Practice Guideline Briefs

Am Fam Physician. 2004 Aug 1;70(3):601-602.

Nausea and Vomiting in Pregnancy

The American College of Obstetricians and Gynecologists (ACOG) has released a new guideline on diagnosing and treating nausea and vomiting (morning sickness) in pregnancy. “ACOG Practice Bulletin No. 52: Nausea and Vomiting of Pregnancy,” appears in the April 2004 issue of Obstetrics and Gynecology and is available online at http://www.greenjournal.org/cgi/reprint/103/4/803.

The guideline reviews the prevalence, risk factors, and clinical recommendations in treating morning sickness. While the cause of morning sickness remains unknown, there are effective treatments to prevent and treat the problem.

Nausea and vomiting are common in early pregnancy, affecting 70 to 85 percent of pregnant women. Morning sickness typically begins within the first nine weeks of pregnancy, with symptoms ranging from mild to severe. Severe morning sickness (hyperemesis gravidarum) occurs in approximately 0.5 to 2 percent of pregnancies. It is the most common indication for hospitalization during early pregnancy and second only to preterm labor as the most common reason for hospitalization during pregnancy.

According to ACOG, some pregnant women have a higher risk of having hyperemesis gravidarum. They include women carrying multiple fetuses, daughters and sisters of women who had the condition, women carrying a female fetus, and women with a history of hyperemesis gravidarum in a previous pregnancy. Other risk factors include a history of motion sickness or migraines.

Some women do not seek treatment for morning sickness because of concerns about treatment safety. Yet, once symptoms progress, treatment can become more difficult. Mild cases may be resolved with lifestyle and dietary changes, and safe and effective treatments are available for more severe cases.

The following recommendations for the prevention and treatment of nausea and vomiting of pregnancy are based on consistent scientific evidence:

  • Taking a multivitamin at the time of conception may decrease the severity of symptoms.

  • Taking Vitamin B6 alone or with doxylamine (an antihistamine) is safe and effective and should be considered a first-line treatment.

The following recommendations are based on limited or inconsistent scientific evidence:

  • Ginger has shown beneficial effects and can be considered a nonpharmacologic option.

  • Antihistamine H1-receptor blockers, phenothiazines, and benzamines have been shown to be safe and effective in treating refractory cases.

  • Early treatment of symptoms is recommended to prevent progression to hyperemesis gravidarum.

  • Treatment with methylprednisolone (a steroid) may be effective in severe cases, but should be a treatment of last resort because of its potential risk to the fetus.

Use of Transcranial Doppler Ultrasonography

The Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology has released a guideline on transcranial Doppler ultrasonography (TCD) and transcranial color-coded sonography as a diagnostic aid in patients with cerebrovascular disease. “Assessment: Transcranial Doppler Ultrasonography” appears in the May 2004 issue of Neurology and is available online at http://www.aan.com/professionals/practice/guideline/index.cfm#Child.

According to the guideline, TCD provides valuable information in two situations: (1) screening children two to 16 years of age with sickle cell disease for risk of stroke, and (2) detecting and monitoring of vasospasms after subarachnoid hemorrhage.

In other situations, TCD was found to provide important information, but the value of the test, compared with other tests, has not been determined. These include detection of cerebral circulatory arrest and brain death, and monitoring of coronary artery bypass graft operations.

In some situations, TCD does provide important information, but other tests are preferable. These include detection of right-to-left cardiac shunts, and evaluation of extracranial internal carotid artery stenosis.

Increases in Fluoroquinolone-Resistant Neisseria Gonorrhoeae

The Centers for Disease Control and Prevention (CDC) has released revised recommendations for gonorrhea treatment based on an increase in fluoroquinolone-resistant Neisseria gonorrhoeae . “Increases in Fluoroquinolone-Resistant Neisseria gonorrhoeae Among Men Who Have Sex with Men—United States, 2003, and Revised Recommendations for Gonorrhea Treatment, 2004” appears in the April 30, 2004, issue of Morbidity and Mortality Weekly Report and is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5316a1.htm.

