Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 19-07: Vomiting of Pregnancy & Hyperemesis Gravidarum + Key Features Download Section PDF Listen +++ ++ Persistent severe vomiting during pregnancy + Clinical Findings Download Section PDF Listen +++ ++ Weight loss Dehydration Starvation ketosis Hypochloremic alkalosis Hypokalemia Mild elevation in liver enzymes + Diagnosis Download Section PDF Listen +++ ++ Pregnancy test (beta-hCG) Thyroid-stimulating hormone (TSH) and free T4 should be checked because thyroid dysfunction can be associated + Treatment Download Section PDF Listen +++ ++ 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 Graphic Jump LocationTable 19–1.Common drugs that are teratogenic or fetotoxic.1View Table||Download (.pdf) 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 Graphic Jump LocationTable 19–2.Drugs and substances that require a careful assessment of risk before they are prescribed for breastfeeding women.1View Table||Download (.pdf) 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 Circulating levels in the neonate are variable. Follow infant’s serum creatinine and blood urea nitrogen levels and thyroid function tests. Tetracyclines Adverse effects on fetal bone growth and dental staining. Valproic acid Long-term effects are unknown. Although levels in milk are low, it is teratogenic, so it should be avoided if possible. 1The above list is not all-inclusive. For additional information, see the below reference from which this information is adapted or the online drug and lactation database, Lactmed, at http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm. ACE, angiotensin-converting enzyme; CNS, central nervous system; SSRIs, selective serotonin reuptake inhibitors. Data from Rowe H et al. Maternal medication, drug use, and breastfeeding. Pediatr Clin North Am. 2013 Feb;60(1):275–94.