Hyperemesis Gravidarum in Emergency Medicine Treatment & Management

Updated: Jan 08, 2016
  • Author: Feras H Khan, MD; Chief Editor: Jeter (Jay) Pritchard Taylor, III, MD  more...
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Treatment

Approach Considerations

The American College of Obstetricians and Gynecologists 2015 updated guidelines  on the treatment of nausea/vomiting in pregnancy recommend the following [10] :

  • The combination of doxylamine and vitamin B6 should be considered first-line pharmacotherapy.
  • Treating nausea and vomiting early in pregnancy, before it progresses, can help control symptoms and prevent more serious complications, including hospitalization.
  • Nausea or vomiting almost always presents before 9 weeks of gestation. When nausea or vomiting begins for the first time after 9 weeks, other conditions should be considered.
  • Taking prenatal vitamins for 3 months before conception may reduce the incidence and severity of nausea and vomiting in pregnancy.
  • In patients with hyperemesis gravidarum who also have suppressed thyroid-stimulating hormone levels, treatment of hyperthyroidism should not begin without evidence (such as goiter, thyroid autoantibodies, or both) of thyroid disease.
  • Treatment with ginger has shown benefit in reducing nausea and can be considered a nonpharmacologic option.
  • Treatment of severe nausea and vomiting of pregnancy or hyperemesis gravidarum with methylprednisolone may be effective in refractory cases; however, the risk profile of methylprednisolone suggests it should be used as a last resort.
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Emergency Department Care

Early treatment of nausea and vomiting of pregnancy may prevent progression to hyperemesis gravidarum. First-line treatment often involves rest and avoidance of sensory stimuli that may act as triggers. Frequent small meals with avoidance of spicy or fatty foods and increasing high-protein snacks are recommended. 

Perform the following:

  • Replace fluids and administer antiemetics, if required. Normal saline or Lactated Ringer solution is recommended.
  • Consider the addition of glucose, multivitamins, magnesium, pyridoxine, and/or thiamine. For any patient in whom vitamin deficiency is a concern, thiamine 100 mg should be given before initiating dextrose-containing fluids.
  • Note: Dextrose solutions may stop fat breakdown.
  • Continue treatment until the patient can tolerate oral fluids and until test results show little or no ketones in the urine.

Hospitalization

In a cost-utility analysis of day care over inpatient management of nausea and vomiting in pregnancy, European investigators found day care management was 70% more cost effective as well as more effective than inpatient care. [11]  However, admit pregnant patients with any of the following:

  • Persistently abnormal vital signs
  • Severe dehydration and inability to tolerate oral fluids
  • Severe electrolyte abnormality
  • Acidosis
  • Infection
  • Malnutrition

Parenteral antiemetics may be administered if the patient's condition is unresponsive to fluids, dietary restrictions, and oral medications.

Weight loss

Patients who continue to lose weight may require supplemental nutrition. Several care reports demonstrate that enteral tube feedings may be well tolerated and are a reasonable first attempt in admitted patients. Rarely, some women require total parenteral nutrition. Peripherally inserted central catheter (PICC) lines have been shown to have a high complication rate in these patients and should not be considered a routine therapy. [12]

Consultations

Obstetrical consultation is indicated if the patient appears to require admission to the hospital secondary to refractory symptoms unresponsive to ED management.

Outpatient care

Patients should ingest frequent small meals with high-carbohydrate or high-protein content. (Avoid offensive odors, fatty foods, spicy foods, iron supplements.)

Some patients may require outpatient maintenance with pyridoxine  (vitamin B-6) with/without doxylamine or ondansetron or other antiemetic may be considered.

Consider the use of Sea Bands, which apply pressure to the acupressure P6 point.

For women infected with H pylori, case reports have suggested improvement in symptoms with eradication of the infection.

Reassure patients. Some women may find benefit in counseling.

For patient education resources, see Pregnancy Center, as well as Pregnancy and Morning Sickness (Vomiting During Pregnancy).

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