Hyperemesis Gravidarum Treatment & Management

  • Author: Dotun A Ogunyemi, MD; Chief Editor: David Chelmow, MD   more...
 
Updated: Aug 16, 2011
 

Medical Care

Initial management should be conservative and may include reassurance, dietary recommendations, and support. Alternative therapies may include acupressure and hypnosis.[36]

  • Studies have not shown a clear benefit of acupressure in patients with hyperemesis gravidarum. However, a randomized study by Rosen et al using pressure or electrical stimulation at the P6 (or Neguian) point on the inside of the wrist showed some efficacy in reducing nausea and vomiting and promoting weight gain in women with hyperemesis gravidarum.[37]
  • More controversy surrounds the benefit of hypnosis, but it has been studied in some cases of hyperemesis gravidarum and has been shown to be beneficial.
  • Psychological counseling may be considered.[36]
  • Outpatient or home intravenous hydration should be considered. If medications and outpatient hydration fail or if severe electrolyte disturbances persist, inpatient admission for intravenous hydration may be necessary.

Pharmacologic therapy

If pharmacologic therapy is necessary, treatment may be initiated using vitamin B-6, 10-25 mg daily, 3-4 times daily; doxylamine, 12.5 mg, 3-4 times daily can be used in addition. The herb, ginger capsules 250 mg 4 times daily, can be added at this point if patient is still vomiting since it has been shown to be effective in randomized trials.[38] Metoclopramide, 5-10 mg taken orally q8h may be used next. Promethazine, 12.5 mg orally or rectally q4h, or dimenhydrinate 50-100 mg orally q4-6h, may be added as well. Ondansetron 4-8 mg orally or IV q8h can be used for further refractory cases. Methylprednisolone, 16 mg orally or IV q8h for 3 days, with a taper to lowest effective dose, can be used if persistent vomiting occurs despite the above therapy. Steroids seem to increase risk for oral clefts in first 10 weeks of gestation.[39, 5]

Metoclopramide is widely used for nausea and vomiting during pregnancy, but information regarding human teratogenicity has been lacking. Matok et al found no increased risk for major congenital malformations, low birth weight, preterm delivery, Apgar scores, or perinatal death between infants of mothers who took metoclopramide within the first trimester compared with infants’ mothers who did not take metoclopramide. The retrospective cohort study included a total of 81,703 infants who were born to women registered in a single health system with computerized maternal and infant hospital records. Of these, 3458 (4.2%) had first trimester exposure to metoclopramide.[40]

Since confirmation of adherence was unavailable, a secondary analysis was performed on infants of mothers who refilled their prescription for metoclopramide at least once (n=758), and no increased risk was found in this subpopulation exposed to metoclopramide compared with infants not exposed. Additionally, the results of the study were unchanged when therapeutic abortions of exposed and unexposed fetuses were included in the analysis.

The study provides clinicians reassurance that metoclopramide does not cause congenital malformations; although, dopamine antagonists can cause maternal extrapyramidal symptoms (ie, acute dystonic reactions, tardive dyskinesia).

If hypokalemia is severe or symptomatic, potassium should be replaced parenterally. Before administering intravenous potassium, renal function should be evaluated. Potassium is usually added to intravenous fluid to achieve a concentration of 40 mEq/L (and not >80 mEq/L). An infusion rate of 10 mEq of potassium per hour should be safe as long as urine output is adequate.

When administrating intravenous hydration to a patient who has severe volume depletion in an effort to prevent the development of Wernicke encephalopathy, avoid intravenous glucose until intravenous thiamine has been administered.

