What is the management approach for hyperemesis?

Management Approach for Hyperemesis Gravidarum

The management of hyperemesis gravidarum requires a stepwise approach starting with dietary modifications and progressing to pharmacological interventions including vitamin B6, ginger, H1-receptor antagonists, and more aggressive therapies for refractory cases. 1

Definition and Assessment

• Hyperemesis gravidarum (HG) is an intractable form of nausea and vomiting in pregnancy characterized by dehydration, weight loss >5% of pre-pregnancy weight, and electrolyte imbalances, affecting 0.3-2% of pregnancies 1, 2
• HG typically starts before week 22 of gestation, with symptoms resolving by week 16 in >50% of patients and by week 20 in 80%, though 10% may experience symptoms throughout pregnancy 1
• Severity can be quantified using the Motherisk Pregnancy Unique Quantification of Emesis (PUQE) score 1

Initial Management: Non-Pharmacological Approaches

• Diet and lifestyle modifications are the first steps in managing symptoms 1
• Recommend small, frequent, bland meals such as the BRAT diet (bananas, rice, applesauce, and toast) 1
• High-protein, low-fat meals can be helpful 1
• Identify and avoid specific triggers such as foods with strong odors or certain activities 1

First-Line Pharmacological Management

• Ginger (250 mg capsule 4 times daily) and vitamin B6 (pyridoxine, 10-25 mg every 8 hours) as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1
• H1-receptor antagonists are considered safe first-line pharmacologic antiemetic therapies 1
  • Doxylamine is FDA-approved and recommended by ACOG for persistent nausea and vomiting of pregnancy 1
  • Doxylamine and pyridoxine are available in 10 mg/10 mg and 20 mg/20 mg combinations 1
  • Other options include promethazine and dimenhydrinate 1

Management of Moderate to Severe Cases

• Intravenous fluid resuscitation to correct dehydration and electrolyte imbalances 1, 2
• Thiamine supplementation to prevent Wernicke encephalopathy 2, 3
• Additional antiemetic options include:
  • Metoclopramide or other dopamine antagonists 1, 4
  • Ondansetron, though further studies are needed to determine safety and efficacy compared to first-line agents 3, 5
• Around-the-clock administration of antiemetics rather than PRN dosing is strongly recommended 1

Management of Refractory Cases

• For patients not responding to standard therapy, consider:
  • Corticosteroids 2, 5
  • Alternative pharmacotherapeutics such as mirtazapine, olanzapine, or gabapentin 4, 5
• Multiple concurrent agents, perhaps in alternating schedules or by alternating routes, may be necessary 1
• Enteral or parenteral nutrition support for cases with prolonged inability to maintain oral intake and ongoing weight loss 5

Pre-emptive Management for Subsequent Pregnancies

• Women with a history of severe NVP or HG in previous pregnancies should be counseled about pre-emptive therapy 6
• Starting antiemetics before or immediately at the onset of symptoms in subsequent pregnancies may prevent progression to severe NVP or HG 6

Monitoring and Follow-up

• Regular assessment of hydration status, electrolyte balance, and weight 1, 2
• Laboratory evaluation for nutritional or vitamin deficiencies 1
• Ultrasonography to detect multiple or molar pregnancies and assess fetal growth 1
• Evaluate for elevated liver enzymes, which can be seen in 40-50% of patients with HG 1

Common Pitfalls to Avoid

• Delaying treatment - early intervention may help prevent progression from mild nausea and vomiting to hyperemesis gravidarum 1
• Inadequate hydration and electrolyte replacement 1
• Failing to provide thiamine supplementation, which can lead to Wernicke encephalopathy 2, 3
• Using PRN dosing rather than scheduled antiemetic administration 1
• Not considering alternative therapies in refractory cases 4, 5