From the Guidelines
For severe hyperemesis gravidarum that doesn't respond to ondansetron (Zofran) and IV hydration, a step-up approach is recommended, starting with metoclopramide 10mg IV/PO every 6-8 hours, as it has been shown to have similar efficacy to promethazine with fewer adverse events 1. When considering treatment options, it's essential to prioritize the prevention of dehydration, correction of electrolyte abnormalities, and support of adequate maternal and fetal nutrition.
- The goals of management are focused on preventing malnutrition, neurologic complications, and supporting fetal growth.
- Laboratory evaluation should focus on the extent of dehydration, nutritional or vitamin deficiencies, and electrolyte imbalances, as elevated levels of liver enzymes can be seen in 40%–50% of patients with hyperemesis gravidarum 1.
- Treatment may require a multidisciplinary team approach involving obstetricians, nutritionists, psychologists, and gastroenterologists to address 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, with a recommended dosage of 100 mg daily for a minimum of 7 days, followed by a maintenance dosage of 50 mg daily until adequate oral intake is established 1.
- If metoclopramide is not effective, methylprednisolone 16mg IV every 8 hours for up to 3 days, followed by tapering over 2 weeks to the lowest effective dosage, may be considered as a last resort, although its administration in the first trimester has been reported to slightly increase the risk of cleft palate when given before 10 weeks of gestation 1.
- In refractory cases, consider temporary enteral nutrition via nasogastric or nasoduodenal tube, or in extreme cases, total parenteral nutrition, and address potential triggers like acid reflux with proton pump inhibitors, such as omeprazole 20mg daily.
- Regular monitoring of electrolytes, ketones, and weight is essential throughout treatment to prevent complications and ensure the best possible outcomes for both mother and fetus.
From the Research
Treatment Options for Hyperemesis Gravidarum Refractory to Ondansetron and IV Hydration
- For women with hyperemesis gravidarum who do not respond to ondansetron and IV hydration, other treatment options can be considered, including:
- Mirtazapine, which has been described in case studies as a useful drug in this context 2
- Corticosteroids, although a randomized, double-blind, placebo-controlled trial found that the addition of parenteral and oral corticosteroids did not reduce the need for rehospitalization later in pregnancy 3
- Pyridoxine and metoclopramide as first-line treatments, followed by prochlorperazine, prednisolone, promethazine, and ondansetron 4
- Ginger, which has been reported to have benefits in some women 4
- Hypnotherapy, which has been successfully used in some cases to resolve the problem of hyperemesis 5
- In severe cases, nasogastric or parenteral nutrition may be necessary 6
- Psychological support is often necessary, as hyperemesis gravidarum can have a significant impact on a woman's quality of life and mental health 6, 4