› 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
Show 44 more ▾