Physicians should consider early treatment of nausea and vomiting in pregnancy to prevent progression to hyperemesis gravidarum, according to an updated practice bulletin from the American College of Obstetricians and Gynecologists.
Recommendations with the strongest evidence for prevention and management of nausea and vomiting in pregnancy include taking prenatal vitamins for 3 months prior to conception, and treating nausea and vomiting with vitamin B6 or vitamin B6 plus doxylamine.
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Patients with hyperemesis gravidarum (HG) and suppressed thyroid-stimulating hormone levels should not receive hyperthyroidism treatment until evidence of thyroid disease has been clearly identified, according to the bulletin published on Aug. 19 (Obstet Gynecol. 2015;126:e12–24).
Though the evidence is weaker, women can also use ginger to ease nausea symptoms. Women experiencing particularly unmanageable nausea and vomiting or HG may find methylprednisolone, 48 mg taken daily orally or intravenously for 3 days, effective in reducing symptoms. But its efficacy is unclear, and it may increase the risk of oral clefts by one or two cases per 1,000 treated women. For this reason, ACOG urged physicians to use caution in prescribing the drug for HG and to avoid it as a first-line agent before 10 weeks gestation.
“Treatment of severe nausea and vomiting of pregnancy or hyperemesis gravidarum with methylprednisolone may be efficacious in refractory cases; however, the risk profile of methylprednisolone suggests it should be a last-resort treatment,” ACOG wrote.
Consensus and expert opinion support the recommendation to use IV hydration for women with HG who are dehydrated or cannot tolerate oral liquids.
“Dextrose and vitamins should be included in the therapy when prolonged vomiting is present, and thiamine should be administered before dextrose infusion to prevent Wernicke encephalopathy,” ACOG recommended.
Women with HG who cannot maintain their weight or do not respond to medical therapy may require enteral tube feeding for nutrition. These women should not receive peripherally inserted central catheters unless absolutely necessary because of the risk of complications.
About half of all pregnant women experience vomiting, and up to 80% experience nausea while pregnant, though only about 0.3%-3% of pregnancies progress to HG, according to ACOG. Although HG, typically diagnosed once other causes have been excluded, lacks clear criteria, it commonly includes at least 5% loss of prepregnancy weight, persistent vomiting not related to other causes, and some measure of acute starvation, such as large ketonuria. There may also be electrolyte, thyroid, and liver abnormalities.
While one study has categorized the severity of nausea and vomiting in pregnancy along a continuum, the most clinically relevant factor is how the patient is affected by her symptoms.
“The woman’s perception of the severity of her symptoms, her desire for treatment, and the potential effect of treatment on her fetus are more likely to influence clinical decision making,” the bulletin states.
The recommendations in the bulletin are based on a literature search between January 1985 and April 2015 of English-language articles in the MEDLINE database, Cochrane Library, and the American College of Obstetricians and Gynecologists’ internal resources and documents.