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Nausea/Vomiting of Pregnancy
Quick Facts
PB153
Hyperemesis gravidarum = extreme
nausea/vomiting (0.3-3% of pregnancies), clinical diagnosis of exclusion
based on typical presentation in the absence of other diseases
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Typical
presentation is persistent nausea/vomiting, acute starvation (as
evidence by ketonuria), weight loss (at least 5% of pre-pregnancy
weight)
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Electrolyte,
liver and thyroid abnormalities may be present (do not check TSH
unless goiter, do not treat TSH suppression unless T3/T4 abnormal)
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Abdominal pain,
fever, headache, abnormal neuro exam, goiter are NOT present
Risk Factors for Nausea/Vomiting
of Pregnancy: high hCG (molar pregnancy, multiple gestation), high
estrogen (female fetus), family & personal history (hormone-receptor
abnormalities and mitochondrial disorders), h/o motion sickness or
migraines
*smoking lowers hCG and estrogen
levels, so nausea/vomiting less common in these women
Effects of Nausea/Vomiting of
Pregnancy
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Maternal:
increased hospital admissions, psychosocial stress, Wernicke
encephalopathy (B1 deficiency), splenic avulsion, esophageal
tears/rupture, pneumothorax, acute tubular necrosis
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Fetal: lower SAB
rate, higher LBW/SGA rate only if true hyperemesis
Treatment of Nausea/Vomiting of
Pregnancy
1.
Non-pharmacologic:
a.
Take daily PNV at
least 3 months prior to conception
b.
Avoid stimuli
including odors, heat, humidity, noise, flickering lights
c.
Eat small, frequent
meals (avoid spicy/fatty foods, protein is better than carbs, eat
something bland in the morning before getting out of bed)
d.
Consider
ginger…efficacy of acupuncture etc. is uncertain
2.
Pharmacologic: early
treatment can prevent progression to more severe symptoms
a.
VitB6 alone or VitB6
+ Doxylamine (an antihistamine, H1-receptor blocker) = FIRST LINE
b.
Phenothiazines
(Promethazine = Phenergan, Prochlorperazine = Compazine)
c.
Benzamides
(Metoclopramide = Reglan)
d.
5HT3
Inhibitors (Ondansetron = Zofran) – evidence is limited re: safety and
efficacy, ?association between 1st
trimester use and cleft palate & cardiac septum defects
e.
Methylprednisolone – known association between 1st
trimester use and clefts, so avoid prior to 10 weeks gestation (most
common regimen in 48 mg daily x3d and, if effective, taper down over 2
weeks…maximum tx duration of 6 weeks)
3.
Hydration: IV fluids
(give thiamine prior to Dextrose to avoid Wernicke’s encephalopathy)
4.
Nutrition: Tube
feeding is “first-line treatment to provide nutritional support to the
woman with hyperemesis gravidarum who is not responsive to medical
therapy and cannot maintain her weight”. TPN via PICC is generally
avoided due to risk of sepsis and VTE.
Indications for Hospitalization:
inability to tolerate PO fluids/dehydration, VS changes, mental status
changes, continued weight loss and/or symptoms refractory to outpatient
management
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