Hyperemesis Gravidarum

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Hyperemesis Gravidarum:

• Hyperemesis Gravidarum is severe nausea and vomiting during early pregnancy, typically starting prior to 9 weeks gestation.
  • NOT associated with significant pain
  • Do not turn off your brain, rule out serious causes before diagnosing the patient with hyperemesis gravidarum
• Workup includes basic chemistry and urinalysis to evaluate electrolytes and signs of starvation ketosis
• Confirm IUP
  • Molar pregnancies or multiple gestation pregnancies can cause a higher amount of HCG and these patients are more likely to have hyperemesis.

• First line treatment for this condition is Vitamin B6 and doxylamine. Some women will respond to P6 acupressure or ginger pills.
• Treatment includes fluids with a source of glucose and antiemetics.
  
  • Promethazine, metoclopromide, and ondansetron are all recommended options by the American College of Obstetrics and Gynecology (ACOG)[1].
  • Ondansetron
    • There are insufficient data on fetal safety with ondansetron use and further studies are warranted
    • There have been studies that fetal exposure to ondansetron increases the risk of pediatric cardiac abnormalities and cleft palate; however, the data is inconsistent.
    • Individual studies of the association between ondansetron and congenital malformations are inconsistent, with some showing an increase in birth defects and others showing no difference [2,3,4]. A recent systematic review of ondansetron use in early pregnancy found eight studies that were adequate for inclusion [5]. Although there was a small increase in the risk of cardiac defects in two of the studies (odds ratio [OR], 2.0; 95% CI; 1.3-3.1 and OR, 1.62; 95% CI; 1.04-2.14), there was no increase in the overall rate of malformations in the ondansetron-exposed patients.
    • ACOG says, “Although some studies have shown an increased risk of birth defects with early ondansetron use, other studies have not. The absolute risk to any fetus is low.”
    • The American College of Obstetrics and Gynecology recommend Ondansetron as an option for patients not controlled on the first line medications Vitamin B6 and doxylamine.
    • Consult with your local Obstetricians

 

1. Erick, Miriam, et al. “ACOG Practice Bulletin 189.” Obstetrics & Gynecology, vol. 131, no. 5, 2018, p. 935., doi:10.1097/aog.0000000000002604.
2. Pasternak B, Svanstrom H, Hviid A. Ondansetron in pregnancy and risk of adverse fetal outcomes [published erratum appears in N Engl J Med 2013;368:2146]. N Engl J Med 2013;368:814–23.
3. Danielsson B, Wikner BN, Kallen B. Use of ondansetron during pregnancy and congenital malformations in the infant. Reprod Toxicol 2014;50:134–7.
4. Einarson A, Maltepe C, Navioz Y, Kennedy D, Tan MP, Koren G. The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study. BJOG 2004;111:940–3.
5. Carstairs SD. Ondansetron use in pregnancy and birth defects: a systematic review. Obstet Gynecol 2016;127:878–83.