What is the management for vomiting in pregnancy?

Management of Vomiting in Pregnancy

The management of vomiting in pregnancy should follow a stepwise approach beginning with diet and lifestyle modifications, followed by vitamin B6 and doxylamine, and escalating to other antiemetics for more severe cases. 1

Understanding Nausea and Vomiting in Pregnancy (NVP)

• Affects 30-90% of pregnant women
• Typically begins at 4-6 weeks, peaks at 8-12 weeks, and subsides by week 20
• Caused by elevated levels of human chorionic gonadotropin, estrogen, and changes in GI motility
• Severity can be assessed using the Motherisk Pregnancy Unique Quantification of Emesis (PUQE) score:
  • Mild: ≤6 points
  • Moderate: 7-12 points
  • Severe: ≥13 points (maximum 15 points)

Treatment Algorithm

Step 1: Diet and Lifestyle Modifications

• Eat small, frequent, bland meals
• Try BRAT diet (bananas, rice, applesauce, toast)
• Focus on high-protein, low-fat meals
• Identify and avoid specific food triggers and strong odors
• Reduce spicy, fatty, acidic, and fried foods

Step 2: Non-Pharmacological Interventions

• Ginger 250 mg capsules four times daily 1

Step 3: First-Line Pharmacological Treatment

• Vitamin B6 (pyridoxine) 10-25 mg every 8 hours 1
• Add doxylamine (available in combination with pyridoxine in 10mg/10mg or 20mg/20mg formulations) 1
  • FDA-approved and recommended by ACOG for persistent NVP

Step 4: Second-Line Pharmacological Treatment

• H1-receptor antagonists: promethazine or dimenhydrinate 1
• Metoclopramide 1
• Ondansetron 1

Step 5: For Severe Cases/Hyperemesis Gravidarum

• Intravenous hydration and correction of electrolyte abnormalities
• Thiamine supplementation (100 mg daily for minimum 7 days, then 50 mg daily) to prevent Wernicke's encephalopathy 1
• Consider intravenous glucocorticoids for refractory cases 1

Hyperemesis Gravidarum (HG)

HG is a severe form of NVP affecting 0.3-2% of pregnancies, characterized by:

• Intractable vomiting
• Dehydration
• Weight loss >5% of pre-pregnancy weight
• Electrolyte imbalances

Management of HG:

1. Comprehensive evaluation for dehydration, nutritional deficiencies, and electrolyte imbalances
2. Intravenous fluid replacement
3. Thiamine supplementation
4. Aggressive antiemetic therapy
5. Consider multidisciplinary approach involving obstetricians, nutritionists, psychologists, and gastroenterologists 1

Important Considerations

• Early intervention is crucial to prevent progression to hyperemesis gravidarum 1
• Liver enzyme elevations can occur in 40-50% of HG patients but typically improve with hydration 1
• Persistent liver chemistry abnormalities despite symptom resolution should prompt investigation for other causes 1
• Ultrasound may be needed to rule out multiple pregnancies, molar pregnancy, or other conditions 1
• Mental health support may be beneficial as HG can cause significant psychological distress 1

Pitfalls to Avoid

1. Dismissing symptoms as normal: NVP is often undertreated, which can lead to progression to more severe forms and hospitalization
2. Delaying treatment: Early intervention may prevent progression to hyperemesis gravidarum
3. Overlooking thiamine supplementation: Essential to prevent Wernicke's encephalopathy, especially in severe cases
4. Failing to assess severity: Use the PUQE score to objectively evaluate symptom severity and guide treatment
5. Not considering differential diagnoses: Other causes of nausea and vomiting should be ruled out, particularly if symptoms are unremitting or presentation is atypical

By following this stepwise approach, most cases of NVP can be effectively managed, improving maternal quality of life and preventing adverse outcomes for both mother and fetus.