From the Guidelines
Hyperemesis gravidarum during the second trimester requires prompt medical attention and a multi-faceted treatment approach, with first-line treatment including oral antiemetics such as doxylamine (10-25mg) combined with pyridoxine (vitamin B6, 10-25mg) taken three to four times daily, as recommended by recent guidelines 1.
Treatment Approach
The treatment of hyperemesis gravidarum involves a stepwise approach, starting with diet and lifestyle modifications, followed by symptom control with vitamin B6 and doxylamine, hydration, and adequate nutrition 1.
- Oral antiemetics such as doxylamine (10-25mg) combined with pyridoxine (vitamin B6, 10-25mg) taken three to four times daily
- If symptoms persist, consider adding dimenhydrinate (50-100mg every 4-6 hours), promethazine (12.5-25mg every 4-6 hours), or metoclopramide (10mg three times daily)
- For severe cases unresponsive to these medications, ondansetron (4-8mg every 8 hours) may be used, though with caution due to potential risks, as noted in recent studies 1
Nutritional Support and Hydration
Intravenous fluid replacement with electrolytes is crucial if dehydration occurs, and nutritional support should include small, frequent meals of bland foods, avoiding triggers, and possibly temporary parenteral nutrition in extreme cases 1.
- Thiamine supplementation (100mg daily) is important to prevent Wernicke's encephalopathy
- Hyperemesis typically improves by mid-pregnancy but can persist throughout pregnancy in some women
Cause and Prevention
The condition results from elevated pregnancy hormones (particularly hCG and estrogen), genetic factors, and possibly Helicobacter pylori infection, as discussed in recent reviews 1.
- Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum, as suggested by recent guidelines 1
- Untreated severe hyperemesis can lead to weight loss, electrolyte imbalances, and nutritional deficiencies affecting both mother and fetus, making proper management essential, as emphasized in recent studies 1
From the Research
Hyperemesis during Second Trimester
- Hyperemesis gravidarum (HG) is a severe and prolonged form of nausea and/or vomiting during pregnancy, affecting 0.3-2% of pregnancies 2.
- HG can persist throughout pregnancy, causing malnutrition, dehydration, electrolyte imbalance, and unintended weight loss, requiring hospital admission in most cases 3.
- The condition can have significant adverse physical and psychological sequelae, and can negatively impact fetal growth and have adverse consequences on the health of the offspring 3, 4.
Treatment Options
- Initial pharmacologic treatment for HG includes a combination of doxylamine and pyridoxine 2.
- Additional interventions include ondansetron or dopamine antagonists such as metoclopramide or promethazine 2, 5, 4.
- Enteral tube feeding and parenteral nutrition are generally reserved for the most intractable cases, where other treatment modalities have failed 3, 5.
- Corticosteroids may be associated with benefit in severe cases 4.
Management
- Assessment requires an objective evaluation using a validated scoring system, as well as calculation of hydration and nutritional status 6.
- Treatment may require a combination of intravenous fluids, anti-emetics, acid suppression, and laxatives 6.
- Outpatient management is optimal, but admission may be required for refractory symptoms, organ dysfunction, or concurrent significant co-morbidities 6.