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임신 중 입덧의 관리- 최준식 제일병원 산부인과 교수
1. 임신 중 입덧의 관리 ,
어떻게 할 것인가 ?
June Seek Choi M.D., PhD., Associate Professor
The Korean Motherisk Program,
Division of Maternal-Fetal Medicine,
Dept. of OB & GYN.,
Cheil General Hospital & Women's Healthcare Center,
College of Medicine, Kwandong University, Seoul, Korea
2. Contents
• Introduction
• Physiology of NVP (nausea and vomiting of
pregnancy)
• Management of Hyperemesis Gravidarum
– Non-pharmacologic Treatment
– Pharmacologic Treatment
– Experience of Cheil General Hospital & Women’s
Healthcare Center (doxylamine+pyridoxine)
4. Introduction(2)
Nausea and vomiting
of pregnancy
Hyperemesis Gravidarun: weight
loss, usually more than 5% of
prepregnancy weight
•Young age
•History of motion sickness
•History of migraines
•Female gender of fetus
•Disorder of fatty acid
oxidation
•Genetic predisposition
Monozygotic twins
Inherited glycoprotein
-hormone receptor defects
Risk Factors
5. Introduction(3)
• Nausea is not limited to the morning as implied by the
outdated term of morning sickness, and although typically
presenting between 4 and 14 weeks of pregnancy, persists
throughout all of pregnancy in 20% of women.
• 8.5 million lost working days per year due to NVP.
6. Introduction(4)
• Severe NVP is the third leading cause for hospitalization
during pregnancy($17,000 per woman).
• Bendectin(doxylamine, pyridoxine, and dicyclomine) until
1982 when it was withdrawn from the market unable to
continue to justify the ongoing costs of litigation
• Hospitalization rates for NVP doubled in both the United
States and Canada,but were subsequently reduced in Canada
with the introduction of Diclectin(doxylamine + pyridoxine).
7. Introduction(5)
Fetal consequences of hyperemesis
HyperemesisHyperemesis
Major congenitalMajor congenital
anomaliesanomalies
< 7kg weight gain< 7kg weight gain
▪▪ Hip dysplasiaHip dysplasia
▪▪ Down syndromeDown syndrome
▪▪ Fetal coagulopathy orFetal coagulopathy or
ChondrodysplasiaChondrodysplasia
▪▪ Low birth weight (RR 2.8)Low birth weight (RR 2.8)
▪▪ Preterm birth (RR 3.0)Preterm birth (RR 3.0)
▪▪ Fetal deathFetal death
BailitJL. 2005
KallenB. 1987
Brunetti-Pierri N et al. 2007
10. Prevention and Lifestyle Approaches
• There is no one diet that is considered ideal for all women
with NVP.
• Eat small frequent meals avoiding both over distention and
complete emptying of the stomach.
• Mild to moderate NVP prefer carbohydrates; breads,
cereals, crackers, pasta, and rice.
• Profound NVP prefer proteins; meat, chicken, fish, and
eggs.
11. Nonpharmacologic Treatment
• Ginger: 250mg po q.i.d.
capsule, tablets, tea
safety data are not available.
• Acupressure: acupressure point P6 (Neiguan)
There is no theoretical risk associated
with the use of acupressure.
12. Pharmacologic Treatment(1)
• First line therapy is a combination doxylamine and
pyridoxine.
• Are the symptoms vestibular in nature and, therefore,
more likely to respond to antihistamines or
anticholinergics or are they visceral and, therefore, more
likely to respond to dopamine or serotonin antagonists?
13. Pharmacologic Treatment(2)
Vitamins and Antihistamines
• Vitamin: Vitamin B6, Vitamin B12
• Antihistamine: H1 receptor antagonist,
H2 receptor antagonist
• Doxylamine/Pyridoxine: 2 tablets at bedtime, 1 in the
morning and 1 in the afternoon
Larger body mass index may need up to 8 tablets/day.
15. Pharmacologic Treatment(4)
Dopamine Antagonists
• Phenothiazines :
Chemoreceptor trigger zone in the
brain to reduce the nausea and are
considered a second line drug
• Metoclopramide:
Upper gastrointestinal motility
stimulant and gastric dysrhythmia is
associated with NVP
• Domperidone and
Droperidol: Treatment of severe
NVP but have very limited data
available.
Phenothiazines
Chlorpromazine: 10-25mg q4-6h po or IM, 50-100mg q4-6h pr
Perphenazine
Prochlorperazine: 5-10mg q6-8h IM or po
Promethazine: 12.5-25mg q4-6h IM or po
Trifluoperazine
Trimethobenzamide
Domperidone: 10-20mg po q6-8h
Droperidol: 0.5-1.0mg/h IV infusion
Metoclopromide: 5-10mg q6h IV or po
May be sedating or rarely
cause extrapyramidal effects
17. Nausea and vomiting of pregnancy:
treatment algorithm
Dimenhydrinate, 50 mg IV (in 50 mL saline, over
20 minutes), every 4 to 6 hours
or
Metoclopramide, 5 to 10 mg IV every 8 hours
or
Promethazine, 12.5 to 25 mg IV every 4 hours
or
Prochlorperazine, 5 to 10 mg IV every 4 hours
(maximum dose, 40 mg/d)
For patients not tolerating oral
intake
Goodwin, 2008
Ondansetron( 온단트 , 조프란 ), 4 to 8 mg
orally or IV every 8 hours
or
Methylprednisolone, 16 mg orally or IV every
8 hours for 3 days. Taper over 2 weeks to lowest
effective dose. If beneficial, limit total duration of
use to 6 weeks.
For persistent vomiting substitute
18. Experience of Cheil General Hospital & Women’s
Healthcare Center (doxylamine+pyridoxine) (1)
2006.01-2010.05
19. Experience of Cheil General Hospital & Women’s
Healthcare Center (doxylamine+pyridoxine) (2)
2006.01-2010.05
20. Experience of Cheil General Hospital & Women’s
Healthcare Center (doxylamine+pyridoxine) (3)
2006.01-2010.05
21. Conclusions
• Accurate diagnosis of nausea and vomiting
• Proper treatment of individualization
(Non-pharmacologic Treatment, Pharmacologic Treatment)
