How to manage gastroenteritis in a 36-week pregnant woman with lower abdominal pain, vomiting, and diarrhea?

From the Guidelines

Managing gastroenteritis in a 36-week pregnant woman requires careful attention to hydration, symptom management, and monitoring for pregnancy complications, with the primary goal of preventing dehydration and managing symptoms to reduce the risk of preterm labor and other complications. The first priority is to prevent dehydration through frequent small sips of oral rehydration solutions like Pedialyte or a homemade solution of 1 liter water with 6 teaspoons sugar and 1/2 teaspoon salt, as recommended by recent guidelines 1. If unable to tolerate oral fluids or showing signs of severe dehydration (decreased urination, dizziness, dry mouth), immediate medical attention is needed for IV fluids. For nausea and vomiting, metoclopramide 10mg orally every 6-8 hours or ondansetron 4-8mg orally every 8 hours can be used under medical supervision, as suggested by the American College of Obstetricians and Gynecologists (ACOG) and supported by recent studies 1. Acetaminophen 650mg every 6 hours can help manage fever and pain. It is essential to avoid NSAIDs, loperamide, and antibiotics unless specifically prescribed, as they may pose risks to the fetus or exacerbate symptoms.

Some key considerations in managing gastroenteritis in pregnancy include:

• Monitoring for warning signs that could indicate pregnancy complications rather than simple gastroenteritis, including regular contractions, decreased fetal movement, vaginal bleeding, or severe abdominal pain, as highlighted in recent clinical practice updates 1.
• The importance of early treatment of nausea and vomiting of pregnancy to reduce progression to hyperemesis gravidarum, as emphasized in recent guidelines 1.
• The use of vitamin B6 (pyridoxine) and doxylamine as first-line treatments for mild cases of nausea and vomiting, with metoclopramide and ondansetron reserved for more severe cases or when first-line treatments are ineffective, as recommended by ACOG and supported by recent studies 1.
• The need for a multidisciplinary team approach involving obstetricians, nutritionists, psychologists, and gastroenterologists to manage severe cases of hyperemesis gravidarum, as suggested by recent clinical practice guidelines 1.

Gastroenteritis typically resolves within 24-72 hours, but at 36 weeks gestation, close monitoring by healthcare providers is essential as dehydration can trigger contractions and potentially lead to preterm labor, emphasizing the need for careful management and prompt medical attention if complications arise, as supported by recent studies 1.

From the FDA Drug Label

The adverse events reported during clinical investigations of loperamide hydrochloride are difficult to distinguish from symptoms associated with the diarrheal syndrome.

The adverse events with an incidence of 1.0% or greater, which were reported at least as often in patients on loperamide hydrochloride as on placebo, are presented in the table below.

Gastrointestinal AE% Constipation 2.6% 0.8%

The adverse events with an incidence of 1.0% or greater, which were more frequently reported in patients on placebo than on loperamide hydrochloride, were: dry mouth, flatulence, abdominal cramp and colic.

The FDA drug label does not answer the question.

From the Research

Management of Gastroenteritis in a 36-Week Pregnant Woman

• The management of gastroenteritis in a 36-week pregnant woman with lower abdominal pain, vomiting, and diarrhea requires careful consideration of the treatment options.
• According to the available studies, ondansetron has been shown to be effective in managing vomiting in patients with acute gastroenteritis 2, 3, 4, 5, 6.
• A study comparing the effects of metoclopramide and ondansetron on emergency service observation times in acute gastroenteritis-related nausea and vomiting cases found that ondansetron had a shorter observation time and less recurrent admission to the emergency department 3.
• Another study comparing the efficacy of oral ondansetron, metoclopramide, and domperidone for managing vomiting in children with acute gastroenteritis found that ondansetron demonstrated superior efficacy in managing AGE-related vomiting in children within 24 hours compared to metoclopramide and domperidone 4.
• A network meta-analysis comparing the efficacy of ondansetron, domperidone, and metoclopramide in treating vomiting in pediatric patients with acute gastroenteritis found that ondansetron was significantly more effective than placebo in achieving cessation of vomiting 6.

Treatment Options

• Ondansetron is a viable treatment option for managing vomiting in patients with acute gastroenteritis, including pregnant women 2, 3, 4, 5, 6.
• Metoclopramide may also be considered, but it has been associated with adverse effects such as weakness and akathisia 3.
• Domperidone is another option, but its efficacy is not as well established as ondansetron 4, 6.

Considerations for Pregnant Women

• When managing gastroenteritis in a 36-week pregnant woman, it is essential to consider the potential risks and benefits of each treatment option.
• Ondansetron has been shown to be safe and effective in pregnant women, but its use should be monitored closely 2, 3, 4, 5, 6.
• Metoclopramide and domperidone may also be used in pregnant women, but their safety and efficacy profiles are not as well established as ondansetron 3, 4.