Pregnancy: Management of Nausea & Vomiting

 Adapted from www.uptodate.com

NVP: nausea and vomiting of pregnancy; HG: hyperemesis gravidarum; OTC: over the counter; P6: pericardium 6; PO: orally; IV: intravenously; PR: per rectum; IM: intramuscularly; Q: every; h: hours; min: minutes; PRN: as needed; BID: two times per day; TID: three times per day; QID: four times per day.* GERD: gastroesophageal reflux disease, which can be treated with H2 receptor antagonists (eg, ranitidine and cimetidine).

General 

1. Start patients with mild cases of NVP on non-pharmacologic interventions.
   • Dietary changes first.
   • Lifestyle modifications (could be disruptive to work day, so reserve for when feasible).
2. If diet and lifestyle changes alone are not working, consider complementary and alternative medicine interventions.
   • Acupressure (NOTE: Should be removed when sleeping at night).
   • Ginger supplement or ginger tea.
3. For patients with persistent NVP or moderate NVP to HG, initiate the non-pharmacologic interventions above plus pharmacotherapy. NOTE: Use clinical judgment; if dehydration is suspected or inability to eat/drink for greater than 12 hours, then go directly to IV fluid replacement + ondansetron 4 mg IV Q 8 h. Otherwise follow a systematic approach, adding/substituting a new agent as indicated in the flow chart.
   • We prefer to treat outpatients with PO drugs, but IV drugs are also often feasible with home health care.
   • If the patient is not achieving control of NVP with one drug, then proceed to the next step in the algorithm.
   • We individualize regimens based upon the patient's side effects and response (control of NVP).
   • Pregnant women with NVP/HG may go on and off drug treatment and may switch back and forth among several different drugs and among oral, IM, PR, and IV routes of administration. We individualize therapy depending on how the patient is responding to her current treatment.

Management of Hyperemesis GravidarumKing Edward Memorial Hospital
Clinical Guidelines -Section C Perth Western Australia 

References:

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3410506/
2. www.uptodate.com
3. Management of Hyperemesis GravidarumKing Edward Memorial Hospital Clinical Guidelines -Section C Perth Western Australia