Hyperemesis Gravidarum – Diagnosis and Treatment
Pregnancy
Context
Nausea and vomiting during pregnancy affect ~85% of women. Hyperemesis gravidarum affects 0.3-3% of pregnant women and can have profound psychosocial consequences in addition to resulting in dehydration, malnutrition, and other medical complications.
Diagnostic Process
Hyperemesis gravidarum should be considered in women in the first trimester of pregnancy after ruling out secondary causes of nausea and vomiting and who present with one of the following:
- Weight loss of 5% or greater from pre-pregnancy weight.
- Dehydration – reduced urinary output, decreased skin turgor, dry mucous membranes, hypotension, tachycardia.
- Electrolyte imbalances.
Management
1Maximum dose of 30 mg in 24 hours or 0.5 mg/kg body weight in 24 hours (whichever is lowest) and for a maximum 5 days.
2Preferably after the first trimester of pregnancy.
3Solutions containing dextrose can precipitate Wernicke’s encephalopathy.
4To prevent Wernicke’s encephalopathy.
5Gradually taper dose until the lowest maintenance dose that controls the symptoms is reached. Corticosteroids are limited to women with refractory hyperemesis gravidarum and preferably after 10 weeks’ gestation.
Indications for Admission
- Ongoing nausea and vomiting, inability to tolerate PO fluids.
- Ongoing nausea and vomiting despite oral antiemetics and associated with ketonuria and/or weight loss greater than 5% of body weight.
- Comorbidities (suspected or confirmed) – e.g., UTI and inability to tolerate antibiotics orally.
Quality Of Evidence?
High
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
Moderate
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
Low
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Justification
Discontinue iron-containing prenatal vitamins during the first trimester and substitute them with folic acid or vitamins low in iron if patients are experiencing nausea and vomiting. (II-2A)
Ginger is recommended to manage symptoms of nausea and vomiting during pregnancy. (I-A)
Acupressure may have benefits in management of nausea and vomiting of pregnancy. (I-B)
Mindfulness-based cognitive therapy can be recommended as an adjunct to pyridoxine therapy for nausea and vomiting during pregnancy. (I-B)
Pyridoxine monotherapy or doxylamine/pyridoxine combination therapy have high efficacy and safety profile and should be first line management for nausea and vomiting of pregnancy. (I-A)
H1 receptor antagonists can be considered to manage acute or chronic episodes of nausea and vomiting of pregnancy. (I-A)
Metoclopramide is a safe adjunct for the management of nausea and vomiting of pregnancy. (II-2B)
Phenothiazines are safe and effective as an adjunct for severe nausea and vomiting of pregnancy. (I-A)
Ondansetron can be used as an adjunct for severe nausea and vomiting of pregnancy but is recommended once other antiemetics have failed due to potential safety concerns in pregnancy. (II-1C)
Avoid corticosteroids during the first trimester due to possible increased risk of oral cleft and use is recommended only in refractory cases. (I-B)
Encourage patients to eat food safe for pregnancy if it appeals to them and to alter their lifestyle if they are experiencing nausea and vomiting. (III-C)
Related Information
Reference List
Campbell K, Rowe H, Azzam H, Lane CA. The management of nausea and vomiting of pregnancy. JOGC. 2016;38(12):1127-1137.
McParlin C, O’Donnell A, Robson SC. Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy. JAMA. 2016;316(13):1392-1401. doi:10.1001/jama.2016.14337
Dean CR, Shemar M, Ostrowski GAU, Painter RC. Management of severe pregnancy sickness and hyperemesis gravidarum. BMJ. 2018;363:1-8.
RCOG Green-top Guideline No. 69. The management of nausea and vomiting of pregnancy and hyperemesis gravidarum. 2016;1:1-27.
Heaton HA. Ectopic Pregnancy and Emergencies in the First 20 Weeks of Pregnancy. In: Tintinalli JE, Ma OJ, Yealy DM, et al., eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill Education; 2020. Accessed January 9, 2022. accessmedicine.mhmedical.com/content.aspx?aid=1166535352
RESOURCE AUTHOR(S)
DISCLAIMER
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by Emergency Care BC (formerly the BC Emergency Medicine Network) and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. Emergency Care BC is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. Emergency Care BC also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 25, 2022
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