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OB
CMECNE

Nausea and Vomiting in Pregnancy – Management Options for Hyperemesis Gravidarum

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Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Recall the criteria for the diagnosis of hyperemesis
2. Discuss the goals of managing nausea and vomiting in pregnancy

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from Dec 31 2017 through Dec 31 2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

CLINICAL ACTIONS:

  • Nonpharmacologic Treatment
  • Pharmacologic Treatment
  • Potential Side Effects of Medications
  • Hyperemesis Gravidarum
  • Key Points / Risk Factors

Nausea and vomiting are common in pregnancy, with a recurrence rate of 15%-81% in subsequent pregnancies. The goal is to not only reduce symptoms but prevent persistent vomiting, known as hyperemesis gravidarum. Consider the following management options:

Nonpharmacologic Treatment

Research limited but the following may be helpful

  • Avoid a full stomach with frequent, small meals every 1–2 hours
    • Minimize spicy or fatty foods
  • Eliminate supplemental iron
    • Substitute folic acid for iron-containing prenatal vitamins
  • Eat
    • Bland or dry foods
    • High-protein snacks and crackers in the morning before getting out of bed
    • Ginger 250 mg 4 times per day
  • Avoid sensory stimuli
    • Odors, heat, humidity, noise, and flickering lights/stimuli that may provoke onset of symptoms
  • Prenatal vitamins for 1 month prior to conception may reduce symptoms
  • Acupressure, acupuncture, or electrical nerve stimulation (acustimulation)
    • P6 or Neiguan point (located three finger breadths below the wrist on the inside of the wrist in between the two tendons)
    • Evidence is inconclusive with conflicting conclusions
    • Consider P6 acupressure with wrist bands

Pharmacologic Treatment

Initial ‘First Line’ Options

  • Vitamin B6 (pyridoxine) or Vitamin B6 plus doxylamine
    • Vitamin B6
      • 10-25 mg orally (alone or in combination with doxylamine 12.5 mg orally) 3 or 4 times per day OR
    • Vitamin B6 10 mg/ doxylamine 10 mg combination
      • 2 tablets orally at bedtime initially, up to 4 tablets per day (1 tablet in the AM, 1 tab in the midafternoon, and 2 tablets at bedtime) OR
    • Vitamin B6 20 mg/ doxylamine 20 mg combination
      • 1 tablet orally at bedtime initially, up to 2 tablets per day (1 tablet in the AM and 1 tablet at bedtime)

If Symptoms Persist Add the Following (presented in alphabetical order)

  • Dimenhydrinate
    • 25-50 mg every 4 to 6 hours, orally as needed (do not exceed 200 mg per day if also on doxylamine) OR
  •  Diphenhydramine
    • 25-50 mg every 4 to 6 hours, orally OR
  • Prochlorperazine
    • 25 mg every 12 hours, rectally OR
  •  Promethazine
    • 12.5-25 mg every 4 to 6 hours, orally or rectally

If Symptoms Persist but No Dehydration Add Any of the Following (presented in alphabetical order)

  • Metoclopramide
    • 5-10 mg every 6 to 8 hours, IM or orally OR
  • Ondansetron
    • 4 mg orally every 8 hours OR
  • Promethazine
    • 12.5-25 mg every 4 to 6 hours, orally, IM or rectally OR 
  • Trimethobenzamide
    • 200 mg every 6 to 8 hours, IM

If Symptoms Persist and the Patient is Dehydrated

  • IV fluid replacement
    • If patient vomiting for > 3 weeks
      • IV thiamine, 100 mg with initial rehydration fluid and 100 mg daily for 2 to 3 days, followed by IV multivitamins are recommended to prevent Wernicke encephalopathy

If Symptoms Persist Even With the Addition of IV Fluids, Add Any of the Following (presented in alphabetical order)

  • Dimenhydrinate IV
    • 50 mg (in 50 mL saline, over 20 min) every 4 to 6 hours OR
  • Metoclopramide IV
    • 5-10 mg every 8 hours OR
  • Ondansetron IV
    • 8 mg, over 15 minutes, every 12 hours OR
  • Promethazine IV
    • 12.5-25 mg every 4 to 6 hours

