m
[
2
9
]
.
Ad
d
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ally
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s
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r
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ile
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ay
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er
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x
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ate
g
astro
in
test
in
al
s
y
m
p
to
m
s
[
2
9
]
.
Ov
er
all,
th
e
ch
ar
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ter
is
tics
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f
r
esp
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2
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r
av
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t
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a
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h
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f
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co
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s
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clu
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tu
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u
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So
a
et
a
l
.
[
3
3
]
,
wh
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r
ep
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a
d
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r
ea
s
e
in
th
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f
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t
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n
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tr
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o
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in
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d
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in
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leaf
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o
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.
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n
th
at
s
tu
d
y
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r
esp
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ap
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ter
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ter
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ati
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ev
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g
in
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’
s
an
tiem
etic
ef
f
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ts
in
p
r
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n
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.
A
r
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en
t
s
y
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tem
atic
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ev
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d
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eta
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a
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o
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ated
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at
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p
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ig
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if
ica
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tly
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ce
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u
s
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v
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m
itin
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p
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m
e
n
with
m
in
im
al
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id
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ts
,
s
u
p
p
o
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tin
g
its
s
af
ety
an
d
e
f
f
icac
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as
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co
m
p
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en
tar
y
th
e
r
ap
y
f
o
r
h
y
p
er
em
esis
g
r
av
id
a
r
u
m
[
1
2
]
.
Similar
ly
,
a
q
u
asi
-
ex
p
er
im
en
tal
s
tu
d
y
r
e
p
o
r
ted
th
at
a
g
in
g
e
r
,
lem
o
n
,
an
d
h
o
n
ey
d
ec
o
ctio
n
s
ig
n
if
ica
n
tly
d
ec
r
ea
s
ed
n
a
u
s
ea
an
d
v
o
m
itin
g
s
co
r
es
co
m
p
ar
e
d
to
an
ed
u
ca
tio
n
-
o
n
ly
g
r
o
u
p
,
in
d
icatin
g
th
e
p
o
ten
tial
b
e
n
ef
it
o
f
co
m
b
in
atio
n
s
in
v
o
lv
in
g
g
in
g
er
a
n
d
h
o
n
e
y
in
clin
ical
p
r
ac
tice
[
3
4
]
.
Oth
er
q
u
asi
-
ex
p
er
im
en
tal
r
esear
ch
also
f
o
u
n
d
th
at
r
eg
u
lar
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o
n
s
u
m
p
tio
n
o
f
g
in
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b
ev
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ag
es
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ig
n
if
ican
tly
r
ed
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ce
d
th
e
f
r
e
q
u
en
cy
o
f
em
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g
r
av
i
d
ar
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m
s
y
m
p
t
o
m
s
,
alig
n
in
g
with
th
e
p
r
esen
t
s
tu
d
y
’
s
f
in
d
in
g
s
[
3
5
]
,
[
3
6
]
.
Fu
r
t
h
er
m
o
r
e,
s
u
p
p
lem
e
n
tatio
n
with
s
tan
d
ar
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ized
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in
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er
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x
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ac
t
r
esu
lted
in
m
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n
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g
f
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l
im
p
r
o
v
em
e
n
ts
in
n
a
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s
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an
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v
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m
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s
ev
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ity
,
wh
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r
ein
f
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ce
s
th
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r
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le
o
f
g
in
g
e
r
wi
th
in
an
ten
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r
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p
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ls
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ef
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n
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-
p
h
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r
m
ac
o
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ter
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.
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m
a
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ical
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er
s
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e
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h
y
p
er
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r
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id
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m
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s
ely
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s
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o
ciate
d
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d
p
r
o
g
ester
o
n
e
le
v
els.
D
u
r
in
g
th
e
f
ir
s
t
tr
im
ester
,
h
C
G
lev
els in
cr
ea
s
e
r
ap
id
l
y
a
n
d
r
ea
ch
a
p
ea
k
b
etwe
en
1
2
an
d
1
6
wee
k
s
o
f
g
estatio
n
,
wh
ich
co
in
cid
es
with
th
e
p
er
io
d
wh
en
n
au
s
ea
an
d
v
o
m
itin
g
ar
e
m
o
s
t
co
m
m
o
n
l
y
r
ep
o
r
ted
.
E
l
ev
ated
p
r
o
g
ester
o
n
e
lev
els
co
n
tr
ib
u
te
to
r
elax
atio
n
o
f
s
m
o
o
t
h
m
u
s
cle
in
th
e
g
astro
in
test
in
al
tr
ac
t,
lead
in
g
to
d
ec
r
ea
s
ed
g
astric
m
o
tili
ty
an
d
d
elay
e
d
g
astric
e
m
p
ty
in
g
.
T
h
ese
p
h
y
s
io
lo
g
ical
ch
an
g
es
ca
n
ex
ac
er
b
ate
n
au
s
e
a
an
d
v
o
m
itin
g
an
d
in
cr
ea
s
e
th
e
r
is
k
o
f
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
wh
en
s
y
m
p
to
m
s
p
er
s
is
t c
o
n
tin
u
o
u
s
ly
[
37
]
,
[
3
8
]
.
Pro
lo
n
g
ed
h
y
p
er
em
esis
g
r
av
i
d
ar
u
m
ca
n
r
esu
lt
in
d
eh
y
d
r
a
tio
n
,
h
em
o
co
n
ce
n
tr
atio
n
,
a
n
d
im
p
air
ed
cir
cu
latio
n
,
th
er
eb
y
r
ed
u
ci
n
g
th
e
d
eliv
er
y
o
f
n
u
t
r
ien
ts
an
d
o
x
y
g
e
n
to
m
ater
n
al
tis
s
u
es.
I
n
s
ev
er
e
ca
s
es,
co
n
tin
u
o
u
s
v
o
m
itin
g
m
a
y
lea
d
to
d
ep
letio
n
o
f
ca
r
b
o
h
y
d
r
at
e
an
d
f
at
r
eser
v
es
as
alter
n
ativ
e
en
er
g
y
s
o
u
r
ce
s
,
wh
ich
f
u
r
th
e
r
wo
r
s
en
s
th
e
m
at
er
n
al
co
n
d
itio
n
.
T
h
ese
m
ec
h
a
n
is
m
s
h
elp
ex
p
lain
wh
y
ef
f
ec
tiv
e
m
an
ag
em
e
n
t
o
f
n
au
s
ea
an
d
v
o
m
itin
g
d
u
r
in
g
p
r
eg
n
a
n
cy
is
ess
en
tial
to
p
r
e
v
en
t
m
o
r
e
s
er
io
u
s
co
m
p
licatio
n
s
an
d
to
m
ain
tain
m
ater
n
al
n
u
tr
itio
n
al
s
tatu
s
.
I
n
ad
d
itio
n
to
p
h
y
s
io
lo
g
ical
f
ac
to
r
s
,
p
s
y
ch
o
s
o
cial
c
o
n
d
itio
n
s
p
lay
a
cr
u
cial
r
o
le
in
th
e
d
e
v
elo
p
m
en
t
an
d
s
ev
er
ity
o
f
n
a
u
s
ea
an
d
v
o
m
itin
g
d
u
r
in
g
p
r
eg
n
a
n
cy
.
