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Duration
OBJECTIVES
OBJECTIVES
VERSUS
INTRODUCTION
Hyperemesis gravidarum is practically defined as
pernicious vomiting in pregnancy that requires
hospitalization.
It typically is associated with dehydration, electrolyte
disturbances, and starvation with consequent weight
loss.
It affects 0.3% to 2.3% of the pregnant population,
whereas nausea and vomiting of pregnancy is far
more common, affecting up to 85% of pregnant women.
The
ACOG
2004 guidelines
dimenhydrinate,metoclopramide,or
promethazine as first-line antiemetic.
Hyperemesis Gravidarum
When the joy of creating life turns
into a struggle for survival and hope
I Wish . . .
I wish that I had never tried to get
pregnant
I wish that in a few months I would
be able to hold my baby
METOCLOPRAMIDE
increases
the movements
or contractions of the muscles
prokinetic
Side Effects
does not cause as many side effects as many other
medicines used to prevent nausea and vomiting.
May include:
Sleepiness or confusion.
Twitching or muscle spasms.
Decreased blood pressure (hypotension).
Rapid or uncontrolled movements of lips and tongue.
Contra indications:
narrow-angle glaucoma, prostate disease, severe low
blood pressure, or rapid, irregular heartbeats.
PROMETHAZINE
Promethazine,
a phenothiazine derivative,
Acts primarily as a strong antagonist of
the H1 receptor (antihistamine) and a
moderate mACh receptor antagonist
(anticholinergic and also has weak to
moderate affinity for the 5-HT2A,[11] 5HT2C,[11] D2,[12][13] and 1-adrenergic
receptors,[14] where it acts as an antagonist
at all sites, as well.
SIDE EFFECTS
Tardive
dyskinesia
Confusion in the elderly
Drowsiness, dizziness, fatigue, more
rarely vertigo Dry mouth
Constipation
Chest discomfort/pressure (typically in
cases when patient is already taking
medication for high blood pressure)
METHODOLOGY
Women
INCLUSION CRITERIA
EXCLUSION CRITERIA
multiple
gestation,
Established nonviable pregnancy,
preexisting medical condition that can cause
nausea and vomiting (eg, culture proven
symptomatic urinary tract infection or dengue fever),
gastrointestinal causes of vomiting (eg,
gastroenteritis),
medical causes of vomiting (eg, diabetic
ketoacidosis),
known allergy to metoclopramide /promethazine
PRIMARY OUTCOME
well-being visual numerical rating scale score and
frequency of vomiting in the first 24 hours
SECONDARY OUTCOMES
visual numerical rating scale scores for nausea at
enrolment and at 8, 16, and 24 hours;
adverse symptoms profile;
ketonuria status at the end of the 24-hour main study
period;
treatment curtailment during the main study period;
total doses of intravenous antiemetic needed during
hospitalization;
admission- to-discharge interval; and
time needed for intravenous rehydration
Study
Antiemetic
Also
At
Visual
STATISTICAL ANALYSIS
SPSS 16
Students t test.
Two-by-two categorical data sets were analyzed
with the Fisher exact test and larger categorical
data sets with the 2 test; ordinal data and non
normally distributed continuous data were
analyzed with the Mann-Whitney U test
RESULTS
Primary outcome
not significantly different.
Median vomiting frequency one (range 026) compared
with two (range 026) (P.81) and
SECONDARY OUTCOME
nausea
SECONDARY OUTCOME.
CONT.
DISCUSSION
A trial directly comparing promethazine with
metoclopramide for hyperemesis gravidarum has
not been done.
However, a three-armed trial of placebo compared
with metoclopramide compared with promethazine
(with the first dose of pethidine) for labor analgesia
has shown that metoclopramide and promethazine
are equally effective in reducing the incidence of
nausea and vomiting but that the sedative effect
was more persistent in the promethazine group.
These findings are similar the data of this study .
Metoclopramide
CONCLUSION
Intravenous
Patient
REFERENCES
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2.
3.
4.
