Medical Care: Initial management should be conservative and may include reassurance, dietary recommendations, and support. Alternative therapies may include acupressure and hypnosis.
Recent studies have not shown a clear benefit of acupressure in patients with HEG. However, a randomized study by Rosen et al using pressure or electrical stimulation at the P6 (or Neguian) point on the inside of the wrist showed some efficacy in reducing nausea and vomiting and promoting weight gain in women with HEG.
More controversy surrounds the benefit of hypnosis, but it has been studied in some cases of HEG and has been shown to be beneficial.
Psychological counseling may be considered.
Reserve pharmacologic therapy for severe and refractory cases. First-line outpatient drug therapy can include oral pyridoxine. If vomiting persists, doxylamine may be added to the pyridoxine or conventional antiemetics may be administered.
Initiate a full laboratory workup in cases of severe refractory HEG (weight loss or the presence of more than trace urine ketones). Outpatient or home intravenous hydration should be considered. If medications and outpatient hydration fail or if severe electrolyte disturbances persist, inpatient admission for intravenous hydration may be necessary.
If hypokalemia is severe or symptomatic, calcium should be replaced parenterally. Before administering intravenous potassium, renal function should be evaluated. Potassium is usually added to intravenous fluid to achieve a concentration of 40 mEq/L (and not >80 mEq/L). An infusion rate of 10 mEq of potassium per hour should be safe as long as urine output is adequate.
When administrating intravenous hydration to a patient who has severe volume depletion in an effort to prevent the development of Wernicke encephalopathy, avoid intravenous glucose until intravenous thiamine has been administered.
If vomiting is recurrent with intravenous hydration and conventional medications fail, a trial of oral corticosteroids is appropriate. Failure of this regimen necessitates consideration of enteral nutrition (either central or peripheral total parenteral nutrition).
Diet: Initial suggestions for dietary modification in patients with nausea and vomiting associated with pregnancy include the following:
Eat when hungry, regardless of normal meal times.
Eat frequent small meals.
Avoid foods high in fat.
Avoid spicy foods.
Avoid emetogenic foods or smells.
Increase intake of bland or dry foods.
Eliminate pills with iron.
High protein snacks are helpful.
Crackers in the morning may be helpful.
Increase intake of carbonated beverages.
Other suggested foods include herbal teas containing peppermint or ginger, other ginger-containing beverages, broth, crackers, unbuttered toast, gelatin, or frozen desserts.
Preconception use of prenatal vitamins may decrease nausea and vomiting associated with pregnancy.
Activity: Some patients note improvement of nausea and vomiting with decreased activity and increased rest. Other patients suggest that fresh outdoor air may improve symptoms.
DRUG TREATMENT : Antihistamines, antiemetics of the phenothiazine class, and promotility agents (eg, metoclopramide) have been used in the treatment of nausea and vomiting during pregnancy.
Vitamin B-6 (pyridoxine) has also been studied in the treatment of nausea and vomiting during pregnancy and reduced nausea and vomiting when compared with placebo.
Ondansetron (Zofran), a serotonin-receptor antagonist, showed no benefit over the antiemetic promethazine (Phenergan), at much greater cost. It may be reserved for refractory cases. A meta-analysis of 6 randomized, double-blind trials showed that ginger was an effective treatment for HEG.
Steroids may be used in patient's refractory to standard therapy. Promethazine (Phenergan) was compared with methylprednisolone in a randomized, double-blind, controlled trial. Methylprednisolone appeared to decrease the rate of readmission for HEG; however, the patients randomized to promethazine had a significantly longer duration of symptoms prior to treatment.
However, concerns exists about association between oral clefts and methylprednisolone use in the first trimester; thus, it should be used with caution before 10 weeks of gestation
1. VITAMINS : ESSENTIAL FOR NORMAL DNA SYNTHESIS & PLAY A ROLE IN VARIOUS METABOLIC PROCESSES
- PYRIDOXINE
2. ANTIEMETICS :
- PROCHLORPERAZINE
- PROMETHAZINE
- CHLORPROMAZINE
- TRIMETHOBENZAMIDE
- METOCLOPRAMIDE
- ONDANSETRON
3. CORTICOSTEROIDS :
- METHYLPREDNISOLONE
4. ANTIHISTAMINES :
- MECLIZINE
- DIPHENHYDRAMINE