What is the management of hyperemesis gravidarum?

From the Guidelines

The management of hyperemesis gravidarum involves a stepwise approach starting with intravenous fluid rehydration and antiemetic medications, with first-line treatment including vitamin B6 (pyridoxine) 10-25 mg three to four times daily, often combined with doxylamine 12.5 mg three to four times daily, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1.

Key Considerations

• Initial treatment includes IV fluids with dextrose and electrolyte replacement, along with thiamine supplementation (100 mg daily) to prevent Wernicke's encephalopathy.
• If symptoms persist, second-line medications include promethazine 12.5-25 mg every 4-6 hours, metoclopramide 10 mg three times daily, or ondansetron 4-8 mg every 8 hours.
• For refractory cases, methylprednisolone 16 mg three times daily for three days with tapering over two weeks may be considered.
• Nutritional support is crucial, starting with small, frequent meals of bland foods and cold liquids.
• Severe cases may require enteral feeding via nasogastric or nasoduodenal tubes, or parenteral nutrition.
• Psychological support is important as the condition significantly impacts quality of life.

Treatment Approach

The treatment approach for hyperemesis gravidarum is guided by the severity of symptoms and may require a multidisciplinary team approach involving obstetricians, nutritionists, psychologists, and gastroenterologists 1.

• The goals of management are prevention of dehydration, correction of electrolyte abnormalities, and support of adequate maternal and fetal nutrition.
• Mental health care professionals can help manage anxiety, depression, and other emotional challenges associated with hyperemesis gravidarum.
• Supplementation with vitamin B6 (pyridoxine) may be suggested as a first-line treatment for mild cases, while vitamin B1 (thiamine) is given to prevent refeeding syndrome and Wernicke encephalopathy 1.

Medications

• Doxylamine and pyridoxine are available in 10 mg/10 mg and 20 mg/20 mg combinations and are safe and well tolerated 1.
• Metoclopramide can be given for nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum, with no increased risk of congenital defects reported 1.
• Ondansetron is given primarily in severe NVP that requires hospitalization, with some studies reporting cases of congenital heart defects when given in the first trimester, thus it should only be administered as a second-line therapy 1.

From the Research

Management of Hyperemesis Gravidarum

The management of hyperemesis gravidarum involves a combination of supportive care, pharmacological interventions, and nutritional support.

• The primary goals of management are to correct dehydration and electrolyte disturbances, control nausea and vomiting, and prevent complications such as Wernicke's encephalopathy and thromboembolism 2, 3, 4.
• Intravenous rehydration therapy is often used to manage severe dehydration and electrolyte imbalances 2, 5.
• Antiemetic medications such as pyridoxine, metoclopramide, prochlorperazine, prednisolone, promethazine, and ondansetron are commonly used to control nausea and vomiting 2, 6, 3.
• Alternative pharmacotherapeutics such as mirtazapine, olanzapine, corticosteroids, and gabapentin may be considered in refractory cases 5.
• Nutritional support, including enteral and parenteral nutrition, may be necessary in cases where oral intake is not tolerated for prolonged periods 5.
• Thiamine replacement is indicated to prevent Wernicke's encephalopathy 4.
• Good psychological support is also essential in managing hyperemesis gravidarum, as it can have a significant impact on a woman's quality of life 2, 4.

Treatment Modalities

Treatment modalities for hyperemesis gravidarum may include:

• Rehydration (intravenous or oral) 2, 5
• Antiemetic therapy (e.g. pyridoxine, metoclopramide, prochlorperazine, prednisolone, promethazine, ondansetron) 2, 6, 3
• Alternative pharmacotherapeutics (e.g. mirtazapine, olanzapine, corticosteroids, gabapentin) 5
• Nutritional support (e.g. enteral and parenteral nutrition) 5
• Thiamine replacement 4
• Psychological support 2, 4

Prevention of Complications

Prevention of complications such as Wernicke's encephalopathy, osmotic demyelination syndrome, and thromboembolism is crucial in managing hyperemesis gravidarum 3, 4.

• Thiamine replacement is indicated to prevent Wernicke's encephalopathy 4.
• Correction of dehydration and electrolyte disturbances can help prevent osmotic demyelination syndrome 3.
• Good psychological support can help prevent thromboembolism 2, 4.