None of the information provided by HGA 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 inline with the Royal College of Obstetricians and Gynaecologists Green Top Guidelines for the Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum. You can find the guidelines here. It may be helpful to print this fact sheet out and take it with your 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 women 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 IV fluid therapy 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 unable or unwilling to give you medication and you want to pursue this treatment option please contact us for information. If you want to avoid taking prescription medication, or want to try additional treatments, see our information about Alternative Therapies below.
Most effective medications for nausea and vomiting are not licensed in pregnancy because pharmaceutical companies usually exclude pregnant women from drug trials. This is not a situation which is likely to change as drug companies do not want to risk lawsuits which may arise if a woman in a trial gives birth to a baby with a birth defect. 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 required such as cases where women have taken them not knowing they were pregnant, or where their sickness has been so severe that they took them as the benefit outweighed the possible risk. That said, there are a number of drugs which are considered safe to take in pregnancy.
Our recommended treatment protocol is as follows:
Mild to moderate NVP or HG
Metoclopramide 10mg orally twice daily (first dose 20-30 minutes before getting out of bed, second dose 1-2pm)
Doxylamine 12.5-25 mg orally at night OR Prochlorperazine 25mg suppository at night (first dose 20-30 minutes before getting out of bed, second dose 1-2pm)
Ranitidine 150mg orally twice daily
Treatment in Day Unit, ED or inpatient
IV fluid replacement with normal saline 1-2L over 1-4 hours
Antiemetics (try sequentially)
Metoclopramide 10mg IV or orally (if tolerating orally)
Prochlorperazine 10mg IM (intramuscular injection) or 25mg orally (if tolerating orally)
Ondansetron 4mg IV or orally (if tolerating orally)
IV potassium, magnesium, thiamine
Ranitidine 50mg IV or 150mg orally (if tolerating orally)
Treatment upon discharge
Continue antiemetics depending on response
Metoclopramide 10mg orally twice daily OR Ondansetron 4mg orally twice daily (first dose 20-30 minutes before getting out of bed, second dose 1-2pm)
Doxylamine 12.5-25 mg orally at night OR Prochlorperazine 25mg suppository at night
Add regular therapy for gastroesophageal reflux
Ranitidine 150mg orally twice daily
Rabeprazole 20mg orally twice daily
Continue antiemetics, acid suppression and IV fluids as required
The best way of treating Hyperemesis is to layer medications together, if a patient is not responding, adding another layer to her medications will help control another symptom. NVP and HG are multifaceted conditions that require the management of a number of symptomatic responses. Since antihistamines control nausea, antiemetics vomiting and antacids, like Ranitidine, 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 stabilising the patient. If treatment is started early enough then further treatment may not be needed. 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.
If treatment is started early enough then further treatment may not be needed. In second and subsequent pregnancies this treatment should be used as a prophylactic (taken before conception to prevent you getting ill), 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 that women 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 and suffering with NVP / HG please click here for more information on safe medications you can take. This information is provided by Wendy Jones, PhD MRPharmS, Breastfeeding and Medication.