In the United States, an estimated 700,000 to 800,000 persons are infected with N. gonorrhoeae annually. Since 1993, the CDC has recommended use of fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) for gonorrhea treatment. Fluoroquinolones are used frequently to treat gonorrhea in the United States because they are inexpensive and easy to administer and their continued use might decrease the use of cephalosporins and delay the development of cephalosporin resistance.

However, local and national data suggest that the prevalence of fluoroquinolone-resistant N. gonorrhoeae (QRNG) among men who have sex with men infected with gonorrhea is close to or exceeds 5 percent. While this level of resistance often is used as the level at which a therapeutic regimen should be changed, other factors, including prevalence of gonorrhea, availability of antimicrobial susceptibility data, and cost of various diagnostic and treatment options, might result in higher or lower thresholds for change. In the absence of anti-microbial susceptibility testing or tests of cure, fluoroquinolones should no longer be used to treat proven or suspected gonococcal infections in men who have sex with men.

Fluoroquinolones also should not be used to treat patients whose gonorrhea was acquired in Asia, the Pacific Islands (including Hawaii), California, and other areas, such as England and Wales, with increased QRNG prevalence. For those infections acquired where QRNG is not endemic, before determining treatment, physicians should obtain travel histories from patients and information on the gender of sex partners from male patients with proven or suspected gonorrhea. A list of places that should be included in a relevant travel history is available online at http://www.cdc.gov/std/gisp.

For male patients with gonorrhea who have sex with men or who provide a history suggesting acquisition of infection in an area with high QRNG prevalence, the CDC recommends ceftriaxone, 125 mg intramuscularly, or cefixime, 400 mg orally (which is not available in the United States); spectinomycin, 2 g intramuscularly, is an alternative. Spectinomycin may be used for urogenital and anorectal gonorrhea but is not sufficiently effective to treat pharyngeal gonorrhea. If Chlamydia trachomatis is not ruled out, each regimen should be followed with either azithromycin, 1 g orally (single dose), or doxycycline, 100 mg orally twice daily for seven days, to treat possible co-infection with chlamydia.

The limited availability of a recommended oral treatment regimen for gonorrhea poses practical problems for treating QRNG. Besides the fluoroquinolones, cefixime, whose manufacture was discontinued in 2002, is the only CDC-recommended oral agent for treating gonorrhea. Although Lupin received Food and Drug Administration approval to manufacture and market cefixime in February 2004, the 400-mg tablets to treat gonorrhea are not yet available; the suspension (100 mg/5 mL) is available. The health departments of California and Washington state have suggested alternative oral treatments (e.g., cefpodoxime, 400 mg) that have not yet been evaluated adequately. The CDC will provide additional information about the availability of cefixime and efficacy of other oral agents for treating gonorrhea as it becomes available (http://www.cdc.gov/std/treatment/cefixime.htm).

The CDC advises physicians to be vigilant in identifying treatment failures when fluoroquinolones are used, advise their patients about the importance of follow-up if symptoms persist, and be prepared to evaluate such cases by culture. In cases of persistent gonococcal infection after treatment with fluoroquinolones, anti-microbial susceptibility testing should be performed. Only culture of N. gonorrhoeae can be used to determine antimicrobial susceptibility. The antimicrobial susceptibility testing panel should, at a minimum, include a fluoroquinolone, ceftriaxone, spectinomycin, azithromycin, and any other drugs in local use for gonorrhea treatment. Arrangements for antimicrobial susceptibility testing can be made by contacting state and local health departments.

Given the apparent low prevalence of QRNG among heterosexuals, a national change in treatment in that group is not recommended at this time. However, QRNG prevalence among heterosexuals is likely to increase over time and already might be high enough in some areas to warrant new local treatment recommendations. For example, increased prevalence of QRNG among heterosexuals has been identified in several counties in Michigan, where recommendations have been made to avoid using fluoroquinolones among all persons infected with gonorrhea. Because gonococcal infections, especially in women, frequently are asymptomatic, monitoring for symptomatic treatment failures alone does not provide a reliable indication of emerging antimicrobial resistance. If prevalence increases nationally among heterosexuals, guidance from the CDC will be forthcoming. Local and state treatment recommendations, technical information, surveillance data, references, and other links related to gonococcal resistance are available at http://www.cdc.gov/std/gisp.


Copyright © 2004 by the American Academy of Family Physicians.
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