Professional Documents
Culture Documents
10/06/09
Nausea & vomiting: common (70-85%)
Severe & intractable form of nausea &
vomiting fluid, electrolyte & acid base
imbalance, nutritional deficiency & weight loss
Peak incidence: 8-12 weeks of pregnancy
Frequency: 0.5-2% of pregnancies
Age: <30 years more likely to experience
hyperemesis
Etiology is unknown
? Elevated human chorionic gonadotropin
(HCG)
? Elevated estradiol
Has not been demonstrated conclusively
Physiologic effects
Weight loss, dehydration, deteriorating nutritional state
and often acid base & electrolyte alterations
Low birth weight infants
Spontaneous abortion, poor neurological development &
preterm delivery
Mild to moderate ketonuria
Thiamine deficiency: increased demand for glucose
metabolism, coupled with the inability to tolerate
adequate food and vitamin/mineral supplements
Wernicke’s encephalopathy
Mild increase in liver enzymes (up to 4×)
Minimize discomfort & symptoms
Prevent/minimize dehydration & electrolyte
imbalance
Prevent/minimize ketonuria
Achieve adequate oral fluid intake: 30-
35ml/kg/day
Prevent unnecessary hospitalization
An obviously dehydrated woman, with
ketonuria > 2++ requires admission for IV
rehydration and antiemetic therapy
For severe, prolonged hyperemesis: IV
thiamine 100mg/day
Extreme case: may require nasogastric or
parenteral nutrition
Drink enough fluids to avoid dehydration,
which exacerbates nausea
Drink small amounts often
Sometimes other fluids are managed better than water –
flat lemonade, sports drinks, fruit juice, clear soup
Small amounts of food more often, rather than large meals
Avoid having empty stomach – nibble on light snacks
between meals
Early morning nausea may be helped by eating a dry
biscuit before getting out of bed
Salty foods may help – try potato crisps or salty biscuits
Avoid fatty, rich or spicy foods
Make the most of your best time of day – eat
well when you feel best or whenever you feel
hungry
If the small of hot food makes you feel ill – try
having cold food instead. If possible avoid
cooking & ask for help from friends & family
Lie down when nauseated
Avoid stress – living with the constant threat
of nausea & vomiting is a stressor in itself
Pyridoxine (vit B6): effective in trials using doses of
30-75mg/day, up to 100mg/day can be given in
divided doses
Metoclopramide: most commonly prescribed,
category B
Antihistamine: promethazine, prochlorperazine,
meclizine, resulting drowsiness (beneficial effect)
Ondasetron: as last resort in view of the increased
costs compared to other medications
Recent evidence showed that intravenous
methylprednisolone did not reduce duration of
symptoms or readmission rates
Class Drug Dosage Ranges Preg. Risk
Catergory
Step 1 Antihistamine Diphenhydramine 25-50mg PO at bedtime B
Supportive
measures
Step 2 Vitamine Pyridoxine 10-25mg PO 3-4 × A
First-line Mx
If no improvement, add promethazine
Dopamine Promethazine 12.5-25mg PO q 4hrs C
antagonist
Step 3a If no improvement, and patient is not dehydrated, add or switch to one of the
Second-line following. If dehydrated, go to 3b
Mx
Prokinetic agent Metoclopramide 5-10mg TDS B
Serotonin Ondansetron 8mg BD B
antagonists
Dopamine Prochlorperazine 5-10mg q 3-4 hours C
antagonist
Step 3b Fluid replacement LR 1st liter, then Based on individual
Acute D51/4 NS patient need
hydration, IV
Vitamine Thiamine 100mg/day
fluids
supplementation
Ginger
Trial: 66 women compared 1g ginger capsule with
placebo, reporting benefit both for nausea & vomiting
with no adverse effects
Forms: tea, biscuits, candy
Acupressure
Involves the stimulation of the P6 Neiguan point either
manually or with elasticised bands
The P6 point is on the inside of the wrist, about 2-3
finger breaths proximal to the wrist crease between the
tendons about 1cm deep
Manual pressure is applied to this point for 5 minutes
every 4 hours
Applied by wearing an elasticised band with a 1cm
round plastic protruding button centred over the point
Unfortunately, evidence is mixed
Women unable to tolerate oral fluids require
admission to hospital
Women should be provided with dietary and
lifestyle advice to prevent dehydration
Maintaining hydration is more important than
nutrition in the short term
Severe or prolonged cases may require
supplementation with thiamine, nasogastric or
parenteral nutrition
Medications are probably underutilised. Of the
various medications shown to be effective,
pyridoxine has the least side effects. The most
commonly prescribed drug is metoclopromide
Parrish C. Management of Hyperemesis Gravidarum with
Enteral Nutrition. Practical Gastroenterology, June 2008
Moran P. et al. Management of Hyperemesis Gravidarum:
the importance of weight loss as a criterion for steroid
therapy. QJ Med 2002; 95:153-158
Sheehan P. Hyperemesis Gravidarum: Assessment and
management. Australian Family Physician 2007;
36(9):698-781
CPM. Management of nausea and vomiting of pregnancy
& Hyperemesis Gravidarum. 2008
Herbert W, et a;. Nause and vomiting of Pregnancy.
Association of professors of Gynecology and Obstetrics,
2001
.