Treatment

These recommendations come directly from the Society of Obstetric Medicine of Australia and New Zealand Guideline For Management Of Nausea And Vomiting Of Pregnancy And Hyperemesis Gravidarum.

Mild to moderate NVP can often be managed without the need for pharmacological intervention. In more severe cases, however, where symptoms are impacting a sufferer’s ability to eat and/or drink and weight loss is occurring the need for treatment increases. While concerns around medication use in pregnancy are valid, failing to treat NVP or HG can do more harm than medication. Increasingly, evidence shows the potentially harmful effects of malnutrition and dehydration during pregnancy, including the first trimester. Malnutrition in early pregnancy has been found to have lifelong cardiometabolic consequences for the offspring. Not treating a patient effectively enough to ensure they can eat and drink adequately is riskier than leaving them untreated. 

Many people are hesitant, or even resistant, to taking medication while pregnant. While there are risks associated with many of the recommended medications, these need to be weighed against the risks of leaving symptoms untreated. 

Additionally, the physical and psychological effects of profound and prolonged nausea and/or vomiting should not be underestimated and quality of life should be a factor in decision-making about treatments. A recent systematic review of qualitative evidence found that even moderate NVP could have a seriously detrimental effect on sufferer’s lives and mental health.

Healthcare professionals should prioritize comprehensive treatment plans for HG sufferers due to the multifaceted nature of the condition. HG significantly impacts a patient's physical health, mental well-being, and overall quality of life. A comprehensive approach addresses not only symptom management but also nutritional support, hydration, mental health support, and advocacy for the patient's needs. By developing a holistic treatment plan, healthcare professionals can better address the complex challenges faced by HG sufferers, improving outcomes and enhancing their overall care experience.

Treatment plans

  • Establish reasonable targets for the treatment plan and manage patient expectation ie. aim for the ability to eat and drink adequately without necessarily complete resolution of NVP

  • Discontinue prenatal multivitamins if they are contributing to symptoms. Many sufferers report an improvement in symptoms after discontinuation of prenatal multivitamins that include iron. The two critical micronutrients which should be continued, if possible, are iodine (150 mcg per day) and folate (at least 400 mcg per day)

  • The timing of taking medications should take into account the pattern of symptoms over a 24 hour period. Symptoms often fluctuate during the day and night and therapy should reflect these individual differences. Using the PUQE-24 score can help you track and establish patterns, see our previous resource on Diagnosis + Assessment

  • The choice of antiemetic should be individualised, based on the sufferer’s symptoms, previous response to treatment and potential side effects:

    • If an antiemetic is ineffective at maximal dose, discontinue before commencing an alternate agent

    • If an antiemetic is partially effective, optimise dosage and timing, and only add additional agents after maximal doses of the first agent have been trialled

    • Oral therapy is usually commenced first and parenteral or subcutaneous treatment reserved for severe cases

    • Written instructions should be given regarding titrating therapy (up and down) as symptoms fluctuate, deteriorate or improve

    • Regular review of therapy is required in all cases

According to the SOMANZ Guidelines any plan for the holistic management of NVP and HG must include: 

  • Interventions to reduce nausea, retching and vomiting 

  • Management of associated gastric dysmotility ie. gastroesophageal reflux and constipation 

  • Maintenance of hydration, fluid and electrolyte replacement 

  • Maintenance of adequate nutrition including the provision of vitamin supplements where required 

  • Psychosocial support 

  • Monitoring and prevention of side effects and adverse pregnancy and fetal outcomes 

Medications for the treatment of NVP and HG may require a range of agents including: 

Antiemetics: vitamin and prescribed 

  • Acid suppression 

  • Stool softeners 

  • Steroids 

  • Other supplements

The best way to treat pregnancy sickness which requires pharmaceutical intervention is to layer medications together. If a patient is not responding to first-line treatments, adding another layer to their medications may provide additional symptom management.

It is important to remember that pharmacological treatment for NVP and HG is only one part of the holistic management of a patient’s condition. Other elements will include, where appropriate, non-drug measures, psychosocial support and ongoing obstetric/midwifery care. 