E
m
o
tio
n
al
s
tr
ess
,
an
x
iety
r
el
ated
to
p
r
e
g
n
an
c
y
,
co
n
ce
r
n
s
ab
o
u
t
m
ater
n
al
an
d
f
etal
h
ea
lth
,
f
in
an
cial
i
s
s
u
es,
an
d
ch
an
g
es
in
s
o
cial
r
o
l
es
ca
n
ex
ac
er
b
ate
s
y
m
p
to
m
s
o
r
r
ed
u
ce
a
wo
m
a
n
’
s
ab
ilit
y
to
co
p
e
with
d
is
co
m
f
o
r
t.
Ps
y
ch
o
lo
g
ical
d
is
tr
ess
m
ay
also
am
p
lify
th
e
p
er
ce
p
tio
n
o
f
n
a
u
s
ea
an
d
v
o
m
itin
g
,
th
er
e
b
y
wo
r
s
en
in
g
th
e
o
v
er
all
ex
p
e
r
ien
ce
o
f
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
.
Ad
d
r
ess
in
g
th
ese
p
s
y
ch
o
s
o
cial
f
ac
to
r
s
is
th
er
ef
o
r
e
an
im
p
o
r
tan
t c
o
m
p
o
n
e
n
t o
f
co
m
p
r
eh
en
s
iv
e
m
ater
n
al
h
ea
lth
ca
r
e
[
3
8
]
.
T
h
e
u
s
e
o
f
g
in
g
er
an
d
h
o
n
e
y
d
ec
o
ctio
n
m
ay
co
n
tr
ib
u
te
n
o
t
o
n
ly
to
p
h
y
s
io
lo
g
ical
s
y
m
p
to
m
r
elief
b
u
t
also
to
im
p
r
o
v
e
d
p
s
y
ch
o
lo
g
ical
co
m
f
o
r
t
am
o
n
g
p
r
eg
n
a
n
t
wo
m
en
.
Gin
g
er
co
n
tain
s
s
ev
er
al
b
io
ac
tiv
e
co
m
p
o
u
n
d
s
,
in
clu
d
in
g
g
in
g
e
r
o
ls
,
s
h
o
g
ao
ls
,
zin
g
ib
er
en
e,
an
d
ess
en
tial
o
il
s
,
wh
ich
p
o
s
s
e
s
s
an
tiem
etic,
an
ti
-
in
f
lam
m
ato
r
y
,
an
d
g
astro
i
n
test
in
al
r
eg
u
lato
r
y
p
r
o
p
e
r
ties
.
Gin
g
er
is
k
n
o
wn
to
ex
e
r
t
its
an
tie
m
etic
ef
f
ec
t
b
y
in
h
ib
itin
g
s
er
o
to
n
i
n
r
ec
ep
to
r
s
in
th
e
g
astro
in
test
in
al
tr
ac
t
a
n
d
ce
n
tr
al
n
er
v
o
u
s
s
y
s
tem
,
th
er
eb
y
r
ed
u
cin
g
th
e
s
tim
u
latio
n
o
f
th
e
v
o
m
itin
g
ce
n
ter
.
Ad
d
itio
n
ally
,
g
in
g
e
r
ca
n
en
h
an
ce
g
astro
in
test
in
al
m
o
tili
ty
an
d
r
ed
u
ce
g
astric
ir
r
itatio
n
,
wh
ic
h
h
elp
s
allev
iate
n
au
s
ea
an
d
v
o
m
itin
g
d
u
r
in
g
p
r
eg
n
an
c
y
[
3
2
]
,
[
3
9
]
.
Ho
n
ey
co
m
p
lem
e
n
ts
th
e
ef
f
e
cts
o
f
g
in
g
er
b
y
p
r
o
v
id
i
n
g
a
n
atu
r
al
s
o
u
r
ce
o
f
en
e
r
g
y
an
d
s
u
p
p
o
r
tin
g
g
astro
in
test
in
al
p
r
o
tectio
n
.
Ho
n
ey
ca
n
co
at
th
e
eso
p
h
ag
ea
l
a
n
d
g
astric
m
u
co
s
a,
r
e
d
u
cin
g
i
r
r
ita
tio
n
ca
u
s
ed
b
y
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
B
o
iled
g
in
g
er
a
n
d
h
o
n
ey
in
terven
tio
n
fo
r
h
yp
eremesis
g
r
a
vid
a
r
u
m
(
N
u
r
s
ya
h
id
S
ir
eg
a
)
443
g
astric
ac
id
an
d
p
r
ev
e
n
tin
g
r
ef
lu
x
th
at
m
ay
tr
ig
g
er
n
au
s
e
a.
Fu
r
th
er
m
o
r
e
,
h
o
n
ey
m
ay
s
tim
u
late
th
e
p
r
o
p
er
f
u
n
ctio
n
in
g
o
f
g
astric
s
p
h
in
c
ter
m
u
s
cles,
h
elp
in
g
to
p
r
ev
en
t
th
e
r
eg
u
r
g
itatio
n
o
f
s
to
m
ac
h
co
n
ten
ts
.
T
h
is
co
m
b
in
atio
n
o
f
g
in
g
er
an
d
h
o
n
ey
th
e
r
ef
o
r
e
o
f
f
er
s
a
s
y
n
e
r
g
i
s
tic
ef
f
ec
t
in
r
ed
u
cin
g
th
e
f
r
e
q
u
en
cy
an
d
s
ev
er
ity
o
f
h
y
p
er
em
esis
g
r
av
id
a
r
u
m
.
Fro
m
th
e
p
er
s
p
ec
tiv
e
o
f
m
ater
n
al
h
ea
lth
s
er
v
ices,
th
e
f
in
d
in
g
s
o
f
th
is
s
tu
d
y
h
av
e
im
p
o
r
tan
t
im
p
licatio
n
s
f
o
r
an
ten
atal
ca
r
e.
Gin
g
er
an
d
h
o
n
ey
d
ec
o
ctio
n
r
ep
r
esen
ts
a
s
im
p
le,
af
f
o
r
d
a
b
le,
an
d
cu
ltu
r
ally
ac
ce
p
tab
le
n
o
n
-
p
h
ar
m
ac
o
l
o
g
ic
al
in
ter
v
en
tio
n
th
at
ca
n
b
e
ea
s
i
ly
im
p
lem
en
ted
b
y
m
id
wiv
es a
n
d
o
th
e
r
m
ater
n
al
h
ea
lth
p
r
o
v
i
d
er
s
.
I
n
co
r
p
o
r
atin
g
th
is
in
ter
v
en
tio
n
in
to
r
o
u
tin
e
an
ten
atal
ed
u
ca
tio
n
an
d
co
u
n
s
elin
g
m
ay
h
el
p
p
r
eg
n
a
n
t
wo
m
en
m
an
a
g
e
m
i
ld
to
m
o
d
er
ate
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
ef
f
ec
tiv
ely
,
r
ed
u
ce
d
is
co
m
f
o
r
t,
an
d
p
r
ev
en
t
p
r
o
g
r
ess
io
n
to
m
o
r
e
s
ev
er
e
co
n
d
itio
n
s
th
at
r
eq
u
ir
e
p
h
ar
m
ac
o
lo
g
ical
o
r
h
o
s
p
ital
-
b
a
s
ed
tr
ea
tm
en
t.
