Medications

Many women will be hesitant, or even resistant, to taking medication while pregnant. While there are risks associated with many of the recommended medications, these need to be weighed against the risks of leaving her symptoms untreated. 

Mild to moderate NVP can often be managed without the need for pharmacological intervention. In more severe cases, however, where symptoms are impacting a woman's ability to eat and/or drink and weight loss is occurring the need for treatment increases. While concerns around medication use in pregnancy are valid, failing to treat NVP or HG can do more harm to mother and child than any medication. 

The treatments listed below are recommended by the SOMANZ Guidelines for Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum. Increasingly, evidence shows the potentially harmful effects of malnutrition and dehydration during pregnancy, including the first trimester. Malnutrition in early pregnancy has been found to have lifelong cardiometabolic consequences for the offspring. Not treating a woman effectively enough to ensure she is able to eat and drink is riskier than leaving her untreated. 

Additionally, the physical and psychological effects of profound and prolonged nausea and/or vomiting on the mother should not be underestimated and quality of life should be a factor in decision making about treatments. A recent systematic review of qualitative evidence found that even moderate NVP could have a seriously detrimental effect on women's lives and mental health.

According to the SOMANZ Guidelines any plan for the holistic management of NVP and HG must include: 

• Interventions to reduce nausea, retching and vomiting 

• Management of associated gastric dysmotility ie gastroesophageal reflux and constipation 

• Maintenance of hydration, fluid and electrolyte replacement 

• Maintenance of adequate nutrition including the provision of vitamin supplements where required 

• Psychosocial support 

• Monitoring and prevention of side effects and adverse pregnancy and fetal outcomes 

And the following considerations for treatment choices in NVP and HG should be made: 

• Establish reasonable targets for the treatment plan and manage patient expectation ie. aim for the ability to eat and drink adequately without necessarily complete resolution of NVP 

• Discontinue prenatal multivitamins if they are contributing to symptoms. Many women report an improvement in symptoms after discontinuation of prenatal multivitamins that include iron. The two critical micronutrients which should be continued, if possible, are iodine (150 mcg per day) and folate (at least 400 mcg per day) 

• The timing of taking medications should take into account the pattern of a woman’s symptoms over a 24 hour period. Symptoms often fluctuate during the day and night and therapy should reflect these individual differences

• The choice of antiemetic should be individualised, based on the woman’s symptoms, previous response to treatment and potential side effects: 

• If an antiemetic is ineffective at maximal dose, discontinue before commencing an alternate agent 

• If an antiemetic is partially effective, optimise dosage and timing, and only add additional agents after maximal doses of the first agent have been trialled 

• Oral therapy is usually commenced first and parenteral or subcutaneous treatment reserved for severe cases

• Written instructions should be given regarding titrating therapy (up and down) as symptoms fluctuate, deteriorate or improve 

• Regular review of therapy is required in all cases

Medications for the treatment of NVP and HG Treatment of NVP and HG may require a range of agents including: 

• Antiemetics: vitamin and prescribed 

• Acid suppression 

• Stool softeners 

• Steroids 

• Other-supplements 

The best way of treating NVP and HG is to layer medications together. If a patient is not responding to first-line treatments, adding another layer to her medications may improve symptom management. NVP and HG are multifaceted conditions that require the management of a number of symptomatic responses. 

It is important to remember that pharmacological treatment for NVP and HG is only one part of the holistic management of a woman’s condition. Other elements will include, where appropriate, non-drug measures, psychosocial support and ongoing obstetric/midwifery care. 

Almost all pharmacological treatment is “off-license” and based on historical experience with the limited amount of high-quality research data described in small trials or systematic reviews or meta-analyses. In all cases, a rational assessment of maternal and fetal risk, particularly teratogenesis, needs to be determined based on the woman’s circumstances. 

A note on ginger:

Upon reading the SOMANZ guidelines you will see that ginger is recommended as a first-line treatment for mild NVP. We have chosen not to include this on our website, or in any associated resources because we do not believe that it is an appropriate treatment for suffering women. Evidence shows no therapeutic advantages in using ginger to treat NVP. Additionally, we believe suggesting it contributes to negatively to a suffering woman's state of mind.

Commencement and titration of pharmacological treatment for NVP or HG: 

Mild-moderate NVP: 

• Start with Pyridoxine (Vitamin B6)

• Add oral antihistamine or dopamine antagonist if needed 

Moderate-severe NVP or inadequate response to initial treatment: 

• Consider IV/IM antihistamine or dopamine antagonist 

• Excessive sedation or inadequate response: add /substitute oral or IV serotonin antagonist at least during daytime 

• Add acid suppression therapy

Refractory NVP or HG: 

• Consider corticosteroids in addition to other antiemetics 

• Intensify acid suppression 

• Manage/prevent constipation with stool softeners

For more information on planning a treatment protocol for your patient please consult the full SOMANZ Guidelines available here. 

MEDICATION GUIDELINES

Dosing: BD: twice a day; TDS: three times per day; QID: four times per day; max: maximum recommended total daily dose; S: sedating, preferably use nocte only

Note: * indicates treatments that should not be combined with a similar mechanism of action and side effects

For more information on pharmacological therapies please consult the full SOMANZ Guidelines available here. 

INTRAVENOUS FLUIDS

Women will often delay seeking treatment for NVP and HG if they don’t realise their symptoms have gone beyond what can be reasonably expected from first trimester sickness. This means that it may be necessary to accelerate her treatment to correct the damage of weeks of untreated illness. IV fluids and electrolyte replacement play an important role in both reversing dehydration and managing NVP and HG long term. They have been shown to reduce vomiting and are, therefore, a valuable part of any treatment plan.