5.
CONT.
6. Ziaei S, Hosseiney FS, Faghihzadeh S. The
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Metoclopramide and diphenhydramine in the
treatment of hyperemesis gravidarum: effectiveness
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Gynecol Reprod Biol 2009;143:439.
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14651858.CD000145.
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outpatient regimens in the management of nausea and vomiting
in pregnancy. J Perinatol 2003;23:5315.
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chorionic gonadotropin and estradiol (E2) on the severity of
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Metoclopramide
(n73)
Promethazine
(n76)
Weight (kg)
54.3 9.1
54.210.5
.95
23.0 3.5
22.5 4.2
.45
Coexisting medical
condition
4 (5.5)
6 (7.9)
.75
1+
16 (21.9)
16 (21.1)
2+
15 (20.5)
12 (15.8)
3+
32 (43.8)
43 (56.6)
4+
10 (13.7)
5 (6.6)
At recruitment
Ketonuria(dipstick)
Metoclopramide
(n73)
Promethazine
(n76)
Nausea score*
5 (2.757)
5 (1.57) .85
.85
Serum sodium
(mmol/L)
134 4
134 2
.78
Serum potassium
(mmol/L)
3.9 0.5
3.9 0.5
.86
Hematocrit
0.39 0.04
0.39 0.03
.57
Pulse
84 13
82 12
.37
Systolic blood
pressure
(mmHg)
114 11
117 12
.15
Diastolic blood
pressure
(mmHg)
69 10
71 11
.24
Primary outcomes
Metoclopramide
(n73)
Promethazine
(n76)
Vomiting
episodes
(n144)
1 (05)
2 (03)
.81
Well-being
VNRS
(n142)
8 (610)
7 (5.259)
.24
7.62.2
7.12.3
.24
Primary
outcomes
Relative
Risk
(95% CI)
NNTb*
(95% CI)
Metoclopramide
(n73)
Promethazine
(n76)
At recruitment (n143)
5 (2.757
5 (1.57)
.85
8 h (n143)
4 (1.55
4 (1.756)
.54
16 h (n137)
3 (15)
3 (15)
.80
24 h (n126)
2 (15)
2 (14)
.99
Secondary outcomes
Nausea score
Metoclopramid Promethazine
e
(n76)
(n73)
Hospital stay (d) (n149)
1.8 (1.52.5)
1.7 (1.52.4)
Nil
54 (75.0))
61 (80.3)
1+
6 (8.3)
7 (9.2)
2+
9 (12.5)
5 (6.6)
3+
3 (4.2)
3 (3.9)
Metoclopramide
(n73)
Promethazine
(n76)
Intravenous
rehydration (h)
(n147)
42 (3359)
39 (3348.75)
.23
4/73 (5.5)
9/76 (11.8)
.25
0/73 (0)
7/76 (9.2)
.014
4 (44.75)
.98
Metoclopramide
(n73)
Promethazine
(n76)
Relative Risk
(95% CI)
NNTb*
(95% CI)
Felt drowsy
41/70 (58.6)
61/73 (83.6)
.001
5 (39)
Unable to sleep
12/70 (17.1)
16/73 (21.9)
.53
0.8 (0.41.5)
28/70 (40.0)
32/73 (43.8)
.74
0.9 (0.61.3)
Felt dizzy
24/70 (34.3)
52/73 (71.2)
<.001
0.5 (0.30.7)
Had diarrhea
4/70 (5.7)
3/73 (4.1)
.71
1.4 (0.36.0)
Had headache
17/70 (24.3)
22/73 (30.2)
.46
0.8 (0.51.4)
Experienced
palpitations
7/70 (10)
12/73 (16.4)
.33
0.6 (0.31.5)
Involuntary muscle
movement
(dystonia
4/70 (5.7)
14 (19.2)
.02
0.3 (0.10.9)
4/70 (5.7)
3/73 (4.1)
.71
1.4 (0.36.0)
Symptoms profile
by questionnaire
(n143)
3 (25)
8 (434)