I
n
th
e
c
o
n
tex
t
o
f
m
id
wif
er
y
p
r
ac
tice,
p
r
o
v
id
in
g
ed
u
ca
tio
n
o
n
th
e
p
r
ep
ar
atio
n
an
d
s
af
e
c
o
n
s
u
m
p
tio
n
o
f
g
in
g
er
an
d
h
o
n
e
y
d
ec
o
ct
io
n
em
p
o
wer
s
p
r
eg
n
an
t
wo
m
en
to
ac
tiv
ely
p
ar
ticip
ate
in
s
elf
-
ca
r
e
d
u
r
in
g
p
r
eg
n
a
n
cy
.
T
h
is
ap
p
r
o
ac
h
ali
g
n
s
with
p
r
o
m
o
tiv
e
an
d
p
r
ev
en
t
iv
e
m
ater
n
al
h
ea
lth
s
tr
ateg
ies,
em
p
h
asizi
n
g
ea
r
l
y
in
ter
v
en
tio
n
,
p
atien
t
ed
u
ca
tio
n
,
an
d
t
h
e
u
s
e
o
f
lo
ca
lly
av
ail
ab
le
n
atu
r
al
r
eso
u
r
ce
s
.
Ultim
a
tely
,
th
e
in
teg
r
atio
n
o
f
g
in
g
er
an
d
h
o
n
e
y
d
ec
o
ctio
n
in
to
m
ater
n
al
h
ea
lth
s
er
v
ices
m
ay
co
n
tr
ib
u
te
to
im
p
r
o
v
e
d
m
ater
n
al
co
m
f
o
r
t,
b
etter
n
u
tr
itio
n
al
i
n
tak
e,
an
d
e
n
h
an
ce
d
q
u
ality
o
f
an
ten
atal
c
ar
e.
4
.
3
.
E
f
f
ec
t
o
f
g
ing
er
a
nd
h
o
ney
deco
ct
io
n
o
n
t
he
f
re
qu
ency
o
f
hy
pere
m
esis
g
ra
v
id
a
rum
in
preg
na
nt
wo
m
en
T
h
e
r
esu
lts
o
f
th
is
s
tu
d
y
in
d
ic
ate
a
s
tatis
t
ically
s
ig
n
if
ican
t
r
ed
u
ctio
n
in
th
e
f
r
eq
u
en
cy
a
n
d
s
ev
er
ity
o
f
h
y
p
er
em
esis
g
r
a
v
id
ar
u
m
f
o
l
lo
win
g
th
e
ad
m
in
is
tr
atio
n
o
f
g
in
g
er
an
d
h
o
n
ey
d
ec
o
ctio
n
.
Prio
r
to
th
e
in
ter
v
en
tio
n
,
th
e
m
ed
ia
n
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
s
co
r
e
was
9
(
r
an
g
e
8
–
1
3
)
,
in
d
icatin
g
th
a
t
m
o
s
t
r
esp
o
n
d
e
n
ts
ex
p
er
ien
ce
d
m
o
d
e
r
ate
to
s
ev
e
r
e
s
y
m
p
to
m
s
.
Af
ter
th
e
in
ter
v
en
tio
n
,
th
e
m
e
d
ian
s
co
r
e
d
ec
r
ea
s
ed
m
ar
k
ed
ly
t
o
4
(
r
an
g
e
4
–
5
)
.
T
h
e
W
ilco
x
o
n
te
s
t
d
em
o
n
s
tr
ated
a
s
ig
n
if
ican
ce
v
alu
e
o
f
p
<
0
.
0
5
,
co
n
f
ir
m
in
g
th
at
th
e
o
b
s
er
v
ed
r
ed
u
ctio
n
was statis
tically
s
ig
n
if
ican
t a
n
d
u
n
lik
ely
t
o
b
e
d
u
e
to
ch
an
ce
.
B
ey
o
n
d
s
tatis
tical
s
ig
n
if
ican
ce
,
th
e
clin
ical
in
ter
p
r
etat
io
n
o
f
th
ese
f
in
d
in
g
s
is
p
ar
ticu
lar
ly
m
ea
n
in
g
f
u
l.
T
h
e
s
u
b
s
tan
tial
r
ed
u
ctio
n
in
th
e
m
ed
ia
n
s
co
r
e
,
ac
co
m
p
an
ied
b
y
a
n
ar
r
o
wer
p
o
s
t
-
in
ter
v
en
tio
n
r
an
g
e,
s
u
g
g
ests
n
o
t
o
n
ly
a
d
ec
r
ea
s
e
in
s
y
m
p
t
o
m
s
ev
er
ity
b
u
t
also
a
m
o
r
e
h
o
m
o
g
en
e
o
u
s
th
er
ap
eu
tic
r
esp
o
n
s
e
am
o
n
g
p
ar
ticip
an
ts
.
T
h
is
p
att
er
n
in
d
icate
s
th
at
th
e
g
in
g
er
an
d
h
o
n
ey
d
ec
o
ctio
n
m
ay
h
av
e
co
n
tr
ib
u
ted
to
s
tab
ilizin
g
s
y
m
p
to
m
in
ten
s
ity
ac
r
o
s
s
in
d
iv
id
u
als.
I
n
m
ater
n
a
l
h
ea
lth
ca
r
e,
c
o
n
s
is
ten
cy
o
f
r
e
s
p
o
n
s
e
is
clin
ically
im
p
o
r
tan
t,
as
h
y
p
er
em
esis
g
r
av
id
ar
u
m
ca
n
s
ig
n
if
ican
tly
d
i
s
r
u
p
t
d
aily
ac
tiv
ities
,
r
ed
u
ce
o
r
al
in
tak
e
,
im
p
ai
r
h
y
d
r
atio
n
s
tatu
s
,
an
d
n
eg
ativ
e
ly
af
f
ec
t
em
o
tio
n
al
well
-
b
ein
g
.
T
h
er
ef
o
r
e,
th
e
in
te
r
v
en
tio
n
ap
p
ea
r
s
to
p
r
o
v
id
e
b
o
th
s
y
m
p
t
o
m
atic
r
elief
an
d
i
m
p
r
o
v
e
d
f
u
n
ctio
n
al
s
tab
il
ity
d
u
r
in
g
ea
r
ly
p
r
e
g
n
an
c
y
.
Per
s
is
ten
t
h
y
p
er
em
esis
g
r
a
v
id
ar
u
m
is
ass
o
ciate
d
with
d
eh
y
d
r
atio
n
,
elec
tr
o
l
y
te
im
b
alan
ce
,
h
em
o
co
n
ce
n
tr
atio
n
,
a
n
d
weig
h
t
lo
s
s
.
Hem
o
co
n
ce
n
tr
atio
n
m
ay
co
m
p
r
o
m
is
e
ef
f
ec
tiv
e
b
lo
o
d
cir
cu
latio
n
,
th
er
eb
y
r
ed
u
cin
g
o
x
y
g
en
an
d
n
u
tr
ien
t
d
eli
v
er
y
to
m
ater
n
al
t
is
s
u
es
an
d
p
o
ten
tially
af
f
ec
tin
g
f
etal
d
ev
elo
p
m
en
t
if
p
r
o
lo
n
g
ed
.
Fro
m
a
p
r
ev
en
ti
v
e
ca
r
e
p
er
s
p
ec
tiv
e,
ea
r
ly
an
d
ef
f
ec
tiv
e
s
y
m
p
to
m
m
a
n
ag
e
m
en
t
is
ess
en
tia
l
to
p
r
ev
en
t
p
r
o
g
r
ess
io
n
to
s
ev
er
e
h
y
p
er
em
esis
g
r
av
id
ar
u
m
r
eq
u
ir
in
g
p
h
ar
m
ac
o
lo
g
ical
th
e
r
a
p
y
o
r
h
o
s
p
italizatio
n
.
