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Prescription, OTC therapies improve nausea, vomiting in pregnancy, hyperemesis gravidarum

Various interventions improved the symptoms of nausea and vomiting in pregnant women who may or may not have hyperemesis gravidarum, according to a systematic review published in JAMA.

Catherine McParlin, PhD, from Newcastle Upon Tyne Hospitals NHS Foundation Trust, and colleagues found that some therapies, such as ginger, metoclopramide and ondansetron, were helpful, but data are mixed.

"Nausea and vomiting in pregnancy is a common but debilitating condition affecting up to 85% of women," McParlin and colleagues noted. "The most severe form, hyperemesis gravidarum, affects 0.3% to 3% of pregnant women and is characterized by intractable vomiting, dehydration, electrolyte imbalance, ketosis, nutritional deficiencies, and weight loss. Symptoms usually start by 6 to 8 weeks’ gestation and subside before 20 weeks. In severe cases, women may require prolonged hospitalization and support from enteral or parenteral nutrition."

The researchers used databases including MEDLINE, EMBASE and Clinicaltrials.gov to search for trials on interventions for vomiting and nausea during pregnancy or hyperemesis gravidarum through June 2016. This process identified 78 studies with 8,930 participants; 67 were randomized clinical trials and 11 were nonrandomized studies.

McParlin and colleagues gave each therapy an evidence grade (A-C) and recommendation (I-III), which were based on the American Heart Association scale. They separated the treatments into three categories: first-line treatments, which are typically initiated by women themselves and include lifestyle changes and over-the-counter therapies; second-line treatments, which are typically initiated by health care providers when women first seek medical care, and include antiemetic drugs, IV fluids and electrolyte replacement; and third-line treatments, which are typically initiated in a hospital setting for women with severe symptoms and include corticosteroids and supportive therapies.

For first-line treatments of mild-to-moderate symptoms, they reported that the following therapies improved mild symptoms:

• ginger (level A, class IIa);
• acupressure (level A, class IIa); and
• vitamin B₆ — pyridoxine (level A, class IIa).

The benefit was unclear for nerve stimulation (level B, class IIb) and acupuncture (level A, class IIb).

For second-line treatments of moderate-to-severe symptoms, they reported that the following therapies improved mild-moderate symptoms:

• vitamin B₆ — pyridoxine/doxylamine (level A, class IIa);
• antihistamines (level B, class IIa); and
• dopamine receptor antagonists (level A, class IIa).

In addition, the combination of psychotherapy and vitamin B₆ was more beneficial than vitamin B₆ alone (level B, class IIa) and serotonin receptor antagonists improved symptoms of all severities (level A, class IIa). Dextrose saline was more beneficial in improving moderate-severe symptoms than normal saline (level B, class IIa). McParlin and colleagues also reported that outpatient treatment was not found to be better or worse than inpatient IV therapy for moderate symptoms (level A, class IIa).

For third-line treatments of moderate-to-severe symptoms, they reported that transdermal clonidine improved symptoms, but was not an established treatment (level B, class IIb) and the benefits of corticosteroids were not certain, but physicians can still consider it as a potential treatment in severe cases (level A, class IIb).

"For mild symptoms of emesis and nausea of pregnancy, ginger, pyridoxine, antihistamines, and metoclopramide were associated with greater benefit than placebo," McParlin and colleagues concluded. "For moderate symptoms, pyridoxine-doxylamine, promethazine, and metoclopramide were associated with greater benefit than placebo. Ondansetron was associated with symptom improvement for a range of symptom severity. Corticosteroids may be associated with benefit in severe cases. Overall, the quality of evidence was low." – by Chelsea Frajerman Pardes

Disclosure: The authors report no relevant financial disclosures.