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Kiung Hsia Ling

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
.

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