Can Perinorm (Metoclopramide) be given during pregnancy?

Metoclopramide (Perinorm) Use in Pregnancy

Metoclopramide can be safely used during pregnancy as it has not been associated with increased risk of major congenital malformations, spontaneous abortions, or stillbirths. 1

Safety Profile in Pregnancy

Metoclopramide has a well-established safety profile for use during pregnancy:

• Large cohort studies show no significant association between metoclopramide exposure in the first trimester and major congenital malformations (25.3 cases per 1000 births in exposed vs. 26.6 per 1000 births in unexposed women) 1
• No increased risk of spontaneous abortion or stillbirth has been observed with metoclopramide use 1
• Twenty years of pharmacovigilance data confirm good maternal and fetal tolerance 2

Indications During Pregnancy

Metoclopramide is particularly useful for:

• Nausea and vomiting in pregnancy 3, 2
• Prevention of Mendelson's syndrome when general anesthesia is required during pregnancy or labor 2
• Management of diabetic gastroparesis 4
• Severe gastroesophageal reflux 4, 5

Dosing Considerations

• Standard dosing is 10-20 mg orally or intravenously every 6-8 hours 3
• Duration of therapy should be limited:
  • Oral preparations are recommended for 4-12 weeks maximum 5
  • Parenteral use should be limited to 1-2 days when possible 5

Potential Side Effects to Monitor

While generally safe in pregnancy, be aware of these potential side effects:

• Extrapyramidal symptoms (acute dystonic reactions, akathisia, tardive dyskinesia) - more common with high doses or prolonged use 3, 4
• Sedation, drowsiness, fatigue 4
• QT prolongation in patients with cardiac conditions 3

Treatment Algorithm

1. First-line options for nausea and vomiting in pregnancy:

   • Vitamin B6 (pyridoxine) supplementation
   • Doxylamine-pyridoxine combination
   • Phenothiazines 3

2. When to use metoclopramide:

   • As a second-line therapy when first-line treatments fail
   • For persistent symptoms, particularly after 10 weeks of pregnancy 3
   • For hyperemesis gravidarum not responding to first-line treatments

3. Monitoring during treatment:

   • Watch for extrapyramidal symptoms, especially with higher doses
   • Consider baseline ECG in patients with cardiac conditions 3
   • Limit duration of therapy to minimize risk of tardive dyskinesia

Clinical Perspective

Metoclopramide is often preferred over ondansetron in pregnancy because:

• Metoclopramide has a longer history of safety data in pregnancy 3
• Ondansetron has been associated with a small absolute increase in risk of congenital defects, including orofacial clefts and ventricular septal defects 3

Important Caveats

• Avoid prolonged use beyond 12 weeks to minimize risk of tardive dyskinesia 4, 5
• Use caution in patients with renal impairment as dose adjustment may be needed 4
• Metoclopramide is excreted in breast milk, but is considered compatible with breastfeeding 4
• The drug may antagonize the effects of dopamine agonists and interact with MAO inhibitors 4

In summary, metoclopramide is a safe option for treating nausea and vomiting during pregnancy when first-line treatments are insufficient, with robust safety data supporting its use throughout all trimesters.