Early treatment of NVP is recommended to prevent progression to HG. Treatment of NVP with vitamin B6 (pyridoxine) alone or plus doxylamine is safe and effective and should be considered the first-line pharmacotherapy.
11 A multicenter randomized controlled trial (RCT) evaluating this combination, found significant symptomatic improvement.
23 Relief of NVP with dopamine antagonists (metoclopramide, promethazine, prochlorperazine, or chlorpromazine) given orally, rectally, intramuscularly, or intravenously has been demonstrated in large groups of patients.
11 Antihistamines, such as dimenhydrinate and diphenhydramine, have been shown to be effective and are frequently used.
11 Evidence is limited on the safety and efficacy of the serotonin 5-HT3 inhibitor, ondansetron. In a small double-blind RCT, ondansetron was found to be more effective than the combination of doxylamine and vitamin B6 (pyridoxine).
24 However, serious adverse effects such as QT interval prolongation, especially in patients with underlying heart problems, hypokalemia, or hypomagnesemia, have been reported.
25 The risk of birth defects in the first trimester is still a matter of debate. Thus, women should be counseled weighing the risks and benefits of ondansetron use before 10 weeks.
11 Corticosteroids for HG should be used with caution and avoided as first-line agents, especially before 10 weeks of gestation, as studies have reported an association between oral cleft and methylprednisolone.
26 The use of antidepressants has been suggested for refractory HG. Mirtazapine was found to be beneficial in cases of HG in the context of depression.
9
Hospitalization is recommended if oral intolerance is a concern or there is lack of response to outpatient management, a change in vital signs or in mental status, and if persistent weight loss occurs.
11 Intravenous hydration should be used. Correction of ketosis and vitamin deficiency should be considered. Dextrose and vitamins should be included, and in severe cases thiamine should be administered before dextrose infusion to prevent Wernicke encephalopathy.
27 Additionally, serum electrolytes must be monitored and corrected accordingly.
9 Enteral tube feeding (nasogastric or nasoduodenal) should be used to provide nutritional support in woman with HG who cannot maintain appropriate weight, especially if malnutrition is present.
11