From the Guidelines
Hyperemesis gravidarum treatment should begin with a stepwise approach, starting with non-pharmacological interventions before progressing to medications, with first-line pharmacological treatment including vitamin B6 (pyridoxine) and doxylamine, as recommended by the most recent guidelines 1. The goals of management of hyperemesis gravidarum are prevention of dehydration, correction of electrolyte abnormalities, and support of adequate maternal and fetal nutrition.
- Treatment is guided by the severity of symptoms and may require a multidisciplinary team approach involving obstetricians, nutritionists, psychologists, and gastroenterologists.
- Mental health care professionals can help manage 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, as it has been shown to be effective in reducing symptoms of hyperemesis gravidarum 1.
- 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.
- For patients who do not respond to first-line therapy, metoclopramide can be given, as it has been shown to have similar efficacy to promethazine in patients hospitalized for hyperemesis gravidarum, with fewer adverse events 1.
- Ondansetron can be given primarily in severe cases that require hospitalization, but its use should be carefully considered due to the potential risk of congenital heart defects when given in the first trimester 1.
- Methylprednisolone can be given as a last resort in patients with severe hyperemesis gravidarum, with a recommended dosage of 16 mg intravenous every 8 hours for up to 3 days, followed by tapering over 2 weeks to the lowest effective dosage and limiting the maximum duration to 6 weeks 1.
From the Research
Hyperemesis Gravidarum Treatment Options
- Initial pharmacologic treatment for hyperemesis gravidarum includes a combination of doxylamine and pyridoxine 2
- Additional interventions include ondansetron or dopamine antagonists such as metoclopramide or promethazine 2
- Mirtazapine is a useful drug for women who are not adequately treated with these medications, acting on noradrenergic, serotonergic, histaminergic, and muscarinic receptors to produce antidepressant, anxiolytic, antiemetic, sedative, and appetite-stimulating effects 2
- Alterations to maternal diet and lifestyle can have protective effects, and medicinal methods of prevention and treatment include nutritional supplements and alternative methods, such as hypnosis and acupuncture, as well as pharmacotherapy 3
Treatment Efficacy and Safety
- The certainty of evidence for different treatments is either low or very low, with few studies of high quality 4
- Acupressure in addition to standard care shows a possible moderate decrease in nausea and vomiting, with low certainty of evidence 4
- Ginger, vitamin B6, antihistamines, metoclopramide, pyridoxine-doxylamine, and ondansetron are associated with improved symptoms compared with placebo 5
- Corticosteroids may be associated with benefit in severe cases, with significant differences reported in emesis reduction compared with metoclopramide 5
Pharmacologic Treatments
- Doxylamine succinate 10 mg/pyridoxine hydrochloride 10 mg (Diclegis) is approved by the U.S. Food and Drug Administration to specifically treat nausea and vomiting of pregnancy 6
- Pyridoxine-doxylamine combination taken preemptively reduces the risk of recurrence of moderate-severe symptoms compared with treatment once symptoms begin 5
- Ondansetron is associated with lower nausea scores and better trend in vomiting scores compared with metoclopramide 5