If Symptoms Still Persist Despite IV Fluids and Above IV Medications, Add the Following (presented in alphabetical order)

  • Chlorpromazine
    • 25-50 mg every 4 to 6 hours IM or IV or 10-25 mg orally every 4 to 6 hours OR
  • Methylprednisolone
    • 16 mg every 8 hours orally or IV for 3 days
    • Taper over 2 weeks to lowest effective dose
    • Limit duration to 6 weeks

Potential Side Effects of Medications

  • Be especially careful if using multiple medications together
  • Use of a dopamine antagonist (e.g., metoclopramide) and various phenothiazine medications (e.g., promethazine, prochlorperazine, or chlorpromazine) increase the risk of
    • extrapyramidal effects (eg, tardive dyskinesia)
    • neuroleptic malignant syndrome (rare)
      • Life-threatening reaction
      • High fever, confusion, rigid muscles, and symptoms of autonomic nervous system instability
  • Serotonin 5-HT3 inhibitors (e.g., ondansetron) in combination with phenothiazine medications (e.g., chlorpromazine) may increase risk of QT interval prolongation

Hyperemesis Gravidarum

  • Most common indication for admission in early pregnancy
    • Occurs in 0.3-3.0% of pregnancies
  • No single accepted definition
    • Diagnosis of exclusion
  • Following are the most common criteria
    • Persistent vomiting unrelated to other causes
    • Significant, large ketonuria
      • Electrolyte, liver and thyroid function tests may be abnormal
    • 5% weight loss from pre-pregnancy weigh
  • Initiate antiemetic therapy before symptom onset to reduce severity of nausea and vomiting
  • IV hydration should be used for patients who cannot tolerate oral liquids or if clinical signs of dehydration are present
  • Ketosis and vitamin deficiency should be corrected
  • Enteral tube feeding is recommended if patient is unresponsive to medical therapy and their weight cannot be maintained
  • Rule out other causes of intractable vomiting before making a diagnosis of hyperemesis gravidarum

SYNOPSIS:

The etiology of nausea and vomiting of pregnancy is unknown, with 50-80% of women experiencing nausea and 50% experiencing vomiting. Ultrasound may be helpful to identify multiple gestation and molar pregnancy (see Risk Factors below).  Abnormal maternal thyroid tests are sometimes seen and are related to gestational transient thyrotoxicosis and/or hyperemesis gravidarum.  Management includes supportive therapy and not antithyroid medications.

KEY POINTS:

  • Risk factors for hyperemesis gravidarum
    • Increased placental mass
      • Molar gestation or multiple gestation
    • History of motion sickness or family or personal history of hyperemesis gravidarum
    • Female fetuses
  • According to ACOG “A patient’s perception of the severity of her symptoms and her desire for treatment are influential in clinical decision making”
    • A validated scoring system has been published known as the mother risk Pregnancy-Unique Quantification of Emesis and nausea (PUQE) that may be helpful (see ‘Learn More – Primary Sources’, below)
  • Symptoms of nausea and vomiting of pregnancy can occur prior to 9 weeks gestation
  • Fetal Effects
    • Evidence is conflicting as to whether there is a higher incidence of small for gestational age and premature  infants born to mothers with hyperemesis gravidarum
    • No association noted with perinatal or neonatal mortality
    • Mild to moderate vomiting has little effect on pregnancy outcome
    • Lower rates of miscarriage have been documented, likely due to healthy placenta and not protective effect of nausea and vomiting
  • ACOG states

it is appropriate to reassure patients that the presence of nausea and vomiting of pregnancy and even hyperemesis gravidarum most often portends well for pregnancy outcome

Learn more:

ACOG Practice Bulletin 189: Nausea and Vomiting of Pregnancy

Nausea and Vomiting of Pregnancy: Using the 24-hour Pregnancy-Unique Quantification of Emesis (PUQE-24) Scale (2009)

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Ondansetron for Nausea During Pregnancy – Is There a Risk for Birth Defects?
Does Doxylamine-Pyridoxine for Nausea in Pregnancy Actually Work?
Practical obstetrics info for your women's healthcare practice

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OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

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