Treatment
None of the information provided by Hyperemesis Australia is meant to suggest any medical course of action. Instead, the information is intended to inform and to raise awareness so that these issues can be discussed by/with qualified Health Care Professionals. The responsibility for any medical treatment rests with the prescriber. All of the following information is in line with the Society of Obstetric Medicine of Australia and New Zealand Guideline For Management Of Nausea And Vomiting Of Pregnancy And Hyperemesis Gravidarum (2019). It may be helpful to print this document out and take it with you to doctor’s appointments.
Contrary to popular belief, there are a number of effective antiemetic (anti-nausea) medications that can be taken in the first trimester of pregnancy. Hyperemesis Gravidarum is typically at its worst in the first trimester and it is important that treatment is begun without delay. Research indicates that antiemetics are more effective the sooner they are begun, and the most recent treatment protocols recommend quick intervention. There is a tendency for GPs to leave sufferers without help until they have lost weight and require IV fluids for dehydration. This is not considered to be best practice. HG can be managed so that no in-patient treatment is required. Weight loss and dehydration should not be a prerequisite for either diagnosis or treatment.
Unfortunately, many GPs are unaware of modern treatment protocols for the management of HG. If your GP is unwilling to give you medication and you want to pursue this treatment option please contact us for information.
Most effective medications for nausea and vomiting are not licensed in pregnancy because pharmaceutical companies usually exclude pregnant people from drug trials. This is not a situation that is likely to change as drug companies do not want to risk lawsuits that may arise if a trial participant gives birth to a baby with a congenital anomaly. This is not to say that these drugs are harmful in pregnancy, it's to say that while safety has not been definitively proven, no evidence of harm has been found either. In order to assess their safety in pregnancy, other sources of information are used such as cases where these medications have been taken before pregnancy was detected. That said, there are a number of drugs that are considered safe to take in pregnancy.
The Society of Obstetric Medicine of Australia and New Zealand recommended treatment protocol is as follows:
Mild NVP or HG
Pyridoxine (Vitamin B6) 10-50mg orally four times daily
Moderate NVP or HG
One of the following taken orally up to three times daily:
Doxylamine 6.25-25mg
Prochlorperazine 5mg
Promethazine 25mg
Metoclopramide 10mg
Ondansetron 4-8mg taken orally two to three times daily
To avoid sedation and for prolonged use i.e. more than 5 days, use Ondansetron during the day
Additional treatment:
H2 antagonist eg. Ranitidine 150-300mg orally twice daily
IV fluids 1-3 x per week as required
Severe HG
Ondansetron 4-8mg taken orally two to three times daily
Nighttime dosing with one of the following:
Metoclopramide 10mg IV or orally (if tolerating orally)
Prochlorperazine 5-10mg IV or orally (if tolerating orally)
Doxylamine 12.5-50mg IV or orally (if tolerating orally)
Cyclizine 12.5-50mg IV or orally (if tolerating orally)
Consider adding:
Prednisone: commence 40-50mg daily or hydrocortisone 100mg IV twice daily and wean Prednisone over 7-10 days to minimal effective dose. May need to continue until symptoms resolve
Additional Treatment:
Cease H2 antagonist and substitute with a proton pump inhibitor twice daily eg. Esomeprazole or Rabeprazole 20mg
IV fluids 1-3 x per week as required. Add IV thiamine if poor oral intake or administering dextrose
Unfortunately, there is no one medication that tackles the many symptoms of NVP and HG so the best way to treat them is to layer medications together. NVP and HG are multifaceted conditions that require the management of a number of symptomatic responses. Since antihistamines control nausea, antiemetics vomiting and antacids stomach acid and reflux, all are required to fully control the illness. Layering them allows for all bases to be covered and ensures a greater chance of successfully controlling symptoms.
In second and subsequent pregnancies first-line treatment should be used as a prophylactic (taken before conception to prevent the onset of symptoms), pre-empting the severity experienced in previous pregnancies. It is most effective when used as early as possible.
Unfortunately, in the case of many first pregnancies, it is often a number of weeks before treatment is started and therefore too late for the 'first step' medications to have much impact, meaning you may need to move on to stronger medication to obtain adequate symptom control.
If you are not managing to take medications orally or are throwing them up after taking them then many of the drugs can be taken in suppository form (put inside your back passage and absorbed into your bloodstream that way). Some can be given first off as an injection by your doctor in the hope you would then keep the next dose down orally. Some medications such as Ondansetron have 'oro-dispersal' versions, i.e. it melts on your tongue, which some women find easier to manage.
If you are currently breastfeeding or chestfeeding and suffering from NVP or HG the Australian Breastfeeding Association has information to help you find out what medication is safe to take.