The American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins has released a document is to review the best available evidence about the diagnosis and management of nausea and vomiting of pregnancy. The purpose of this document is to review the best available evidence about the diagnosis and management of nausea and vomiting of pregnancy and it has been published online in Journal of Obstetrics & Gynecology. This is an update on earlier one published in September 2015.
Nausea and vomiting of pregnancy is a common condition that affects the health of a pregnant woman and her fetus and it should be distinguished from nausea and vomiting related to other causes.The symptoms of nausea and vomiting of pregnancy manifest before 9 weeks of gestation in almost all affected women. In case a pregnant woman experiences nausea and vomiting for the first time after 9 weeks of gestation, other conditions should be considered in the differential diagnosis including cholelithiasis or diabetic gastroparesis.
Nausea and vomiting affecting women during pregnancymay range from mild retching to a more severe form hyperemesis gravidarum, Hyperemesis gravidarum can be debilitating and deplete a woman’s nutrition and is most common indication for admission to the hospital during the first part of pregnancy .Hyperemesis gravidarum is diagnosed by exclusion with patient having severe and persistent vomiting not related to other causes leading to acute starvation and ketonuria. There may be weight loss to the tune of at least 5% of pre -pregnancy weight. This may be accompanied by Electrolyte, thyroid, and liver abnormalities .
Level A recommendations :
- Pregnant women should use Vitamin B6 (pyridoxine) alone or in combination with doxylamine as first-line pharmacotherapy.
- Women should be encouraged to take prenatal vitamins for 1 month before fertilization as it may decrease the incidence and severity of nausea and vomiting during pregnancy.
- The American College of Obstetricians and Gynecologists does not recommend any antithyroid medication for abnormal maternal thyroid tests caused by gestational transient thyrotoxicosis or hyperemesis gravidarum, or both, and .
Level B recommendations:
- Ginger is a nonpharmacologic treatment as it has been found useful in the treatment of nausea and vomiting of pregnancy.
- Methylprednisolone may be used in severe nausea and vomiting of pregnancy as a last-resort because of its risk profile.
Level C recommendations:
- The treatment of nausea and vomiting of pregnancy should be instituted early as it may prevent it from progressing to a serious form of hyperemesis gravidarum.
- Intravenous hydration ought to be given to patients who are unable to tolerate oral fluids for a prolonged period leading to dehydration
- Strongly consider correction of ketosis and vitamin deficiency. Include dextrose and vitamins in therapy in cases of prolonged vomiting; consider administering thiamine before dextrose infusion to prevent Wernicke encephalopathy.
- All those women with hyperemesis gravidarum who do not respond to medical therapy and are not able to maintain their weight, enteral tube feeding (nasogastric or nasoduodenal) should be started as first-line treatment to support nutrition .
- Only as a last resort in women with hyperemesis gravidarum, peripherally inserted central catheters may be used as serious complications are associated with this intervention leading to maternal morbidity.
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Dr. Kamal Kant Kohli
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