Hyperemesis gravidarum medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Medical Therapy

Because of the potential for severe dehydration and other complications, HG is generally treated as a medical emergency. Treatment of HG may include antiemetic medications and intravenous rehydration. If medication and IV hydration are insufficient nutritional support may be required.

Management of HG can be complicated because not all women respond to treatment. Coping strategies for uncomplicated morning sickness, which may include eating a bland diet and eating before rising in the morning, may be of some assistance but are unlikely to resolve the disorder on their own.

Non-Pharmacologic Therapy

• Dietary modifications:
  • Try small amounts of food often during the day, as opposed to large meals.
  • Food that is high in protein and low in carbohydrates and fat eases digestion.
  • Try to stay hydrated by drinking liquids in small quantities during the day.
  • Ginger is recommended by the American College of Obstetrics and Gynecology (ACOG) for treating nausea and vomiting of pregnancy.

• Thiamine: Supplementation with thiamine is mainstay in the treatment of HG as it can prevent the development of Wernicke's Encephalopathy

• Intravenous fluid hydration: IV hydration is often required in patients with a severe presentation of HG.

Pharmacologic therapy

• Antihistamines:

• Antiemetics:

• Benzamides:

• Serotonin receptor antagonists:

• Acid-reducing medications:

• Corticosteroids:

IV Hydration

IV hydration often includes supplementation of electrolytes as persistent vomiting frequently leads to a deficiency. Likewise supplementation for lost thiamine (Vitamin B1) must be considered to reduce the risk of Wernicke's encephalopathy.

After IV rehydration is completed, patients generally progress to frequent small liquid or bland meals. After rehydration, treatment focuses on managing symptoms to allow normal intake of food.

Medications

While no medication is considered completely risk-free for use during pregnancy, there are several which are commonly used to treat HG and are believed to be safe.

The standard treatment in most of the world is Benedictin (also sold under the trademark name Diclectin), a combination of doxylamine succinate and vitamin B6. However, due to a series of birth-defect lawsuits in the United States against its maker, Merrill Dow, Benedictin is not currently on the market in the U.S. (None of the lawsuits were successful, and numerous independent studies and the Food and Drug Administration (FDA) have concluded that Benedictin does not cause birth defects.) Its component ingredients are available over-the-counter (doxylamine succinate is the active ingredient in many sleep medications), and some doctors will recommend this treatment to their patients.

Antiemetic drugs, especially ondansetron (Zofran), are effective in many women. The major drawback of ondansetron is its extremely high cost. In severe cases of HG, the Zofran pump may be more effective than tablets. Metoclopramide is sometimes used in conjunction with antiemetic drugs; however, it has a somewhat higher incidence of side effects. Other medications less commonly used to treat HG include Marinol, corticosteroids and antihistamines.

Practice in United Kingdom

The practice in the United Kingdom, following the thalidomide tragedy, is to generally use older drugs for which there has been a greater experience of use in pregnancy. Hence the first choice drug is promethazine with second choice being either metoclopramide or prochlorperazine; with the administration of thiamine strongly recommended.

Nutritional Support

Women who do not respond to IV rehydration and medication may require nutritional support. Patients might receive parenteral nutrition (intravenous feeding via a PICC line) or enteral nutrition (via a nasogastric tube or a nasojejunum tube).

Complementary and Alternative Medicine

Some women with HG find relief with complementary or alternative medicine, including chiropractic, homeopathy, acupuncture and energy psychology.

There is anecdotal evidence for the benefits of medical marijuana, which is more widely used to treat nausea and increase appetite during chemotherapy, but has been used for the same purpose in treating HG. The effects of cannabis on the fetus are not well understood, though no studies have yet established significant adverse effects.