Outpatient Management of Hyperemesis
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Nausea and vomiting of pregnancy are common during pregnancy. However, before attributing hyperemesis to pregnancy the patient should be evaluated for other possible causes.

The differential diagnosis includes but is not limited to [1]:

  • Acute fatty liver of pregnancy
  • Addison's disease
  • Appendicitis
  • Cholelithiasis
  • Diabetic ketoacidosis
  • Drug toxicity or intolerance
  • Gastroenteritis
  • Gastroparesis
  • HELLP syndrome
  • Hepatitis
  • Hyperthyroidism
  • Intestinal obstruction
  • Migraines
  • Molar pregnancy
  • Ovarian torsion
  • Pancreatitis
  • Peptic ulcer disease
  • Pyelonephritis
  • Tumors of the central nervous system
  • Uremia

Diagnostic work-up:

  • Obstetric ultrasound to rule out gestational trophoblastic neoplasia (molar pregnancy)
  • Serum electrolytes and creatinine
  • Liver function tests
  • Thyroid function tests
  • CBC
  • Additional imaging studies and laboratories should be performed as suggested by history or physical examination findings.

  • Patients presenting in the third trimester should be evaluated for:
      • Acute fatty liver
      • HELLP syndrome

Dietary modifications and nonpharmacological treatment
[2-9]:

If the diagnosis of hyperemesis is made and the patient is not found to be dehydrated, then the following dietary and lifestyle modifications may be recommended to reduce episodes of nausea and vomiting:

  • Avoid bad odors.
  • Eat some soda crackers in the morning.
  • Eat when you can.
  • Eat small meals often (for example, every 2 hours), instead of three big meals.
  • Don't overeat at meals.
  • Separate solid and liquid food by at least 2 hours.
  • Eat bland foods. Avoid rich, fatty foods.
  • Try to eat foods cold or at room temperature.
  • The BRATT diet (bananas, rice, applesauce, toast and tea) may help

Foods which appeal to pregnant women and are likely to be tolerated

Juices
Fruity popsicles
Gelatin desserts
Chicken broths
Ginger ale (non diet)
Sugared decaffeinated teas
Lemonade
Mushroom soup
Chips
Pretzels
Pickles
Brown rice
Celery sticks
Apples
Mashed potatoes
Bread
Noodles
Cake
Sugary cereal
Dry crackers

Foods unlikely to be tolerated.

Foods cooked with grease or oil
Fatty meats
Butter, or margarine
Gravy
Mayonnaise or salad dressing
Acidic foods (like citrus fruits and tomatoes)
Fried foods
Bacon or salt pork
Spicy foods


    • Sit upright for 45 minutes after eating.
    • Avoid caffeine, alcohol and tobacco.
    • If you think your morning sickness is related to your vitamins, talk with your doctor about prescribing another vitamin (Usually an enteric coated vitamin with less or no iron).
    • Ginger 250 mg four times daily may help.
    • Motion sickness bracelets (Sea Bands) have helped a few women.

    Patient Diet Instructions

    Medications [10-13]:

    If the above measures do not alleviate the patient's symptoms and the patient IS NOT DEHYDRATED then consider:

      • Pyridoxine 25 mg PO TID WITH
      • Unisom Sleep Tabs (Doxylamine Succinate 25 mg) 1/2 tablet TID

    If hyperemesis persists and the patient is not dehydrated you may add (try each agent in turn):

      • Dimenhydrinate (Category B) B 50-100mg q4-6 hours PO OR
      • Promethazine (Category C) 5-10 mg Q 6 to 8 hours PO/PR

    If hyperemesis persists and the patient is not dehydrated you may add one of the following (try each agent in turn):

      • Metoclopramide (Category B) 5-10 mg PO q 8 hours PO OR
      • Ondansetron (Category B) 8 mg q 8 to 12 hours PO

      • OR
      • Prochlorperazine (Category C) 5-10 mg Q 6 hour PO

    See also:

 

REFERENCES

    1. ACOG (American College of Obstetrics and Gynecology) Practice Bulletin: nausea and vomiting of pregnancy. Obstet Gynecol. 2004;103(4):803-14. PUBMED

    2. Tufts University Diet & Nutrition Letter 1994; 11(1):6-7

    3 Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. In: The Cochrane Library, Issue 3, 2001. Oxford: Update Software. Search date 2001; primary sources Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register.

    4. Fischer-Rasmussen W, Kjaer SK, Dahl C, Asping U. Ginger treatment of hyperemesis gravidarum. Eur J Obstet Gynecol Reprod Biol 1991;38:1924. (Level II-2)

    5. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial. Obstet Gynecol 2001; 97:57782. (Level I)

    6. Smith C, et al A randomized controlled trial of ginger to treat nausea and vomiting in pregnancy.
    Obstet Gynecol. 2004 Apr;103(4):639-45.  PMID: 15051552

    7. Portnoi G - Prospective comparative study of the safety and effectiveness of ginger for the treatment of nausea and vomiting in pregnancy. Am J Obstet Gynecol. 2003 Nov;189(5):1374-7.
    PMID: 14634571

    8. Belluomini, J., Litt, R.C., Lee, K.A. and Katz, M. Acupressure for nausea and vomiting of pregnancy: a randomized, blinded study Obstetrics & Gynecology 1994;84:245-248.

    9. Roscoe JA, Matteson SE.Acupressure and acustimulation bands for control of nausea: A brief review. Am J Obstet Gynecol. 2002;186:1054-1058.

    10. Sahakian, V., Rouse, D., Sipes, S., Rose, N. and Niebyl, J. (1991) Vitamin B6 is effective therapy for nausea and vomiting of pregnancy: a randomized, double-blind placebo-controlled study. Obstetrics & Gynecology

    11. Magee LA, Mazzotta P, Koren G. Evidence-based view of safety and effectiveness of pharmacologic therapy for nausea and vomiting of pregnancy (NVP). Am J Obstet Gynecol. 2002 May;185(5 Suppl Understanding):S256-61. Review. PMID: 12011897

    12. Levichek Z, Atanackovic G, Oepkes D, Maltepe C, Einarson A, Magee L, Koren G. Nausea and vomiting of pregnancy. Evidence-based treatment algorithm. Can Fam Physician. 2002 Feb;48:267-8, 277.PMID: 11889884

    13.Nelson-Piercy C. Treatment of nausea and vomiting in pregnancy. When should it be treated and what can be safely taken? Drug Saf. 1998 Aug;19(2):155-64. PMID: 9704251

 Created: 3/18/2002  M Hellen Rodriguez, M.D
Update: 11/14/2004  M Hellen Rodriguez, M.D


Copyright © 2009 by San Gabriel Valley Perinatal Medical Group, Inc. All rights reserved. www.peridocs.com . Reproduced with permission.
 



 

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