The American Association of Clinical Endocrinologists say that methyldopa or nifedepine are preferred in pregnancy
If preeclampsia – use magnesium sulfate
ACE inhibitors should be avoided in pregnancy because they are associated with fetal renal dysgenesis or death if used in second and third trimesters and cardiovascular or central nervous system malformations in the first trimester
CBC, electrolytes, BUN, creatinine
Urine dip for protein and a 24-hour urine collection for creatinine clearance and protein excretion
Recommend discontinuing Lisinopril since it is an ACEI and start her on a beta blocker
Example: Labetalol or Propranolol for first line choice because it is not associated with mild fetal growth restriction like some other beta blockers are like Atenolol
It is important to gain a healthy amount of weight during pregnancy!
Even if you are overweight – pregnancy is not the time to lose weight!
Pre-pregnancy weight Recommended weight gain Underweight (BMI < 18.5) 28 to 40 pounds Normal Weight (BMI 18.5 to 24.9) 25 to 35 pounds Overweight (BMI 25 to 29.9) 15 to 25 pounds Obese (BMI >30) 11 to 20 pounds
Distribution of kilograms, at the end of pregnancy Baby – 3.1 to 3.6 kilograms (6 to 8 pounds) Breasts Increase – 0.5 to 1.5 kilograms (1 to 2 pounds) Increase of uterus - 1 kilogram (1 to 2 pounds) Placenta – 0.5 to 1 kilograms (1 to 2 pounds) Fluids / water / - 1 kilogram (1 to 2 pounds) Blood Increase – 1.5 to 2 kilograms (3 to 4 pounds) Increased body fluids- 1 to 1.5 kilograms(2-3 pounds) Fat and protein- 3 to 4 kilograms (8-10 pounds) Total - 11 to 16 kilograms (25 to 35 pounds)
Can also be called PIH or Pregnancy induced hypertension or Toxemia.
Preeclampsia, which occurs after the 20th week of pregnancy, is characterized by new-onset or worsening hypertension, albuminuria, and hyperuricemia, sometimes with coagulation abnormalities. In some patients, preeclampsia may develop into a hypertensive urgency or emergency and may require hospitalization, intensive monitoring, early fetal delivery, and parenteral antihypertensive and anticonvulsant therapy.
Mild Preeclampsia : high blood pressure, water retention and proteinurea.
Severe Preeclampsia : headache, blurred vision, photosensitivity, N/V, dysuria, pain in the upper right abdomen, SOB, tendency to bruise easily.
The diagnosis of hyperemesis gravidarum should lead to immediate hospitalization of an affected individual in order to restore fluids and replace electrolytes by infusing medication and fluids intravenously.
D5 NS bag containing 100mg thiamine given IV (banana bag)
Electrolyte deficiences are treated: K, Mg, and P are replaced as needed
Vitamin supplementation (particularly vitamins B6, C and thiamine) may also be recommended. Thiamine supplementation is specifically recommended to prevent the development of Wernicke's encephalopathy.
With these treatments, in many cases, vomiting may stop. If vomiting continues, antiemetic drug therapy may be recommended.
Food should not be given orally until vomiting stops and dehydration has been corrected.
Tube feeding or parenteral feeding is appropriate.
After vomiting stops, affected individuals should receive enteral nutritional supplementation as needed to calm nausea. Physicians should then slowly and carefully reintroduce fluids and small, frequent meals into an affected individual's diet. Meals should consist of foods that are high in carbohydrates and low in fat.
No drug is universally approved for treatment of hyperemesis gravidarum and few drugs are considered completely safe during pregnancy.
Choose the drug that targets the main symptom trigger (e.g. motion) she experiences. If there are many triggers, and/or her nausea and vomiting are more severe, start with serotonin antagonists . Intervene early if she has a history of hyperemesis gravidarum .
The risks associated with the medication must be assessed against the potential complications associated with prolonged starvation and dehydration.
Often effective in mothers who have multiple triggers (smell, motion, etc.), a history of hormone sensitivity, and/or moderate to severe vomiting. If a woman has a history of HG that responded to serotonin antagonists, it should be used early and as a first line drug to minimize severity.
IMPORTANT : Effects are dose dependent. Expensive intravenous therapies may sometimes be avoided if higher doses are used. Best taken on a strict schedule and weaned very slowly when asymptomatic for over two weeks. It is not uncommon for women to require this medication until delivery. Different brands may have different effects.
