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combination. Poor oral intake, along with gastrointestinal slowing of pregnancy, and use of ondansetron, may cause significant constipation. Pre-emptive and assertive management with laxatives and / or rectal therapy is required.
Maintenance of hydration Fluid and electrolyte replacement should be considered as needed. Many women with HG find fluids more difficult to tolerate then food. In many cases of HG, IV fluids are required for both hydration and to reduce nausea. These may be needed up to 2-3 times per week until oral intake of fluids and NVP improves. Outpatient or Hospital in the Home administration is preferable to hospitalisation
Table 2. Medications for treatment of nausea and vomiting of pregnancy and hyperemesis gravidarum 5
Antiemetics and corticosteroids
Laxatives
Mild PUQE-24 ≤7
• Ginger and / or
• Pyridoxine( vitamin B6)
Moderate PUQE-24 = 7-12
One of the following:
• Doxylamine( plus pyridoxine)
• Cyclizine
• Metoclopramide
• Prochlorperazine
• Promethazine or
• Ondansetron *( plus laxative / s) unless there are compelling indications such as type 1 diabetes. 5 If IV fluids are required, EUC as well as LFTs should be checked regularly( every 1-2 weeks).
Thromboprophylaxis Consider thromboprophylaxis with low molecular weight heparin for patients who are immobilised, especially if other
Severe( PUQE-24 ≥13) and / or inadequate oral intake or hyperemesis gravidarum— outpatient management
• Ondansetron *( plus laxative / s) Add additional antiemetics as required, especially for night-time dosing:
• Doxylamine( plus pyridoxine) or
• Cyclizine or
• Metoclopramide or
• Promethazine or
• Prochlorperazine If significant symptoms persist:
• Consider corticosteroids **: Oral: prednisone / prednisolone or IV: methylprednisolone or hydrocortisone
• Consider droperidol
Docusate 120mg oral once or twice a day and / or macrogol oral once or twice a day and / or lactulose 15-30mL oral once or twice a day
Acid suppression One of the following: H2 antagonist: famotidine, nizatidine or PPI: esomeprazole, rabeprazole, omeprazole, lansoprazole
IV therapy
IV 0.9 % saline 1-2L, 1-3 times per week as required Add IV thiamine 300mg per week if poor oral intake or administering glucose
Cease H2 antagonist and commence PPI or Increase dose of PPI: Esomeprazole, rabeprazole, omeprazole, lansoprazole
* Data are conflicting but there may be an additional three in 10,000 risk of orofacial clefts and three in 1000 risk of ventricular septal defect although the overall risk of congenital malformations is not increased. 10 Avoid in women with pre-existing cardiac QT prolongation. ** No overall increase in major congenital malformation. Data are conflicting but there may be a very small additional risk of orofacial clefts when used before 10 weeks’ gestation. Chronic use: potential Cushing’ s syndrome, mood disturbance, hypertension, hyperglycaemia, preterm rupture of membranes and preterm delivery. PUQE = Pregnancy-Unique Quantification of Emesis
risk factors for VTE are present.
Psychosocial assessment and support When depression is suspected, monitoring with a validated tool is indicated. Early referral to the perinatal mental health team can be helpful. If mood effects are severe enough to warrant consideration of antidepressant therapy, mirtazapine may improve appetite and reduce nausea, in addition to offering potential antidepressant benefits, and there are some data to support its use in HG. 22-25
Keeping up to date with regular antenatal care Most women with NVP or HG are in early pregnancy. It is important to ensure that appropriate early antenatal care is not neglected, including indicated ultrasounds. Early antenatal booking may provide improved access to specialist care of HG as well as perinatal mental health support. Avoid glucose tolerance tests and consider alternate methods of screening for gestational diabetes in those at high risk for the condition, such as home blood glucose monitoring or HbA1C / fasting blood glucose.
References on request from kate. kelso @ adg. com. au
Online resource
Society of Obstetric Medicine of Australia and New Zealand: Position statement on the management of nausea and vomiting in pregnancy and hyperemesis gravidarum bit. ly / 4hZyQVD
Uncontrolled hyperemesis gravidarum is associated with adverse fetal and maternal events.