From the Guidelines
Hyperemesis in pregnancy, characterized by excessive vomiting, is typically not associated with major adverse maternal or fetal outcomes, but may lead to low birth weight and premature delivery, and its significance lies in the need for supportive treatment with rehydration, correction of electrolyte abnormalities, thiamine supplementation, and anti-emetic therapy. The condition usually occurs in the first trimester and is marked by persistent vomiting, weight loss, dehydration, and ketonuria 1. According to the American Association for the Study of Liver Diseases, liver chemistry abnormalities typically resolve with hydration and resolution of vomiting, but persistent abnormalities should prompt investigation for another etiology 1.
Key Considerations
- Hyperemesis gravidarum occurs in 0.35% to 2.0% of pregnancies and is characterized by persistent vomiting with weight loss, dehydration, and ketonuria 1.
- The severity of vomiting during pregnancy can be quantified with a scoring system, such as the Motherisk Pregnancy Unique Quantification of Emesis score 1.
- Treatment includes rehydration, correction of electrolyte abnormalities, nutrition, thiamine supplementation, and anti-emetic therapy, with options like ondansetron, metoclopramide, and promethazine 1.
- Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum, and stepwise treatment consists of symptom control with vitamin B6 and doxylamine, hydration, and adequate nutrition 1.
Management and Prevention
- Diet and lifestyle modification are the initial steps in managing symptoms, including reducing spicy, fatty, acidic, and fried foods, and eating small, frequent, and bland meals 1.
- Specific triggers, such as certain foods with strong odors or activities, should be identified and avoided 1.
- If symptoms are persistent or severe, therapeutic options include ginger, vitamin B6, and H1-receptor antagonists like doxylamine and promethazine 1.
From the Research
Significance of Hyperemesis in Pregnancy
- Hyperemesis gravidarum (HG) is a severe and prolonged form of nausea and/or vomiting during pregnancy, affecting 0.3-2% of pregnancies 2.
- HG is defined by dehydration, ketonuria, and more than 5% body weight loss, and can have a significant impact on the quality of life of pregnant women 2, 3.
- If left untreated, hyperemesis can lead to potentially fatal maternal and fetal complications, making early treatment crucial 4, 3.
Treatment Options for Hyperemesis
- Initial pharmacologic treatment for HG includes a combination of doxylamine and pyridoxine, with additional interventions including ondansetron or dopamine antagonists such as metoclopramide or promethazine 2.
- Ondansetron has been shown to be effective in treating severe nausea and vomiting of pregnancy, with some studies suggesting it may be more effective than metoclopramide 5, 6.
- Subcutaneous medications, such as metoclopramide and ondansetron, have also been used to treat severe NVP, with significant improvement in symptoms and reduced need for hospitalization 6.
Impact of Hyperemesis on Pregnancy Outcomes
- Hyperemesis can lead to poor quality of life and increased risk of potentially fatal maternal and fetal complications, highlighting the importance of early treatment 3.
- The use of antiemetics, such as ondansetron and metoclopramide, has been shown to improve outcomes for women with hyperemesis, with reduced symptoms and improved quality of life 4, 5, 6.
- However, changes in treatment guidelines, such as the European Medical Agency's warning on metoclopramide, can impact treatment outcomes and may lead to increased rates of termination of pregnancy 3.