From the Guidelines
Hyperemesis gravidarum is treated with a stepwise approach beginning with oral rehydration, antiemetics, and lifestyle modifications, with first-line medications including vitamin B6 and doxylamine, as recommended by the most recent guidelines 1. The treatment approach for hyperemesis gravidarum involves a combination of non-pharmacological and pharmacological interventions.
- Non-pharmacological interventions include:
- Oral rehydration
- Lifestyle modifications, such as small, frequent meals and avoiding triggering foods and smells
- Ginger supplements (250mg four times daily)
- Acupressure or acupuncture
- Pharmacological interventions include:
- First-line medications: vitamin B6 (10-25mg three times daily) combined with doxylamine (10-12.5mg three times daily), or as the combination product Diclegis/Diclectin
- Second-line treatments: phenothiazines like promethazine (12.5-25mg every 4-6 hours) or prochlorperazine (5-10mg every 6-8 hours), and metoclopramide (10mg three times daily)
- For severe cases requiring hospitalization: IV fluids to correct dehydration and electrolyte imbalances, along with IV antiemetics such as ondansetron (4-8mg every 8 hours)
- Thiamine supplementation (100mg daily) to prevent Wernicke's encephalopathy
- Corticosteroids like methylprednisolone (16mg three times daily, tapered over 2 weeks) for refractory cases, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1. The goals of management of hyperemesis gravidarum are to prevent dehydration, correct electrolyte abnormalities, and support adequate maternal and fetal nutrition, as outlined in the European Association for the Study of the Liver Clinical Practice Guidelines on the management of liver diseases in pregnancy 1. Prompt treatment is essential as hyperemesis can lead to significant weight loss, dehydration, electrolyte abnormalities, and nutritional deficiencies that may affect both mother and fetus. It is also important to note that the use of ondansetron in pregnancy has been associated with an increased rate of orofacial clefting, although the absolute risk is still relatively low 1. Therefore, the treatment of hyperemesis gravidarum should be individualized and guided by the severity of symptoms, with careful consideration of the potential risks and benefits of each treatment option 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.
- Other treatments that have shown promise in reducing symptoms of HG include ginger, vitamin B6, antihistamines, and corticosteroids 3, 4.
Non-Pharmacologic Interventions
Non-pharmacologic interventions can also play a crucial role in managing HG symptoms.
- Acupressure has been shown to have a possible moderate decrease in nausea and vomiting, with low certainty of evidence 5.
- Enteral feeding may be effective for very severe symptoms, although it is an extreme method of treatment 3.
- Day case management for moderate to severe symptoms is feasible, acceptable, and as effective as inpatient care 3.
Economic Considerations
The economic analysis of treatments for HG is limited by the lack of effectiveness data, but comparison of costs between treatments highlights the implications of different choices 3.
- The cost-effectiveness of treatments for HG should be considered when making decisions about patient care.
Limitations of Current Evidence
The current evidence for treatments of HG is limited by the quantity and quality of the data available 5, 3, 4.
- Further research is needed to establish more robust evidence for the treatment of HG, including the use of validated scoring systems and clear descriptions and measurements of core outcomes 5.