T
h
e
f
in
d
i
n
g
s
o
f
th
is
s
tu
d
y
s
u
g
g
est
th
at
g
in
g
er
an
d
h
o
n
ey
d
e
co
ctio
n
m
ay
s
er
v
e
as
an
ea
r
ly
s
u
p
p
o
r
tiv
e
s
tr
ateg
y
to
m
ain
tain
m
ater
n
al
p
h
y
s
io
lo
g
ical
s
tab
ilit
y
d
u
r
in
g
t
h
e
cr
itic
al
f
ir
s
t tr
im
ester
.
T
h
ese
r
esu
lts
ar
e
co
n
s
is
ten
t
with
p
r
ev
io
u
s
s
tu
d
ies
d
em
o
n
s
tr
atin
g
th
e
ef
f
ec
tiv
en
ess
o
f
g
in
g
er
-
b
ased
in
ter
v
en
tio
n
s
in
r
ed
u
ci
n
g
n
au
s
ea
an
d
v
o
m
itin
g
d
u
r
i
n
g
p
r
e
g
n
an
cy
.
Su
lis
ty
o
wati
[
3
8
]
r
ep
o
r
ted
a
s
tatis
tically
s
ig
n
if
ican
t
r
ed
u
ctio
n
in
n
au
s
e
a
an
d
v
o
m
itin
g
s
co
r
es
am
o
n
g
f
ir
s
t
-
tr
im
ester
p
r
e
g
n
an
t
wo
m
en
r
ec
eiv
i
n
g
g
in
g
er
an
d
h
o
n
e
y
d
ec
o
ctio
n
(
p
<
0
.
0
0
5
)
.
Oth
er
q
u
asi
-
ex
p
er
im
en
t
al
an
d
clin
ical
s
tu
d
ies
h
a
v
e
s
im
ilar
ly
s
h
o
wn
th
at
g
in
g
er
b
ev
er
ag
es
an
d
g
in
g
e
r
s
u
p
p
lem
en
tatio
n
s
ig
n
if
ican
tly
r
ed
u
ce
em
esis
g
r
av
id
a
r
u
m
s
ev
er
ity
s
co
r
es,
s
u
p
p
o
r
tin
g
th
e
th
er
a
p
eu
tic
v
al
u
e
o
f
g
in
g
er
as a
co
m
p
lem
e
n
tar
y
in
ter
v
e
n
tio
n
.
T
h
e
f
in
d
i
n
g
s
o
f
th
e
p
r
esen
t
s
tu
d
y
ar
e
f
u
r
th
er
s
u
p
p
o
r
te
d
b
y
r
ec
en
t
in
ter
n
atio
n
al
e
v
id
en
ce
.
A
2
0
2
5
s
y
s
tem
atic
r
ev
iew
an
d
m
eta
-
an
aly
s
is
co
n
d
u
cted
b
y
Gao
[
1
2
]
ev
alu
ated
th
e
clin
ical
ef
f
e
ctiv
en
ess
o
f
g
in
g
er
s
u
p
p
le
m
en
tatio
n
in
allev
iatin
g
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
ac
r
o
s
s
m
u
ltip
le
s
tu
d
ies
an
d
h
ea
lth
ca
r
e
s
ettin
g
s
.
T
h
e
m
eta
-
an
aly
s
is
d
em
o
n
s
tr
ated
t
h
at
g
in
g
er
s
ig
n
if
ican
tly
r
ed
u
c
ed
th
e
r
is
k
a
n
d
s
ev
er
ity
o
f
n
au
s
ea
an
d
v
o
m
itin
g
s
y
m
p
to
m
s
am
o
n
g
p
r
e
g
n
an
t
w
o
m
en
with
h
y
p
er
em
esis
g
r
av
i
d
ar
u
m
,
with
a
n
o
d
d
s
r
atio
o
f
0
.
4
1
(
9
5
%
C
I
:
0
.
2
2
–
0
.
7
9
;
p
=
0
.
0
0
8
)
.
I
m
p
o
r
tan
tly
,
th
e
r
e
v
iew
r
ep
o
r
ted
n
o
m
ajo
r
ad
v
er
s
e
m
ate
r
n
al
o
r
f
etal
e
f
f
e
cts
ass
o
ciate
d
with
g
in
g
er
u
s
e,
r
ein
f
o
r
cin
g
its
s
af
ety
p
r
o
f
ile
as
a
co
m
p
lem
e
n
tar
y
th
er
a
p
y
d
u
r
in
g
p
r
eg
n
a
n
c
y
.
T
h
ese
f
in
d
in
g
s
s
tr
en
g
th
en
th
e
b
io
lo
g
ical
a
n
d
clin
ical
p
lau
s
ib
ilit
y
o
f
th
e
cu
r
r
en
t
s
tu
d
y
,
as
th
e
s
ig
n
if
ican
t
r
ed
u
ctio
n
in
h
y
p
er
em
esis
g
r
av
i
d
ar
u
m
s
co
r
e
s
o
b
s
er
v
ed
af
ter
th
e
ad
m
i
n
is
tr
atio
n
o
f
g
in
g
er
a
n
d
h
o
n
e
y
d
ec
o
ctio
n
is
co
n
s
is
ten
t
with
h
ig
h
-
lev
el
e
v
id
en
ce
d
er
i
v
ed
f
r
o
m
s
y
s
tem
atic
ev
alu
atio
n
.
T
h
e
co
n
v
er
g
en
ce
o
f
r
esu
lts
b
etwe
en
th
e
p
r
esen
t
q
u
asi
-
ex
p
er
im
e
n
tal
s
tu
d
y
an
d
th
is
r
ec
en
t
m
eta
-
an
aly
s
is
s
u
g
g
ests
th
at
g
in
g
er
-
b
ased
in
te
r
v
en
tio
n
s
,
wh
et
h
er
ad
m
in
is
ter
ed
as
s
tan
d
ar
d
ized
s
u
p
p
lem
en
ts
o
r
h
er
b
al
d
ec
o
ctio
n
s
,
m
ay
o
f
f
er
a
r
e
liab
le
an
d
ev
id
en
ce
-
in
f
o
r
m
e
d
ap
p
r
o
ac
h
f
o
r
m
an
a
g
in
g
h
y
p
e
r
e
m
esis
g
r
av
id
ar
u
m
with
in
m
ate
r
n
al
h
ea
lth
ca
r
e
s
er
v
ices
[
1
2
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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:
2
2
5
2
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8
8
0
6
I
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t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
15
,
No
.
2
,
J
u
n
e
20
26
:
4
3
7
-
4
4
8
444
T
h
e
r
esu
lts
o
f
th
is
s
tu
d
y
ar
e
s
u
p
p
o
r
ted
b
y
a
r
an
d
o
m
ized
,
p
lace
b
o
-
co
n
tr
o
lled
tr
ial
co
n
d
u
cted
b
y
Sab
er
i
et
a
l
.
[
4
0
]
,
w
h
ich
d
em
o
n
s
tr
ated
th
at
g
in
g
er
s
ig
n
if
ica
n
tly
r
ed
u
ce
d
n
a
u
s
ea
an
d
v
o
m
itin
g
s
y
m
p
to
m
s
i
n
p
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eg
n
a
n
t
wo
m
en
u
n
d
er
1
6
we
ek
s
o
f
g
estatio
n
co
m
p
a
r
ed
to
p
lace
b
o
.
