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Hyperemesis Gravidarum

For further information, see CMDT Part 19-07: Vomiting of Pregnancy & Hyperemesis Gravidarum

Key Features

  • Persistent severe vomiting during pregnancy

Clinical Findings

  • Weight loss

  • Dehydration

  • Starvation ketosis

  • Hypochloremic alkalosis

  • Hypokalemia

  • Mild elevation in liver enzymes

Diagnosis

  • Pregnancy test (beta-hCG)

  • Thyroid-stimulating hormone (TSH) and free T4 should be checked because thyroid dysfunction can be associated

Treatment

  • Hospitalization with nothing by mouth and intravenous fluids and vitamins as indicated

  • Antiemetics

    • Promethazine, 12.5–25 mg orally, rectally, or intravenously every 4–6 hours

    • Metoclopramide, 5–10 mg orally or intravenously every 6 hours

    • Ondansetron, 4–8 mg orally or intravenously every 8 hours

      • Has been associated in some studies with congenital anomalies

      • Data are limited, but the risks and benefits of treatment should be addressed with the patient

  • As soon as possible, start a dry diet with 6 small daily feedings

  • Once stabilized, patients may remain at home, even if intravenous fluids are required

  • To limit the risk of teratogenicity, drug use in the first half of pregnancy should be limited to those of major importance to life and health (Tables 19–1 and 19–2)

  • Total parenteral nutrition is rarely necessary

Table 19–1.Common drugs that are teratogenic or fetotoxic.1
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Table 19–1. Common drugs that are teratogenic or fetotoxic.1

ACE inhibitors

Alcohol

Androgens

Angiotensin-II receptor blockers

Antiepileptics (phenytoin, valproic acid, carbamazepine)

Benzodiazepines

Cyclophosphamide

Diazoxide

Diethylstilbestrol

Disulfiram

Ergotamine

Estrogens

Griseofulvin

Isotretinoin

Lithium

Methotrexate

Misoprostol

NSAIDs (third trimester)

Opioids (prolonged use)

Radioiodine (antithyroid)

Reserpine

Ribavirin

Sulfonamides (second and third trimesters)

Tetracycline (third trimester)

Thalidomide

Tobacco smoking

Warfarin and other coumarin anticoagulants

1Many other drugs are also contraindicated during pregnancy. Evaluate any drug for its need versus its potential adverse effects. Further information can be obtained from the manufacturer or from any of several teratogenic registries around the country.

Go to https://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm134848.htm for more information.

ACE, angiotensin-converting enzyme; NSAIDs, nonsteroidal anti-inflammatory drugs.

Table 19–2.Drugs and substances that require a careful assessment of risk before they are prescribed for breastfeeding women.1
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Table 19–2. Drugs and substances that require a careful assessment of risk before they are prescribed for breastfeeding women.1
...
Drugs Concern
Atenolol Hypotension and bradycardia in the infant. Metoprolol and propranolol are preferred.
Ciprofloxacin Adverse effects on fetal cartilage and bone. Must weigh risks versus benefits.
Codeine, oxycodone CNS depression. Unpredictable metabolism.
Cyclophosphamide Neonatal neutropenia. No breastfeeding.
Diphenhydramine Present in very small quantities in milk; sources are conflicting with regard to its safety.
Fluoxetine Present in breast milk in higher levels than other SSRIs. Watch for adverse effects like an infant’s fussiness and crying.
Lisinopril Unknown effects. Captopril or enalapril is preferred if an ACE inhibitor is needed.
Lithium

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