If persistent dehydration, electrolyte loss, and/or weight loss occur despite above therapy, nutrition supplementation by either the parenteral or enteral route is indicated. The standard method has been via total parenteral nutrition (TPN). However, documented risks of bacteremia, sepsis, and thrombosis have been associated with the PICC lines required for TPN supplementation. Nasogastric tube placement and subsequent enteral feeding has been shown in small series and reports to be a valid alternative, with less complication risks, similar efficacy, and similar outcomes in regard to neonatal outcome when compared with TPN.[41]

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Surgical Care

In some refractory severe cases of hyperemesis gravidarum, if maternal survival is threatened, or if hyperemesis gravidarum is causing severe physical and psychological burden, termination of the pregnancy should be considered.[42]

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Consultations

  • Patients with HEG should be under the care of an obstetrician who is familiar with this disorder.
  • Consultation with a psychiatrist or psychologist may be warranted because psychological assessment may be needed. In some cases, even supportive or focal psychotherapy or psychiatric medications may be indicated. Behavioral therapy may be beneficial early in the course of HEG.
  • When certain disorders are considered the cause of nausea and vomiting (see Differentials), referral to a gastroenterologist or surgeon may be necessary.
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Diet

Initial suggestions for dietary modification in patients with nausea and vomiting associated with pregnancy include the following:

  • Eat when hungry, regardless of normal meal times.
  • Eat frequent small meals.
  • Avoid fatty and spicy foods and emetogenic foods or smells. Increase intake of bland or dry foods.
  • Eliminate pills with iron.
  • High protein snacks are helpful.
  • Crackers in the morning may be helpful.
  • Increase intake of carbonated beverages.
  • Other suggested foods include herbal teas containing peppermint or ginger, other ginger-containing beverages, broth, crackers, unbuttered toast, gelatin, or frozen desserts.
  • Preconception use of prenatal vitamins may decrease nausea and vomiting associated with pregnancy.
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Activity

Some patients note improvement of nausea and vomiting with decreased activity and increased rest. Other patients suggest that fresh outdoor air may improve symptoms.

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Proceed to Medication
 
 
Contributor Information and Disclosures
Author

Dotun A Ogunyemi, MD  Associate Professor of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA; Residency Program Director, Clerkship Director, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center

Dotun A Ogunyemi, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, National Medical Association, and Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Alex Fong, MD  Staff Physician, Obstetrics and Gynecology Department, Cedars-Sinai Medical Center

Alex Fong, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Tiffany Chen Herrero, MD  Resident Physician, Department of Obstetrics and Gynecology, Cedars Sinai Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Suzanne R Trupin, MD, FACOG  Clinical Professor, Department of Obstetrics and Gynecology, University of Illinois College of Medicine at Urbana-Champaign; CEO and Owner, Women's Health Practice; CEO and Owner, Hada Cosmetic Medicine and Midwest Surgical Center

Suzanne R Trupin, MD, FACOG is a member of the following medical societies: American Association of Gynecologic Laparoscopists, American College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, American Medical Association, Association of Reproductive Health Professionals, International Society for Clinical Densitometry, and North American Menopause Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Richard S Legro, MD  Professor, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Pennsylvania State University College of Medicine; Consulting Staff, Milton S Hershey Medical Center

Richard S Legro, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa, and Society of Reproductive Surgeons

Disclosure: Korea National Institute of Health and National Institute of Health (Bethesda, MD) Honoraria Speaking and teaching; Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) Honoraria Speaking and teaching; American College of Obstetrics and Gynecologists (Washington, DC) Honoraria Speaking and teaching; National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Think Tank Panel (Bethesda, MD) Honoraria Speaking and teaching; University of Illinois (Chicago, IL) Honoraria Speaking and teaching; Georgetown University Hospital (Washington, DC) Honoraria Speaking and teaching; Heilongjiang University (Harbin, China) Speaking and teaching; New England Fertility Society (Nashua, NJ) Honoraria Speaking and teaching; William Beaumont Hospital Division of Reproductive Endocrinology and Infertility (Detroit, MI) Honoraria Speaking and teaching; Wayne State University School of Medicine (Detroit MI) Honoraria Speaking and teaching

Frederick B Gaupp, MD  Consulting Staff, Department of Family Practice, Hancock Medical Center

Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Chief Editor

David Chelmow, MD  Leo J Dunn Distinguished Professor and Chair, Department of Obstetrics and Gynecology, Virginia Commonwealth University Medical Center

David Chelmow, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, Phi Beta Kappa, Sigma Xi, Society for Gynecologic Investigation, and Society for Medical Decision Making

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Giulia A Michelini, MD to the development and writing of this article.

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