Alth
o
u
g
h
th
e
p
ar
ticip
an
ts
wer
e
p
r
im
ar
ily
ex
p
er
ien
cin
g
n
au
s
ea
an
d
v
o
m
itin
g
o
f
p
r
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n
a
n
cy
r
ath
e
r
th
an
s
ev
er
e
h
y
p
er
em
esis
g
r
av
id
ar
u
m
,
th
e
f
in
d
in
g
s
r
em
ain
r
elev
a
n
t
b
ec
au
s
e
b
o
th
co
n
d
itio
n
s
lie
with
in
th
e
s
a
m
e
clin
ical
s
p
ec
tr
u
m
.
T
h
e
r
a
n
d
o
m
ized
co
n
tr
o
lled
d
esig
n
s
tr
en
g
th
en
s
th
e
ev
id
e
n
ce
f
o
r
g
in
g
er
’
s
an
tiem
etic
ef
f
ec
tiv
en
ess
.
T
h
e
co
n
s
is
ten
cy
b
etwe
en
th
e
R
C
T
f
in
d
in
g
s
an
d
th
e
s
y
m
p
to
m
r
ed
u
ctio
n
o
b
s
er
v
ed
i
n
th
is
s
tu
d
y
r
ei
n
f
o
r
ce
s
th
e
r
o
le
o
f
g
in
g
er
,
in
clu
d
in
g
i
n
d
ec
o
ctio
n
f
o
r
m
co
m
b
in
e
d
with
h
o
n
ey
,
as
a
s
af
e
an
d
ef
f
ec
ti
v
e
n
o
n
-
p
h
ar
m
ac
o
lo
g
ical
in
ter
v
en
tio
n
in
m
ater
n
al
h
ea
lth
ca
r
e
[
4
0
]
.
Pre
v
io
u
s
s
y
s
tem
atic
ev
id
en
ce
h
as
also
co
n
s
is
ten
tly
s
u
p
p
o
r
te
d
th
e
ef
f
ec
tiv
en
ess
an
d
s
af
ety
o
f
g
in
g
e
r
in
m
an
ag
in
g
p
r
eg
n
a
n
cy
-
r
elate
d
n
au
s
ea
an
d
v
o
m
itin
g
.
A
wid
ely
cited
s
y
s
tem
atic
r
ev
iew
an
d
m
eta
-
an
aly
s
is
b
y
Viljo
en
et
a
l
.
[
4
1
]
co
n
clu
d
e
d
th
at
g
in
g
e
r
s
ig
n
if
ica
n
tly
r
ed
u
c
ed
n
au
s
ea
s
y
m
p
to
m
s
with
o
u
t
in
cr
ea
s
in
g
ad
v
er
s
e
m
ater
n
al
o
r
f
etal
o
u
tco
m
es.
Alth
o
u
g
h
p
u
b
lis
h
ed
ea
r
lier
,
th
is
s
tu
d
y
r
em
ain
s
an
im
p
o
r
tan
t
f
o
u
n
d
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n
al
r
ef
er
en
ce
,
d
em
o
n
s
tr
atin
g
th
a
t
g
in
g
er
h
as
lo
n
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b
ee
n
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n
tific
ally
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alu
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n
ized
as
a
s
af
e
co
m
p
lem
en
tar
y
th
er
a
p
y
in
p
r
eg
n
an
cy
.
T
h
e
f
i
n
d
in
g
s
o
f
th
e
p
r
esen
t
s
tu
d
y
th
er
e
f
o
r
e
alig
n
with
estab
lis
h
ed
s
cien
tific
tr
en
d
s
s
u
p
p
o
r
tin
g
g
i
n
g
er
u
s
e
in
t
h
e
m
an
a
g
em
en
t
o
f
n
au
s
ea
an
d
v
o
m
itin
g
d
u
r
in
g
p
r
eg
n
a
n
cy
[
4
1
]
.
A
r
ec
en
t
q
u
asi
-
ex
p
er
im
en
tal
s
tu
d
y
f
u
r
t
h
er
s
tr
en
g
th
en
s
th
e
ev
id
en
ce
s
u
p
p
o
r
tin
g
h
er
b
al
co
m
b
in
atio
n
th
er
ap
ies
in
m
a
n
ag
in
g
p
r
eg
n
an
cy
-
r
elate
d
n
au
s
ea
a
n
d
v
o
m
itin
g
.
Nu
r
m
asy
ith
a
h
et
a
l
.
[
3
4
]
r
e
p
o
r
ted
th
at
a
d
ec
o
ctio
n
co
n
tain
i
n
g
g
in
g
e
r
,
lem
o
n
,
an
d
h
o
n
ey
s
ig
n
if
ican
t
ly
r
ed
u
ce
d
n
au
s
ea
an
d
v
o
m
it
in
g
s
co
r
es
am
o
n
g
p
r
e
g
n
a
n
t
wo
m
en
with
em
esis
g
r
av
id
a
r
u
m
c
o
m
p
a
r
ed
to
a
c
o
n
tr
o
l
g
r
o
u
p
r
ec
ei
v
in
g
s
tan
d
a
r
d
ed
u
ca
tio
n
.
T
h
e
s
tu
d
y
d
em
o
n
s
tr
ated
m
ea
n
in
g
f
u
l
clin
ical
im
p
r
o
v
em
en
t
af
ter
r
eg
u
lar
co
n
s
u
m
p
tio
n
o
f
th
e
h
er
b
al
d
ec
o
ctio
n
,
h
ig
h
lig
h
tin
g
th
e
p
o
ten
tial
s
y
n
e
r
g
is
tic
ef
f
ec
t
o
f
co
m
b
i
n
in
g
g
in
g
er
with
o
t
h
er
n
at
u
r
al
in
g
r
ed
ie
n
ts
s
u
ch
as
h
o
n
e
y
.
T
h
ese
f
in
d
in
g
s
ar
e
h
ig
h
ly
r
el
ev
an
t
to
th
e
p
r
esen
t
s
tu
d
y
,
as
th
e
in
ter
v
e
n
tio
n
s
im
ilar
ly
u
tili
ze
d
a
g
in
g
e
r
an
d
h
o
n
ey
d
ec
o
ctio
n
,
t
h
er
eb
y
r
ein
f
o
r
cin
g
th
e
s
cien
tific
ju
s
tific
atio
n
f
o
r
im
p
lem
en
tin
g
s
u
c
h
h
er
b
al
co
m
b
in
atio
n
s
in
clin
ical
an
d
p
r
im
a
r
y
m
ater
n
al
h
ea
lth
ca
r
e
s
ettin
g
s
[
3
4
]
.
A
s
y
s
tem
atic
r
ev
iew
p
u
b
lis
h
ed
in
B
MC
C
o
m
p
lem
en
tar
y
Me
d
icin
e
an
d
T
h
er
a
p
ies
co
n
clu
d
ed
th
at
g
in
g
er
is
o
n
e
o
f
th
e
m
o
s
t
co
n
s
is
ten
tly
ef
f
ec
tiv
e
co
m
p
lem
en
t
ar
y
th
er
ap
ies
f
o
r
r
ed
u
cin
g
n
au
s
e
a
an
d
v
o
m
itin
g
i
n
p
r
eg
n
a
n
cy
.
