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JAMA. 2016 Oct 4;316(13):1392-1401. doi: 10.1001/jama.2016.14337.

Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review.

Author information

1
Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, Tyne and Wear, United Kingdom.
2
Institute of Health and Society, Newcastle University, Newcastle, Tyne and Wear, United Kingdom.
3
Institute of Cellular Medicine, Newcastle University, Newcastle, Tyne and Wear, United Kingdom.
4
Health Economics Group, Institute of Health and Society, Newcastle, Tyne and Wear, United Kingdom.
5
Women's Health Academic Centre, King's Health Partners, London, United Kingdom.
6
Institute of Health and Society, Newcastle University, Newcastle, Tyne and Wear, United Kingdom6Health and Social Care Institute, Teesside University, Middlesbrough, Cleveland, United Kingdom.
7
North Tyneside Clinical Commissioning Group, North Shields, Tyne and Wear, United Kingdom.
8
Former Trustee of Pregnancy Sickness Support, Hull, East Yorkshire, United Kingdom.
9
UK Teratology Information Service (UKTIS) and Institute of Genetic Medicine, Newcastle, Tyne and Wear, United Kingdom.

Abstract

Importance:

Nausea and vomiting affects approximately 85% of pregnant women. The most severe form, hyperemesis gravidarum, affects up to 3% of women and can have significant adverse physical and psychological sequelae.

Objective:

To summarize current evidence on effective treatments for nausea and vomiting in pregnancy and hyperemesis gravidarum.

Evidence Review:

Databases were searched to June 8, 2016. Relevant websites and bibliographies were also searched. Titles and abstracts were assessed independently by 2 reviewers. Results were narratively synthesized; planned meta-analysis was not possible because of heterogeneity and incomplete reporting of findings.

Findings:

Seventy-eight studies (n  = 8930 participants) were included: 67 randomized clinical trials (RCTs) and 11 nonrandomized studies. Evidence from 35 RCTs at low risk of bias indicated that ginger, vitamin B6, antihistamines, metoclopramide (for mild symptoms), pyridoxine-doxylamine, and ondansetron (for moderate symptoms) were associated with improved symptoms compared with placebo. One RCT (n = 86) reported greater improvements in moderate symptoms following psychotherapy (change in Rhodes score [range, 0 {no symptoms} to 40 {worst possible symptoms}], 18.76 [SD, 5.48] to 7.06 [SD, 5.79] for intervention vs 19.18 [SD, 5.63] to 12.81 [SD, 6.88] for comparator [P < .001]). For moderate-severe symptoms, 1 RCT (n = 60) suggested that pyridoxine-doxylamine combination taken preemptively reduced risk of recurrence of moderate-severe symptoms compared with treatment once symptoms begin (15.4% vs 39.1% [P < .04]). One RCT (n = 83) found that ondansetron was associated with lower nausea scores on day 4 than metoclopramide (mean visual analog scale [VAS] score, 4.1 [SD, 2.9] for ondansetron vs 5.7 [SD, 2.3] for metoclopramide [P = .023]) but not episodes of emesis (5.0 [SD, 3.1] vs 3.3 [SD, 3], respectively [P = .013]). Although there was no difference in trend in nausea scores over the 14-day study period, trend in vomiting scores was better in the ondansetron group (P = .042). One RCT (n = 159) found no difference between metoclopramide and promethazine after 24 hours (episodes of vomiting, 1 [IQR, 0-5] for metoclopramide vs 2 [IQR, 0-3] for promethazine [P = .81], VAS [0-10 scale] for nausea, 2 [IQR, 1-5] vs 2 [IQR, 1-4], respectively [P = .99]). Three RCTs compared corticosteroids with placebo or promethazine or metoclopramide in women with severe symptoms. Improvements were seen in all corticosteroid groups, but only a significant difference between corticosteroids vs metoclopramide was reported (emesis reduction, 40.9% vs 16.5% at day 2; 71.6% vs 51.2% at day 3; 95.8% vs 76.6% at day 7 [n = 40, P < .001]). For other interventions, evidence was limited.

Conclusions and Relevance:

For mild symptoms of nausea and emesis of pregnancy, ginger, pyridoxine, antihistamines, and metoclopramide were associated with greater benefit than placebo. For moderate symptoms, pyridoxine-doxylamine, promethazine, and metoclopramide were associated with greater benefit than placebo. Ondansetron was associated with improvement for a range of symptom severity. Corticosteroids may be associated with benefit in severe cases. Overall the quality of evidence was low.

Summary for patients in

PMID:
27701665
DOI:
10.1001/jama.2016.14337
[Indexed for MEDLINE]

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