Almost all pharmacological treatment is “off-license” and based on historical experience with the limited amount of high-quality data described in small trials, systematic reviews or meta-analyses. In all cases, a rational assessment of maternal and foetal risk, particularly teratogenesis, needs to be determined based on the patient’s circumstances.

Treatment

The Society of Obstetric Medicine of Australia and New Zealand recommended treatment protocol is as follows:

  • Pyridoxine (Vitamin B6) 10-50mg orally four times daily

  • One of the following taken orally up to three times daily:

    • Doxylamine 6.25-25mg

    • Prochlorperazine 5mg

    • Promethazine 25mg

    • Metoclopramide 10mg

    • Ondansetron 4-8mg taken orally two to three times daily

    To avoid sedation and for prolonged use i.e. more than 5 days, use Ondansetron during the day

    Additional treatment:

    • H2 antagonist eg. Ranitidine 150-300mg orally twice daily

    • IV fluids 1-3 x per week as required

    • Ondansetron 4-8mg taken orally two to three times daily

    Nighttime dosing with one of the following:

    • Metoclopramide 10mg IV or orally (if tolerating orally)

    • Prochlorperazine 5-10mg IV or orally (if tolerating orally)

    • Doxylamine 12.5-50mg IV or orally (if tolerating orally)

    • Cyclizine 12.5-50mg IV or orally (if tolerating orally)

    Consider adding:

    • Prednisone: commence 40-50mg daily or hydrocortisone 100mg IV twice daily and wean Prednisone over 7-10 days to minimal effective dose. May need to continue until symptoms resolve

    Additional Treatment:

    • Cease H2 antagonist and substitute with a proton pump inhibitor twice daily eg. Esomeprazole or Rabeprazole 20mg

    • IV fluids 1-3 x per week as required. Add IV thiamine if poor oral intake or administering dextrose

  • Intravenous Fluid Replacement

    Sufferers will often delay seeking treatment if they don’t realise their symptoms have gone beyond ‘normal’. It may be necessary to accelerate treatment to reverse dehydration.

    IV fluids have been shown to reduce vomiting and are a valuable part of any treatment plan. IV fluid therapy should ideally be administered in an outpatient setting, as this has been associated with equivalent patient satisfaction outcomes and lower total hospitalisation days in small studies. Clear pathways for access to outpatient fluid therapy can give patients a sense of control over their symptoms which can be very helpful

  • Nutritional Therapies

    If the sufferer does not respond to the recommended management interventions, they should be assessed by a dietitian to consider commencing short-term enteral feeding. Small studies have shown enteral feeding is safe and effective in temporarily aiding foetal and maternal nutrition in severe HG. Undertake a detailed nutritional assessment to determine the feeding regimen required.

    If enteral nutritional support is unsuccessful, trial parenteral nutrition. Total parenteral nutrition is a complex intervention. It should only be used as a last measure as it can be associated with serious complications

  • Pregnancy Termination

    Research suggests that as many as 10% of HG sufferers will terminate a pregnancy due to the condition. Termination should only be discussed when all other treatment avenues have been exhausted with little efficacy.

    The goal should always be to avoid the termination of a pregnancy because of unmanaged HG. No patient should have to end a pregnancy because their symptoms are too severe for them to cope with, so abortion should be the absolute last resort. If you have a patient requesting information about termination please direct them to Marie Stopes International Australia

The primary objective of management plans for Hyperemesis Gravidarum (HG) should be to minimise the need for in-patient hospital stays while effectively addressing the severity of a patient's condition. While hospitalisation may be necessary in cases of extreme HG symptoms to provide intravenous fluids, nutritional support, medication administration, and close monitoring, the aim of treatment should be to optimise outpatient care whenever possible.

This approach not only reduces the burden on healthcare resources but also promotes the well-being of patients by allowing them to receive necessary treatment in a more comfortable and familiar environment.

It is, however, essential to acknowledge that in some instances, hospitalisation may be unavoidable to ensure the safety and health of both the patient and their unborn child, particularly in cases of severe dehydration, malnutrition, or metabolic imbalances.

Inpatient vs Outpatient