T
h
e
r
ev
iew
r
ep
o
r
ted
th
at
g
in
g
er
s
ig
n
if
ican
tly
d
ec
r
ea
s
ed
n
a
u
s
ea
s
ev
er
ity
co
m
p
ar
ed
to
p
lace
b
o
,
with
n
o
s
er
io
u
s
ad
v
e
r
s
e
ef
f
ec
t
s
o
n
m
o
th
er
s
o
r
f
etu
s
es.
T
h
ese
f
in
d
in
g
s
s
u
p
p
o
r
t
th
e
r
esu
lts
o
f
th
e
p
r
esen
t
s
tu
d
y
,
wh
ich
also
d
e
m
o
n
s
tr
ate
d
a
s
ig
n
if
ican
t
r
e
d
u
ctio
n
in
h
y
p
e
r
em
esis
g
r
av
id
ar
u
m
s
ev
er
ity
a
f
ter
th
e
ad
m
in
is
tr
atio
n
o
f
g
in
g
er
an
d
h
o
n
ey
d
ec
o
ctio
n
.
T
h
e
b
i
o
l
o
g
i
c
a
l
p
l
a
u
s
i
b
i
li
t
y
o
f
t
h
e
s
e
f
i
n
d
i
n
g
s
ca
n
b
e
e
x
p
l
ai
n
e
d
b
y
t
h
e
p
h
a
r
m
a
c
o
l
o
g
i
ca
l
p
r
o
p
e
r
t
i
e
s
o
f
g
i
n
g
e
r
.
G
i
n
g
e
r
c
o
n
t
ai
n
s
b
i
o
a
c
ti
v
e
c
o
m
p
o
u
n
d
s
s
u
c
h
a
s
g
i
n
g
e
r
o
l
s
,
s
h
o
g
a
o
l
s
,
z
i
n
g
i
b
e
r
e
n
e
,
a
n
d
e
s
s
e
n
t
i
al
o
i
ls
t
h
a
t
e
x
h
i
b
i
t
a
n
t
ie
m
e
t
ic
a
n
d
a
n
t
i
-
i
n
f
la
m
m
a
t
o
r
y
e
f
f
e
c
ts
.
Gi
n
g
e
r
h
a
s
b
e
e
n
s
h
o
w
n
t
o
i
n
h
i
b
i
t
s
e
r
o
t
o
n
in
(
5
-
H
T
3
)
r
e
c
e
p
t
o
r
s
i
n
t
h
e
g
a
s
t
r
o
i
n
t
e
s
t
i
n
a
l
t
r
ac
t
a
n
d
c
e
n
t
r
a
l
n
e
r
v
o
u
s
s
y
s
t
e
m
,
t
h
e
r
e
b
y
r
e
d
u
c
i
n
g
s
t
i
m
u
l
a
t
i
o
n
o
f
t
h
e
v
o
m
i
t
i
n
g
c
e
n
t
e
r
.
A
d
d
i
t
i
o
n
a
l
l
y
,
g
i
n
g
e
r
m
a
y
e
n
h
a
n
c
e
g
a
s
t
r
i
c
m
o
t
i
li
t
y
a
n
d
a
c
c
e
l
e
r
a
t
e
g
as
t
r
i
c
e
m
p
t
y
i
n
g
,
c
o
u
n
t
e
r
a
c
t
i
n
g
t
h
e
p
r
o
g
e
s
t
e
r
o
n
e
-
i
n
d
u
c
e
d
r
e
l
a
x
a
tio
n
o
f
s
m
o
o
t
h
m
u
s
c
le
t
h
a
t
c
o
n
t
r
i
b
u
t
e
s
t
o
n
a
u
s
e
a
d
u
r
i
n
g
p
r
e
g
n
a
n
c
y
[4
2
]
.
T
h
e
s
e
m
e
c
h
a
n
i
s
m
s
p
r
o
v
i
d
e
a
p
h
y
s
i
o
lo
g
i
c
a
l
b
a
s
i
s
f
o
r
t
h
e
o
b
s
e
r
v
e
d
r
e
d
u
c
t
i
o
n
i
n
s
y
m
p
t
o
m
s
e
v
e
r
i
t
y
.
Ho
n
ey
m
ay
co
m
p
le
m
en
t
th
e
ac
tio
n
o
f
g
in
g
er
th
r
o
u
g
h
g
a
s
tr
o
in
test
in
al
p
r
o
tectiv
e
an
d
n
u
tr
itio
n
al
m
ec
h
an
is
m
s
.
Ho
n
ey
co
n
tain
s
m
in
er
als
s
u
ch
as
s
o
d
iu
m
,
ca
lciu
m
,
m
ag
n
esiu
m
,
ir
o
n
,
p
h
o
s
p
h
o
r
u
s
,
an
d
p
o
tass
iu
m
,
as
well
as
s
m
all
a
m
o
u
n
ts
o
f
v
itam
in
s
in
clu
d
in
g
B
-
co
m
p
lex
v
itam
in
s
[4
3
]
.
I
ts
d
em
u
lcen
t
p
r
o
p
e
r
ties
allo
w
h
o
n
e
y
to
co
at
th
e
eso
p
h
ag
ea
l
an
d
g
astric
m
u
c
o
s
a,
p
o
ten
tially
r
ed
u
ci
n
g
ir
r
itatio
n
ca
u
s
ed
b
y
g
astric
ac
i
d
an
d
m
in
im
izin
g
r
ef
lu
x
-
r
elate
d
n
au
s
ea
.
Ho
n
ey
m
a
y
also
h
el
p
r
eg
u
late
g
astric
s
p
h
in
cter
f
u
n
ctio
n
an
d
p
r
o
v
id
e
r
ea
d
ily
ab
s
o
r
b
a
b
le
ca
r
b
o
h
y
d
r
ates,
w
h
ich
ca
n
s
u
p
p
o
r
t
en
e
r
g
y
r
esto
r
atio
n
in
p
r
eg
n
a
n
t
wo
m
en
ex
p
e
r
ien
cin
g
r
ed
u
ce
d
in
tak
e
d
u
e
to
v
o
m
it
in
g
[4
2
]
.
T
h
e
co
m
b
in
atio
n
o
f
g
in
g
er
an
d
h
o
n
ey
,
th
er
ef
o
r
e
,
m
ay
p
r
o
d
u
ce
a
s
y
n
er
g
is
tic
ef
f
ec
t,
ad
d
r
ess
in
g
b
o
th
n
e
u
r
o
c
h
em
ical
p
ath
way
s
o
f
n
au
s
ea
a
n
d
g
astro
i
n
test
in
al
co
m
f
o
r
t.
T
h
e
h
o
r
m
o
n
al
c
o
n
tex
t
o
f
ea
r
ly
p
r
e
g
n
an
c
y
f
u
r
th
er
s
u
p
p
o
r
ts
th
e
in
ter
p
r
etatio
n
o
f
th
ese
f
in
d
in
g
s
.
Hy
p
er
em
esis
g
r
av
id
ar
u
m
is
s
tr
o
n
g
ly
ass
o
ciate
d
with
elev
a
ted
lev
els
o
f
h
C
G
an
d
p
r
o
g
e
s
ter
o
n
e.
