From the Guidelines
Corticosteroids can be considered as a third-line treatment for hyperemesis gravidarum that is refractory to first-line and second-line treatments. The most recent and highest quality study, published in the Journal of Hepatology in 2023 1, suggests that corticosteroids are compatible with use in pregnancy, including in the first trimester. According to this study, a typical dosing regimen for corticosteroids in the management of hyperemesis gravidarum includes intravenous hydrocortisone 100 mg twice daily, followed by conversion to oral prednisolone 40-50 mg daily, with the dose gradually tapered until the lowest maintenance dose that controls the symptoms is reached.
Key points to consider when using corticosteroids for hyperemesis gravidarum include:
- Corticosteroids should only be considered after other treatments have failed, including antiemetics, IV hydration, and vitamin supplementation
- Treatment should be initiated in a hospital setting where the patient can be monitored for response and potential side effects
- The mechanism of action likely involves reducing inflammation and modulating the immune response that may contribute to severe nausea and vomiting
- Steroids should be used cautiously during pregnancy, particularly in the first trimester, due to a small increased risk of cleft palate with first-trimester exposure
Other studies, such as those published in Gastroenterology in 2024 1 and 1, also support the use of corticosteroids as a third-line treatment for hyperemesis gravidarum, but the study published in the Journal of Hepatology in 2023 1 provides the most recent and highest quality evidence on this topic.
The use of corticosteroids in the management of hyperemesis gravidarum is also supported by best practice advice, which suggests that early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum, and that stepwise treatment consists of symptom control with vitamin B6 and doxylamine, hydration, and adequate nutrition, with ondansetron, metoclopramide, promethazine, and intravenous glucocorticoids may be required in moderate to severe cases 1.
From the Research
Role of Corticosteroids in Hyperemesis Gravidarum
- Corticosteroids may be associated with benefit in severe cases of hyperemesis gravidarum 2
- A study found that improvements were seen in all corticosteroid groups, with a significant difference between corticosteroids and metoclopramide in reducing emesis 2
- Methylprednisolone was associated with better control of hyperemesis gravidarum symptoms than standard of care in a network meta-analysis of randomized clinical trials 3
- Prednisolone is listed as a treatment option for hyperemesis gravidarum, with a category A rating, indicating that it is considered safe for use during pregnancy 4
Comparison with Other Treatments
- Corticosteroids were compared with other treatments, including metoclopramide, promethazine, and ondansetron, with varying results 2, 3
- Acupuncture and acupressure were also found to be associated with better therapeutic benefits than other interventions for treating hyperemesis gravidarum 3
- The quality of evidence for the use of corticosteroids in hyperemesis gravidarum is generally considered low 2, 3
Clinical Use
- Corticosteroids, such as methylprednisolone and prednisolone, may be considered as a treatment option for severe hyperemesis gravidarum 2, 4, 3
- However, the use of corticosteroids should be carefully considered and monitored due to potential side effects and the limited quality of evidence supporting their use 2, 3