From the Guidelines
Hyperemesis gravidarum treatment should prioritize early intervention with vitamin B6 and doxylamine, followed by ondansetron, metoclopramide, or promethazine for moderate to severe cases, as recommended by the most recent guidelines 1. The primary goal of treatment is to manage severe nausea and vomiting, prevent dehydration and malnutrition, and support maternal and fetal health.
- Initial management includes:
- Small, frequent meals of bland foods
- Avoiding triggers
- Adequate hydration
- First-line medications:
- Vitamin B6 (10-25mg three times daily) combined with doxylamine (12.5mg three to four times daily)
- Can be given separately or as the combination drug Diclegis/Diclectin
- For more severe cases:
- Antiemetics like ondansetron (4-8mg every 8 hours), metoclopramide (10mg three times daily), or promethazine (12.5-25mg every 4-6 hours) may be used
- Hospitalization is necessary for severe dehydration, requiring IV fluids, electrolyte replacement, and possibly IV antiemetics
- Additional considerations:
- Thiamine supplementation (100mg daily) to prevent Wernicke's encephalopathy
- Corticosteroids like methylprednisolone may be considered in refractory cases
- Enteral or parenteral nutrition might be needed in extreme cases According to the European Association for the Study of the Liver Clinical Practice Guidelines, doxylamine and pyridoxine, and phenothiazines are recommended as first-line pharmacologic treatment of hyperemesis gravidarum, while metoclopramide and ondansetron are recommended as second-line therapies 1. The American College of Gastroenterology also recommends a step-up approach for patients who do not respond to first-line therapy, with metoclopramide and ondansetron being used for more severe cases 1. It is essential to weigh the benefits and risks of each medication, considering the potential for adverse effects, such as extrapyramidal symptoms and oculogyric crises with phenothiazines and metoclopramide, and the increased risk of orofacial clefting with ondansetron 1.
From the Research
Treatment Options for Hyperemesis Gravidarum
The treatment for hyperemesis gravidarum (HG) typically involves a combination of pharmacologic and non-pharmacologic interventions.
- Initial pharmacologic treatment for HG includes a combination of doxylamine and pyridoxine 2.
- Additional interventions include ondansetron or dopamine antagonists such as metoclopramide or promethazine 2.
- For women who are not adequately treated with these medications, mirtazapine may be a useful option, as it has been described in case studies to have antiemetic effects 2.
- Current best-practice management also includes symptomatic treatment with anti-emetic pharmacological treatment, rehydration if needed, and psychological support 3.
Antiemetic Treatment
- The use of meclizine, prochlorperazine, and ondansetron has increased over time, leading to a yearly increase in the percentage of women using any antiemetic 4.
- Metoclopramide was the most used antiemetic in pregnancy, but its use dropped by 30% after the European Medical Agency (EMA) warning in 2013 4.
- The EMA warning on metoclopramide temporarily limited pre-hospital antiemetic provision, associated with hospitalization at lower gestational length and indication of an increase in termination of pregnancy 4.
Systematic Reviews of Treatments
- A systematic review of 25 studies found that the certainty of evidence for different treatments is either low or very low, except for acupressure in addition to standard care, which showed a possible moderate decrease in nausea and vomiting 5.
- Another systematic review found evidence that ginger, antihistamines, metoclopramide, and vitamin B6 are better than placebo, and that Diclectin is more effective than placebo and ondansetron is more effective at reducing nausea than pyridoxine plus doxylamine 6.
- The review also found that promethazine is as, and ondansetron is more, effective than metoclopramide for severe NVP/HG, and that i.v. fluids help correct dehydration and improve symptoms 6.