This week on the podcast we examine the common and very troublesome problem of vomiting in pregnancy, from mild morning sickness to the more severe hyperemesis gravidarum.
Take home messages:
- Standard investigations include FBC, UEC, LFT, TFTs, urinalysis and obstetric ultrasound
- In severe cases, consider secondary causes of vomiting such as urosepsis, GI or neurological pathology
- Dietary advice, ginger and P6 acupressure have mixed evidence but are unlikely to do harm and useful for some patients
- Pyridoxine (vitamin B6) and doxylamine have the best evidence for safety and efficacy and are recommended for first line
- Second line options include metoclopramide, prochlorperazine and promethazine which are all considered safe in early pregnancy
- If significant ketonuria, electrolyte imbalance or dehydration, refer for intravenous hydration, parenteral anti-emetics and thiamine
References & Resources:
Treatment of Nausea and Vomiting In Pregnancy – Australian Prescriber 2014
A Survey of Prescribing for Management of Nausea and Vomiting in Pregnancy in Australasia – ANZJOG 2013
Hyperemesis Gravidarum – O&G Magazine 2014
and Letter to the Editor: Nausea and Vomiting in Pregnancy – O&G Magazine 2014
Interventions for Treating Hyperemesis Gravidarum – Cochrane Library 2013
Antenatal Clinical Practice Guidelines (Australia)
ACOG guideline (USA)
SOGC guideline (Canada)
NICE guideline (UK – but appears to be geoblocked from elsewhere)
We have made a brief correction to the podcast regarding risks with IV rehydration, you might notice an erroneous comment regarding central pontine demyelination if you downloaded it pre-correction. Hopefully no confusion caused by this, and podcast now updated 🙂
and another post-publication edit – I finally got my hands on the NICE guidelines it turns out that for our friends in the UK, antihistamines are in favour (cyclizine and promethazine) but B6 is not recommended on account of concerns re: peripheral neuropathy. Just goes to show there is still a lot of grey area in this subject!
Thanks Penny. Was very useful. What about the sedating effects of the antihistamines and restavit? Do you find that prohibitive in their use? I know personally phenergen knocks me out for about 36 hours eve just 2-3 mg is very sedating for myself ( not used in pregnancy so don’t know if that is different). Just wondering cos if these women can’t function at work from vomiting if using sedating agents us really giving the better quality of life or just less vomiting?
Hey Bec – yep, you’re absolutely right. Although they are usually limited to nocte use, sedation is indeed the main drawback with the anthistamines. Always a matter of weighing up the pros and cons.
Hi. Great discussion. I find B6 the best place to start, phenergan at night but usually end up needing to prescribe maxolon / stemetil for first thing in the morning / daytime (often when symptoms are at their worst) because of sedating side effects.
On several occasions i have sent a letter to my (regional) hospital medical director asking for them to supply ondansetron for a few months for patients with significant hyperemesis gravidarium if the patient can’t afford it. This is obviously cheaper than repeated ED presentations or admissions and is often available via tertiary centres (I believe equality is important). I’ve had luck so far with this approach as the cost-benefit analysis is pretty clear for the few cases this applies to and makes the world of difference for some patients.
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Hi, thank you for your great episodes. Is it possible to download them?
You can access the podcast also through itunes or your favourite podcast app. We don’t currently publish the download links but if you had a specific episode you wanted to download I could send you a link.