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Medication

Medication Summary

Antihistamines, antiemetics of the phenothiazine class, and promotility agents (eg, metoclopramide) have been used in the treatment of nausea and vomiting during pregnancy.

Vitamin B-6 (pyridoxine) has also been studied in the treatment of nausea and vomiting during pregnancy and reduced nausea and vomiting when compared with placebo.

Ondansetron (Zofran), a serotonin-receptor antagonist, showed no benefit over the antiemetic promethazine (Phenergan), at much greater cost. It may be reserved for refractory cases. A meta-analysis of 6 randomized, double-blind trials showed that ginger was an effective treatment for hyperemesis gravidarum.

Steroids may be used in patient's refractory to standard therapy. Promethazine (Phenergan) was compared with methylprednisolone in a randomized, double-blind, controlled trial. Methylprednisolone appeared to decrease the rate of readmission for hyperemesis gravidarum; however, the patients randomized to promethazine had a significantly longer duration of symptoms prior to treatment.

However, concerns exist about association between oral clefts and methylprednisolone use in the first trimester; thus, it should be used with caution before 10 weeks of gestation.

Class Summary

Essential for normal DNA synthesis and play a role in various metabolic processes.

Pyridoxine (Nestrex)

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Marketed in combination formulations with doxylamine (Benedectin, Dilectin).

Benedectin was taken off the market in the United States in the 1980s because of liability issues, but it is available in Canada. Doxylamine is probably not teratogenic and can be used in combination with pyridoxine at a dose of 10-12.5 mg PO qd/bid.

Class Summary

Not approved by the US Food and Drug Administration but are remedies believed to improve symptoms.

Ginger

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A randomized, double-blind, crossover trial of a ginger extract was shown to be more beneficial for reducing symptoms than placebo.

Class Summary

Useful in the treatment of symptomatic nausea.

Doxylamine/pyridoxine (Diclegis)

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Mechanism of action for efficacy to treat morning sickness is unknown. It contains doxylamine, an ethanolamine antihistamine derivative, and pyridoxine, a vitamin B6 analog. It is the only FDA-approved medication for treatment of nausea and vomiting of pregnancy who have not adequately responded to dietary and lifestyle changes.

Prochlorperazine (Compazine)

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May relieve nausea and vomiting by blocking postsynaptic mesolimbic dopamine receptors through anticholinergic effects and depressing reticular activating system. In a placebo-controlled study, 69% of patients given prochlorperazine reported significant symptom relief, compared to 40% of patients in the placebo group.

Promethazine (Phenergan)

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For symptomatic treatment of nausea in vestibular dysfunction. Antidopaminergic agent effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to brainstem reticular system.

Chlorpromazine (Thorazine, Ormazine)

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Mechanisms responsible for relieving nausea and vomiting include blocking postsynaptic mesolimbic dopamine receptors, anticholinergic effects, and depression of RAS. Blocks alpha-adrenergic receptors and depresses release of hypophyseal and hypothalamic hormones.

Trimethobenzamide: (Tebamide, Tigan)

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Acts centrally to inhibit the medullary chemoreceptor trigger zone.

Metoclopramide (Reglan)

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Blocks dopamine receptors and (when given in higher doses) also blocks serotonin receptors in chemoreceptor trigger zone of the CNS; enhances the response to acetylcholine of tissue in upper GI tract causing enhanced motility and accelerated gastric emptying without stimulating gastric, biliary, or pancreatic secretions; increases lower esophageal sphincter tone.

Ondansetron: (Zofran)

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Selective 5-HT3-receptor antagonist, blocking serotonin, both peripherally on vagal nerve terminals and centrally in the chemoreceptor trigger zone.

Class Summary

These agents have profound and varied metabolic effects.

Methylprednisolone (Medrol, Solu-Medrol)

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May improve symptoms of nausea and vomiting.

Class Summary

Studied in nausea and vomiting during pregnancy and in small numbers of patients with hyperemesis gravidarum, providing relief in 82% of patients. Appears to be as efficacious as pyridoxine in another study.

Meclizine (Antivert)

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Decreases excitability of middle ear labyrinth and blocks conduction in middle ear vestibular-cerebellar pathways. These effects are associated with relief of nausea and vomiting.

Diphenhydramine (Benadryl)

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Competes with histamine for H1-receptor sites on effector cells in the gastrointestinal tract, blood vessels, and respiratory tract; anticholinergic and sedative effects are also seen

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Author

Dotun A Ogunyemi, MD Vice Chair of Patient Safety and Quality, William Beaumont Hospital; Professor, Oakland University, William Beaumont School of Medicine; Clinical Services Professor of Obstetrics and Gynecology, University of California, Los Angeles, David Geffen School of Medicine

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, Society for Maternal-Fetal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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, Society of Reproductive Surgeons, American Society for Reproductive Medicine, Endocrine Society, Phi Beta Kappa

Disclosure: Received honoraria from Korea National Institute of Health and National Institute of Health (Bethesda, MD) for speaking and teaching; Received honoraria from Greater Toronto Area Reproductive Medicine Society (Toronto, ON, CA) for speaking and teaching; Received honoraria from American College of Obstetrics and Gynecologists (Washington, DC) for speaking and teaching; Received honoraria from National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Thi.

Chief Editor

Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, General Obstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Additional Contributors

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 College of Obstetricians and Gynecologists, American Institute of Ultrasound in Medicine, International Society for Clinical Densitometry, AAGL, North American Menopause Society, American Medical Association, Association of Reproductive Health Professionals

Disclosure: Nothing to disclose.

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.

Acknowledgements

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

Hyperemesis Gravidarum Medication

Medication Summary

Vitamins

Class Summary

Pyridoxine (Nestrex)

Pyridoxine (Nestrex)

Herbal medications

Class Summary

Ginger

Ginger

Antiemetics

Class Summary

Doxylamine/pyridoxine (Diclegis)

Doxylamine/pyridoxine (Diclegis)

Prochlorperazine (Compazine)

Prochlorperazine (Compazine)

Promethazine (Phenergan)

Promethazine (Phenergan)

Chlorpromazine (Thorazine, Ormazine)

Chlorpromazine (Thorazine, Ormazine)

Trimethobenzamide: (Tebamide, Tigan)

Trimethobenzamide: (Tebamide, Tigan)

Metoclopramide (Reglan)

Metoclopramide (Reglan)

Ondansetron: (Zofran)

Ondansetron: (Zofran)

Corticosteroids

Class Summary

Methylprednisolone (Medrol, Solu-Medrol)

Methylprednisolone (Medrol, Solu-Medrol)

Antihistamines

Class Summary

Meclizine (Antivert)

Meclizine (Antivert)

Diphenhydramine (Benadryl)

Diphenhydramine (Benadryl)

Hyperemesis Gravidarum Medication

Medication Summary

Vitamins

Class Summary

Pyridoxine (Nestrex)

Herbal medications

Class Summary

Ginger

Antiemetics

Class Summary

Doxylamine/pyridoxine (Diclegis)

Prochlorperazine (Compazine)

Promethazine (Phenergan)

Chlorpromazine (Thorazine, Ormazine)

Trimethobenzamide: (Tebamide, Tigan)

Metoclopramide (Reglan)

Ondansetron: (Zofran)

Corticosteroids

Class Summary

Methylprednisolone (Medrol, Solu-Medrol)

Antihistamines

Class Summary

Meclizine (Antivert)

Diphenhydramine (Benadryl)

References

Tables

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