Du
r
in
g
th
e
f
ir
s
t
1
2
–
1
6
wee
k
s
o
f
g
estatio
n
,
h
C
G
lev
els
p
ea
k
,
co
in
ci
d
in
g
with
th
e
h
ig
h
est
in
cid
e
n
ce
o
f
n
au
s
ea
an
d
v
o
m
itin
g
.
Pro
g
ester
o
n
e
r
ed
u
c
es
g
astro
in
test
in
al
m
o
tili
ty
b
y
r
elax
in
g
s
m
o
o
th
m
u
s
cle,
co
n
t
r
ib
u
tin
g
to
d
ela
y
ed
g
astric
em
p
ty
in
g
an
d
in
c
r
ea
s
ed
n
a
u
s
ea
[4
2
]
.
W
h
ile
th
ese
h
o
r
m
o
n
al
ch
an
g
es
ar
e
p
h
y
s
i
o
lo
g
ical,
e
x
ce
s
s
iv
e
s
en
s
itiv
ity
ca
n
r
esu
lt
in
s
ev
er
e
s
y
m
p
to
m
s
.
T
h
e
e
f
f
ec
tiv
en
ess
o
f
g
i
n
g
er
an
d
h
o
n
ey
d
ec
o
ctio
n
s
u
g
g
ests
th
at
n
o
n
-
p
h
ar
m
ac
o
l
o
g
ical
m
o
d
u
latio
n
o
f
g
astro
in
test
in
al
f
u
n
ctio
n
m
ay
m
itig
ate
th
e
s
y
m
p
t
o
m
atic
im
p
ac
t
o
f
h
o
r
m
o
n
a
l
f
lu
ctu
atio
n
s
with
o
u
t in
ter
f
er
in
g
with
n
o
r
m
al
p
r
e
g
n
an
c
y
p
r
o
c
ess
es.
I
m
p
o
r
ta
n
tly
,
th
e
in
ter
p
r
etatio
n
o
f
th
ese
f
i
n
d
in
g
s
ex
te
n
d
s
b
ey
o
n
d
b
io
l
o
g
ical
m
ec
h
a
n
is
m
s
to
th
e
co
n
tex
t
o
f
m
ater
n
al
h
ea
lth
s
er
v
ices.
Gin
g
er
an
d
h
o
n
ey
d
ec
o
ctio
n
r
ep
r
esen
ts
a
lo
w
-
c
o
s
t,
cu
ltu
r
ally
ac
ce
p
tab
le,
an
d
ea
s
ily
ac
ce
s
s
ib
le
i
n
ter
v
e
n
tio
n
th
at
ca
n
b
e
im
p
lem
e
n
t
ed
in
p
r
im
ar
y
h
ea
lth
ca
r
e
s
e
ttin
g
s
.
I
n
r
eso
u
r
ce
-
lim
ited
ar
ea
s
wh
er
e
ac
ce
s
s
to
p
h
ar
m
ac
o
lo
g
ical
an
tiem
etics
m
ay
b
e
r
estricte
d
o
r
ac
co
m
p
an
ied
b
y
co
n
ce
r
n
s
r
eg
ar
d
in
g
f
etal
s
af
ety
,
e
v
id
e
n
ce
-
b
ased
n
o
n
-
p
h
ar
m
ac
o
lo
g
i
ca
l
alter
n
ativ
es
ca
n
s
tr
en
g
th
en
an
ten
atal
ca
r
e
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
B
o
iled
g
in
g
er
a
n
d
h
o
n
ey
in
terven
tio
n
fo
r
h
yp
eremesis
g
r
a
vid
a
r
u
m
(
N
u
r
s
ya
h
id
S
ir
eg
a
)
445
s
er
v
ices.
I
n
teg
r
atin
g
s
u
ch
i
n
ter
v
en
tio
n
s
in
to
r
o
u
tin
e
a
n
ten
at
al
co
u
n
s
elin
g
m
ay
r
ed
u
ce
th
e
b
u
r
d
e
n
o
f
m
ild
t
o
m
o
d
er
ate
h
y
p
er
e
m
esis
g
r
av
id
a
r
u
m
an
d
p
o
te
n
tially
d
ec
r
ea
s
e
u
n
n
ec
ess
ar
y
m
ed
icaliza
tio
n
.
Fo
r
m
id
wif
er
y
p
r
a
ctice
,
ed
u
c
atio
n
o
n
th
e
p
r
ep
ar
atio
n
,
d
o
s
a
g
e,
an
d
s
af
e
co
n
s
u
m
p
tio
n
o
f
g
in
g
er
an
d
h
o
n
ey
d
ec
o
ctio
n
alig
n
s
with
p
r
o
m
o
tiv
e
an
d
p
r
ev
en
tiv
e
m
a
ter
n
al
h
ea
lth
s
tr
ateg
ies.
Mid
wiv
es
p
lay
a
p
iv
o
tal
r
o
le
in
ea
r
l
y
p
r
eg
n
a
n
cy
c
o
u
n
s
elin
g
an
d
ca
n
em
p
o
wer
p
r
eg
n
an
t
w
o
m
en
t
o
en
g
ag
e
i
n
s
u
p
er
v
is
ed
s
elf
-
m
an
ag
em
en
t.
T
h
is
ap
p
r
o
ac
h
en
h
an
ce
s
p
atien
t
-
ce
n
te
r
ed
ca
r
e,
im
p
r
o
v
es
m
ater
n
al
co
n
f
id
e
n
ce
,
an
d
s
u
p
p
o
r
ts
h
o
lis
tic
an
ten
atal
s
er
v
ice
d
eliv
er
y
.
I
n
co
n
clu
s
io
n
,
th
e
r
ed
u
ctio
n
i
n
h
y
p
er
em
esis
g
r
av
id
a
r
u
m
f
r
e
q
u
en
cy
o
b
s
er
v
e
d
in
t
h
is
s
tu
d
y
is
n
o
t
o
n
ly
s
tatis
t
ically
s
ig
n
if
ican
t
b
u
t
also
clin
ically
r
elev
a
n
t.
T
h
e
c
o
m
b
in
atio
n
o
f
g
in
g
er
a
n
d
h
o
n
ey
d
em
o
n
s
tr
ates
b
io
lo
g
ical
p
la
u
s
ib
ilit
y
,
co
n
s
is
ten
cy
with
p
r
io
r
r
esear
ch
,
a
n
d
p
r
ac
tical
ap
p
licab
ilit
y
with
in
m
ater
n
al
h
ea
lth
s
er
v
ices.
T
h
ese
f
in
d
in
g
s
s
u
p
p
o
r
t
th
e
in
teg
r
atio
n
o
f
g
in
g
e
r
an
d
h
o
n
ey
d
ec
o
ctio
n
as
an
ev
id
en
ce
-
in
f
o
r
m
e
d
co
m
p
lem
en
tar
y
in
ter
v
e
n
tio
n
in
an
ten
atal
ca
r
e,
p
ar
ticu
lar
l
y
f
o
r
th
e
m
an
a
g
em
en
t
o
f
m
ild
to
m
o
d
er
ate
h
y
p
er
em
esis
g
r
a
v
id
ar
u
m
.
Desp
ite
th
ese
p
r
o
m
is
in
g
f
in
d
i
n
g
s
,
th
is
s
tu
d
y
h
as
s
ev
er
al
lim
itatio
n
s
.
