What is the initial management for Hyperemesis gravidarum?

From the Guidelines

The initial management for hyperemesis gravidarum involves a stepwise approach starting with intravenous fluid rehydration to correct electrolyte imbalances and dehydration, as recommended by the most recent guidelines 1.

Initial Management

The goal is to control symptoms while ensuring adequate hydration and nutrition for both mother and fetus.

• First-line antiemetic therapy typically includes pyridoxine (vitamin B6) 10-25 mg orally three to four times daily, often combined with doxylamine 12.5 mg orally three to four times daily, as suggested by the American College of Obstetricians and Gynecologists (ACOG) 1.
• If symptoms persist, second-line medications include promethazine 12.5-25 mg orally, rectally, or IV every 4-6 hours; metoclopramide 10 mg orally or IV every 6-8 hours; or ondansetron 4-8 mg orally or IV every 8 hours, as recommended by the European Association for the Study of the Liver Clinical Practice Guidelines 1.

Thiamine Supplementation and Nutrition

• Thiamine supplementation (100 mg IV daily for 3 days, then 50 mg orally daily) is crucial to prevent Wernicke's encephalopathy, especially before administering glucose-containing fluids, as emphasized by the American Association for the Study of Liver Diseases 1.
• Nutritional support may be necessary, starting with small, frequent meals of bland foods and progressing to enteral or parenteral nutrition if oral intake remains inadequate.

Hospitalization

Hospitalization is often required for women with severe dehydration, electrolyte abnormalities, weight loss exceeding 5% of pre-pregnancy weight, or those who fail outpatient management, as indicated by the guidelines 1. The most recent and highest quality study, published in 2024, provides the basis for these recommendations 1, prioritizing morbidity, mortality, and quality of life as the primary outcomes.

From the Research

Initial Management for Hyperemesis Gravidarum

The initial management for Hyperemesis Gravidarum (HG) involves a combination of pharmacologic and non-pharmacologic interventions.

• The 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.
• Assessment requires an objective evaluation using a validated scoring system such as the PUQE-24 score, as well as calculation of hydration and nutritional status 3.
• Treatment may require a combination of intravenous fluids, anti-emetics, acid suppression, and laxatives 3.

Nutritional Management

• HG can cause malnutrition, dehydration, electrolyte imbalance, and unintended weight loss, requiring hospital admission in most cases 4.
• Effective treatment requires a combination of medical interventions, lifestyle changes, dietary changes, supportive care, and patient education 4.
• Enteral tube feeding and parenteral nutrition are generally reserved for the most intractable cases, where other treatment modalities have failed 4.

Other Considerations

• There is limited evidence-based research on the effectiveness of dietary approaches for HG 4.
• Wernicke encephalopathy is a rare but very serious and avoidable consequence of unmanaged HG 4, 5.
• Studies on treatments for hyperemesis gravidarum are few, and the certainty of evidence for different treatments is either low or very low 6.