Highly selective antagonists of 5-HT3 receptors in the vagus, chemotrigger zone and gut. Mostly Class B drugs Ondansetron (Zofran) Granisetron (Kytril) Mirtazapine (Remeron) Palonosetron (Aloxi) Dolasetron (Anzemet)
Effective for MILD cases of nausea and vomiting during pregnancy or as adjunctive therapy with more potent medications. Women mostly sensitive to motion may benefit most. Antihistamines with sedative effects can be helpful for sleep.
Common side-effects: Drowsiness, dry mouth, blurred vision, constipation, urinary retention, restlessness, insomnia, sedation, upset stomach, nervousness, headache. Mostly Class B Drugs
This class of drugs is helpful both for reflux and for prevention of gastric irritation which worsens nausea. They should be considered whenever a woman is vomiting frequently and/or cannot eat and drink sufficiently. Studies suggest they are safe during pregnancy. Mostly Class B drugs.
Common side-effects: Headache, dizziness, difficulty sleeping, constipation, diarrhea.
Ranitidine (Zantac) Famotidine (Pepcid) Lansoprazole (Prevacid) Cimetidine not recommended during pregnancy due to antiandrogenic effects in humans.
May be helpful in women who typically vomit after eating/drinking. Their main symptoms often are GI specific (motion sickness or sensitivity to light/sound) and these women may or may not respond to other medications such as Zofran. These drugs are sometimes used in conjunction with meds such as Zofran. Use with antihistamines to minimize side-effects.
Common side-effects: Drowsiness, dizziness, abdominal pain, diarrhea, restlessness, EPS, depression.
Extrapyramidal symptoms include: involuntary movements, tremors and rigidity, body restlessness, muscle contractions and changes in breathing and heart rate.
FDA recommends this drug be taken for up to 12 weeks. Risks of serious side-effects increase thereafter.
Blocks dopamine receptors in the CTZ and increases the CTZ threshold & decreases the sensitivity of visceral nerves that transmit afferent impulses from the GI tract to the vomiting center. Class B Drug
Not recommended until after 10 weeks of gestation.
Complications including reduced birth weight, increased risk of preeclampsia, increased risk of oral and lip clefts, and impaired fetal brain development have been reported when corticosteroids were administered during early pregnancy.
Women with hypothyroidism may have an exaggerated response to corticosteroids; thus any steroid should be used with caution in these mothers. Also, women with Type 1 Diabetes may require as much as a 40% increase in their insulin when high dose steroids are started.
Methylprednisolone is classified as pregnancy category C. Prednisone is classified as category B.
Pharmacologic Therapy for Nausea and Vomiting in Pregnancy
American Academy of Family Physicians
Medication Dosage Preg. Category Pyridoxine 25mg PO TID A Doxylamine 25mg PO QD * Antiemetics Chlorpromazine 10-25mg PO 2-4x/day C Prochlorperazine 5-10mg PO 3-4x/day C Promethazine 12.5-25mg PO Q4-6H C Trimethobenzamide 250mg PO 3-4x/day C Ondansetron 8mg PO 2-3x/day B Droperidol 0.5-2mgIV or IM Q3-4H C Antihistamines Diphenhydramine 25-50mg PO Q4-8H B Meclizine 25mgPO Q4-6H B Dimenhydrinate 50-100mg PO Q4-6H B Motility Drug Metoclopramide 5-10mg PO 3x/day B Corticosteroid Methylprednisolone 16mg PO 3x daily; then taper C
Women on bed rest often have significant pain due to atrophy, musculoskeletal changes and immobility. It often increases in the third trimester due to rapid fetal weight gain and growth. Use of these treatment modalities often assists in muscle relaxation and toxin release, thus having some increase in her sense of well-being.
Horehound – has been used in traditional medicine to relieve morning sickness. Consult with an expert in botanical medicine before using during pregnancy.
Ginger – Three RCTs and one randomized crossover trial found that ginger reduced nausea and vomiting in early pregnancy.
The classic acupuncture point for nausea and seasickness, called Pericardium 6 is located in the middle of the inner wrist, three finger breadths away from the wrist crease, between the two tendons. RCTs show varying effectiveness.
If a woman is unable to leave her home due to HG, consider full spectrum lighting to ease potential depression .
Medical hypnosis may be used as an adjunctive treatment option for women with hyperemesis gravidarum. Controversy surrounds the benefit of hypnosis, but it has been studied in some cases of hyperemesis gravidarum and has been shown to be beneficial.