T
h
e
ab
s
en
ce
o
f
a
co
n
tr
o
l
g
r
o
u
p
lim
its
th
e
ab
ilit
y
to
estab
l
is
h
ca
u
s
al
in
f
er
e
n
ce
,
an
d
t
h
e
r
elativ
ely
s
m
all
s
am
p
le
s
ize
m
ay
af
f
ec
t
g
en
er
aliza
b
ilit
y
.
Fu
tu
r
e
r
a
n
d
o
m
ized
co
n
tr
o
lled
tr
ials
with
la
r
g
er
p
o
p
u
latio
n
s
ar
e
r
ec
o
m
m
e
n
d
ed
t
o
co
n
f
ir
m
t
h
e
ef
f
ec
tiv
en
ess
o
f
g
in
g
er
a
n
d
h
o
n
ey
d
ec
o
ctio
n
in
d
iv
er
s
e
clin
ic
al
s
ettin
g
s
.
5.
CO
NCLU
SI
O
N
T
h
is
s
tu
d
y
d
em
o
n
s
tr
ates
th
at
th
e
ad
m
in
is
tr
atio
n
o
f
g
in
g
er
a
n
d
h
o
n
e
y
d
ec
o
ctio
n
s
ig
n
if
ican
tl
y
r
ed
u
ce
s
th
e
f
r
eq
u
en
cy
an
d
s
ev
er
ity
o
f
h
y
p
e
r
em
esis
g
r
av
id
a
r
u
m
(
p
<
0
.
0
5
)
,
in
d
icatin
g
th
at
th
e
in
te
r
v
en
tio
n
e
f
f
ec
tiv
ely
ac
h
iev
ed
th
e
r
esear
ch
o
b
jecti
v
e.
T
h
e
m
a
r
k
ed
d
ec
lin
e
in
m
e
d
ian
s
y
m
p
to
m
s
co
r
es
r
ef
lects
b
o
th
s
tatis
tical
an
d
clin
ical
im
p
r
o
v
em
en
t
am
o
n
g
p
r
eg
n
a
n
t
wo
m
en
.
Pra
ctica
lly
,
th
is
f
in
d
in
g
s
u
p
p
o
r
ts
th
e
in
teg
r
atio
n
o
f
g
in
g
er
an
d
h
o
n
ey
d
ec
o
cti
o
n
as
a
lo
w
-
co
s
t,
s
af
e,
an
d
ac
ce
s
s
ib
le
co
m
p
lem
en
tar
y
t
h
er
ap
y
with
in
a
n
te
n
atal
ca
r
e
s
er
v
ices.
Fu
tu
r
e
r
esear
ch
is
r
ec
o
m
m
en
d
ed
to
em
p
l
o
y
c
o
n
tr
o
lled
d
es
ig
n
s
an
d
lar
g
er
s
am
p
les
to
f
u
r
th
er
s
tr
en
g
th
en
th
e
ev
id
en
ce
b
ase.
ACK
NO
WL
E
DG
M
E
N
T
S
T
h
e
au
th
o
r
s
ap
p
r
ec
iated
all
r
esp
o
n
d
e
n
ts
f
o
r
s
u
p
p
o
r
tin
g
an
d
f
a
cilitatin
g
th
e
d
atab
ase
s
ea
r
ch
.
F
UNDING
I
NF
O
R
M
A
T
I
O
N
Au
th
o
r
s
s
tate
n
o
f
u
n
d
in
g
in
v
o
lv
ed
.
AUTHO
R
CO
NT
RI
B
UT
I
O
NS ST
A
T
E
M
E
N
T
T
h
is
jo
u
r
n
al
u
s
es
th
e
C
o
n
tr
ib
u
to
r
R
o
les
T
ax
o
n
o
m
y
(
C
R
ed
iT)
to
r
ec
o
g
n
ize
in
d
iv
id
u
al
au
th
o
r
co
n
tr
ib
u
tio
n
s
,
r
ed
u
ce
au
th
o
r
s
h
ip
d
is
p
u
tes,
an
d
f
ac
ilit
ate
co
llab
o
r
atio
n
.
Na
m
e
o
f
Aut
ho
r
C
M
So
Va
Fo
I
R
D
O
E
Vi
Su
P
Fu
Nu
r
s
y
ah
id
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E
g
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r
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J
asm
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ti
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I
r
m
a
Mu
s
tik
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Nin
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✓
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R
ah
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awa
ti W
ah
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R
o
s
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Ar
ief
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Pu
tr
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Dewi
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Hen
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E
lis
a
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a
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C
:
C
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p
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Au
th
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r
s
s
tate
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o
co
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lict o
f
in
t
er
est.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
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8
8
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6
I
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t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
15
,
No
.
2
,
J
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e
20
26
:
4
3
7
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4
4
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446
E
T
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CAL AP
P
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th
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p
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tai
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r
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Po
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ticip
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tiality
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m
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ea
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esp
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t.
DATA AV
AI
L
AB
I
L
I
T
Y
T
h
e
d
ata
th
at
s
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p
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th
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t
h
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r
,
[
NS
]
,
u
p
o
n
r
ea
s
o
n
ab
le
r
eq
u
est.
RE
F
E
R
E
NC
E
S
[
1
]
H
.
W
i
n
k
j
o
sas
t
r
o
,
I
l
m
u
K
e
b
i
d
a
n
a
n
.
Ja
k
a
r
t
a
:
Y
a
y
a
sa
n
B
i
n
a
P
u
s
t
a
k
a
S
a
r
w
o
n
o
P
r
a
w
i
r
o
h
a
r
d
j
o
,
2
0
1
7
.
[
2
]
K
.
A
u
st
i
n
,
K
.
W
i
l
s
o
n
,
a
n
d
S
.
S
a
h
a
,
“
H
y
p
e
r
e
mes
i
s
g
r
a
v
i
d
a
r
u
m,”
N
u
t
r
i
t
i
o
n
i
n
C
l
i
n
i
c
a
l
Pra
c
t
i
c
e
,
v
o
l
.
3
4
,
n
o
.
2
,
p
p
.
2
2
6
–
2
4
1
,
A
p
r
.
2
0
1
9
,
d
o
i
:
1
0
.
1
0
0
2
/
n
c
p
.
1
0
2
0
5
.
[
3
]
Ke
m
e
n
k
e
s,
“
P
r
o
f
i
l
K
e
s
e
h
a
t
a
n
I
n
d
o
n
e
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a
T
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h
u
n
2
0
2
3
,
”
K
e
m
e
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t
e
ri
a
n
K
e
se
h
a
t
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n
RI
,
v
o
l
.
1
,
n
o
.
1
,
p
.
1
,
2
0
2
3
.
[
4
]
R
S
U
D
I
.
A
.
M
o
i
e
s
,
“
D
a
t
a
R
e
k
a
m
M
e
d
i
k
,
”
S
a
mari
n
d
a
,
2
0
2
4
.
[
5
]
S
.
Ti
n
t
i
e
t
a
l
.
,
“
P
r
e
v
a
l
e
n
c
e
a
n
d
b
u
r
d
e
n
o
f
n
a
u
se
a
a
n
d
v
o
mi
t
i
n
g
i
n
p
r
e
g
n
a
n
t
w
o
m
e
n
:
i
n
t
e
r
i
m
a
n
a
l
y
si
s
o
f
t
h
e
p
u
r
i
t
y
su
r
v
e
y
,
”
Eu
r
o
p
e
a
n
J
o
u
r
n
a
l
o
f
O
b
s
t
e
t
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