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• PTSD Postpartum
  Read more on the relationship between Post Traunmatic Stress Disorder and HG.
• PPD
  Read more on postpartum depression.

• Nausea and Vomiting of Pregnancy: State of the Art 2000
  Summary articles from a conference on nausea and vomiting in pregnancy.

Suggested Protocol

The HER Foundation receives e-mails from women around the world being treated with varying medical interventions, some being refused any medications early in pregnancy, while others are being given high doses of risky medications. The care varies greatly and often results in adverse outcomes for many women including repeated terminations, psychological trauma, or gastrointestinal injury.

"It is our goal to create a protocol that will be adopted by hospitals and emergent care centers who treat HG patients to ensure consistent, quality care for women with HG."

Kimber MacGibbon, RN
HER Foundation, Founder

Important Note: Women with HG are miserable for months and their complaints and requests should be taken seriously. Every possible comfort measure should be taken to minimize unnecessary suffering and discomfort. Your care and treatment of this woman may determine if she will suffer from both physical and psychological complications, including PTSD (post-traumatic stress disorder), during her pregnancy and postpartum.

1. Admit & Assess.

• Admit to a private room to minimize noxious stimuli from other patients, and excessive interruption by medical staff. (Your assistance with insurance reimbursement may be needed.) Many patients cannot tolerate bright lights and noises such as phones and TV's. They may vomit at the sight or sound of food in the hallways or nurses station. Thus, a quiet room at the end of the hall is strongly preferred therapeutically. Fatigue worsens HG, so ensure she is sleeping and ask all staff to avoid waking her.
   
• Establish a compasionate rapport with the mother.

• Weigh her and evaluate severity of weight loss.  
• R/O other disorders presenting with nausea and vomiting  
• General Metabolic And Hormonal Status: Check lab reports closely, especially electrolytes, hormone levels (HCG, thyroid function, Quantitative bHCG), U/A & culture, h-pylori, CBC (to screen for early signs of infection), LFT's (Liver Function Test), and glucose (for patients receiving TPN with insulin). When performing GTT's (glucose tolerance tests), use apple juice or jelly beans instead of Glucola. It will often be more accurate since patients can often tolerate those better.  
• Order an ultrasound to rule out gestational trophoblastic disease (GTD), and gall bladder or pancreatic disorders.  
• Monitor I&O's
• Record weight changes (qod if inpatient)
• Check urine ketones at least every 8 hours

2. Rehydrate carefully with fluids and vitamins. Continue hydration until able to tolerate PO fluids and little or no urine ketones.

• Lactated ringers or D5LR with 20 KCl are typically used. Use dextrose solutions to minimize fat breakdown. Also consider Myer's Cocktail or a Banana Bag. 
• Warm IV fluids for comfort, and prevention of caloric loss. She may be anemic, leaving her prone to being cold.  
• Treat marginal electrolyte deficiency if she is dehydrated. Vomiting will likely recur.  
• Consider addition of antioxidants such as glutathione. HG is associated with oxidative stress. (See research below)  
• Add glucose, vitamins (esp. B6 & B12, C and K), magnesium for all women, including those on TPN, or TPPN (PDF)(Total Peripheral Parenteral Nutrition). Use strict aseptic technique and utmost caution when caring for a patient's central line. Sepsis threatens mom and baby. (For more info see Nutritional Therapies.)

Rational:

• A sudden onset or worsening of Wernicke's encephalopathy following glucose administration may be observed in thiamine deficient patients. Administer thiamine before or together with dextrose-containing fluids in patients with a suspected thiamine-deficiency.
   
• Consequences of Magnesium Deficiency on the Enhancement of Stress Reactions; Preventive and Therapeutic Implications (A Review) Mildred S. Seelig, MD, MPH, Master ACN [See section on Toxemias of Pregnancy]
   
• Rapid correction of dehydration and electrolytes can cause life-threatening cardiovascular and neurological complications.

3. Prescribe Antiemetic Medicines. Review medication history and patient response. The risk of administration must be balanced against the sequelae of prolonged starvation and dehydration.

Note: Medications typically work best on a schedule v. prn. Early intervention may prevent the need for repeated IV's. Wean slowly when patient is asymptomatic for more than 2 weeks to avoid relapse.

Most Common Medications:
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 HG.

• Serotonin Antagonists: Ondansetron (Zofran), Granisetron (Kytril), Dolasetron (Anzemet)*
• Phenothiazines: Prochlorperazine (Compazine), Promethazine (Phenergan)**
• Prokinetic Agents: Metoclopramide (Reglan)
• Anti-reflux Agents: Ranitidine (Zantac), Famotidine (Pepcid), Lansoprazole (Prevacid)***
• Steroid Therapy: Medrol (Methylprednisolone, Solu-Medrol), Deltasone (Prednisone)
  
  * GENERICS NOW AVAILABLE. Expense may be outweighed by decrease in complications and admissions.
  ** High rate of adverse side-effects.
  *** Treating reflux and decreasing acid production can significantly decrease nausea and vomiting.

• More info on choosing a drug »

4. Refer for multidisciplinary consults as needed.

• Physical therapy - if on bed rest either by necessity or prescription.
  • Educate on progressive exercise to minimize atrophy. Begin consults during first admission or after a month of limited mobility. Continue therapy into late pregnancy if symptoms continue to decrease pain and fatigue that will impair her recovery and ability to care for her newborn.
     
• Nutritional
  • If patient loses more than 10% of her body weight within the first few months and shows no sign of improvement, nutritional intervention is very important. Without support, patient is at risk for complications and may have a prolonged recovery.
  • Assess need for Nutritional Therapies
  • Consider a liver sparing diet if tolerated (carbohydrates, no fat, fresh steamed vegetables, no sugar, no dairy products, and very small meals, eaten often)

• Home Health
   
• Gastroenterology
  • Evaluate for H-pylori infection, PEG/PEGJ insertion, and complications of vomiting/reflux

5. Consider referral for complementary and alternative therapies such as hypnosis, massage, chiropractic, homeopathy, acupressure, etc.

6. Implement patient comfort measures.

• Warm IV fluids before administration to avoid discomfort and calorie loss due to shivering.
• Offer warmed blankets and a quiet, odor-free room.
• Use Lidocaine for IV insertion and utilize most skilled personnel to avoid scarring related to multiple IV attempts.
• Administer antiemetics and vitamins via IV or PR, avoid IM injections due to muscle atrophy.

7. Offer patient education tools.

• Increase understanding of condition and treatments
• Educate on coping and support
• Teach patient signs of dehydration and how to use Ketostix at home
• Provide assurance of the risks and outcomes of treatment
• Request completion of assessment forms
• Refer mothers and their supporters to our website: http://HelpHER.org

Updated on: Mar. 24, 2010