›Fluids and vitamins
›Initial IV fluids
›Normal saline 1 liter bolus
›Repeat bolus based on vitals and urine output
›Reassess after each liter
›Lactated Ringer 1 liter bolus alternative
›Consider if hyperchloremic acidosis concern
›Thiamine
›Thiamine IV 100 mg
›Give before dextrose containing fluids
›Repeat daily if ongoing vomiting or malnutrition risk
›Dextrose containing fluids
›Dextrose 5 percent in normal saline after thiamine if ketosis or hypoglycemia
›Transition to oral carbohydrates when tolerated
›Electrolyte replacement
›Potassium chloride IV replacement for hypokalemia
›Typical peripheral infusion rate limits per local policy
›Repeat potassium mmol/l after replacement
›Magnesium sulfate IV for hypomagnesemia
›Repeat magnesium mmol/l after replacement
Antiemetic stepwise regimen
›Antiemetic stepwise regimen
›First line in pregnancy
›Pyridoxine oral 10 to 25 mg every 6 to 8 hours
›Class I recommendation supported by obstetric guidelines
›Minimal fetal risk in typical dosing
›Doxylamine oral 12.5 mg every 6 to 8 hours
›Combine with pyridoxine for enhanced effect
›Sedation counseling for outpatient use
›Antihistamine options
›Dimenhydrinate IV 50 mg every 4 to 6 hours as needed
›Avoid duplicate sedating antihistamines
›Monitor anticholinergic effects
›Diphenhydramine IV 25 to 50 mg every 4 to 6 hours as needed
›Useful for nausea and dystonia prevention with dopamine antagonists
›Dopamine antagonists
›Metoclopramide IV 10 mg every 6 to 8 hours as needed
›Monitor akathisia and dystonia
›Consider diphenhydramine coadministration if prior reactions
›Prochlorperazine IV 10 mg every 6 hours as needed
›Extrapyramidal symptom risk counseling
›QT prolongation risk consideration
›Promethazine IV 12.5 to 25 mg every 4 to 6 hours as needed
›Sedation and hypotension risk
›Tissue injury risk with IV extravasation
›Serotonin antagonist
›Ondansetron IV 4 mg every 6 to 8 hours as needed
›QT prolongation risk assessment
›Use after first line failure based on guideline variation
›Refractory escalation
›Combination therapy with different mechanisms
›Pyridoxine plus doxylamine plus metoclopramide sequence
›Add ondansetron if inadequate response
›Corticosteroid option for refractory hyperemesis
›Methylprednisolone oral or IV 16 mg every 8 hours for 3 days
›Taper over 2 weeks if response
›Avoid before 10 weeks gestation when possible due to orofacial cleft signal in some data
›Adjuncts and nutrition
›Acid suppression for reflux contribution
›Famotidine oral or IV 20 mg twice daily
›Consider if heartburn prominent
›Compatible with pregnancy in typical dosing
›Proton pump inhibitor option for refractory reflux
›Omeprazole oral 20 mg daily
›Nonpharmacologic measures
›Small frequent meals
›Ginger supplementation as tolerated
›Avoid trigger odors and large fatty meals
›Nutrition escalation
›Enteral feeding consideration for prolonged inability to maintain intake
›Parenteral nutrition consideration for severe refractory cases with specialist oversight