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Effectiveness of Treatment Options for Hyperemesis Gravidarum
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Am Fam Physician. 2008 Nov 1;78(9):1089-1090.
Background: Hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy, may cause maternal electrolyte disturbances; weight loss; dehydration; and, sometimes, the need for iatrogenic premature birth. The disorder commonly persists throughout pregnancy, possibly leading to prolonged or repeated hospitalizations. In addition to the patient avoiding trigger foods and eating small meals, treatment may involve antiemetic medications, intravenous fluid and electrolyte replacement, and, possibly, supplemental nutrition. Peripherally inserted central catheters (PICCs) are sometimes used to facilitate prolonged parenteral nutrition and intravenous fluid replacement. Dobbhof feeding tubes have also been shown to be beneficial in patients with hyperemesis gravidarum. Holmgren and colleagues compared maternal and neonatal outcomes after treatment with antiemetic medications alone or with the medications plus a nasogastric/nasoduodenal feeding tube or PICC.
The Study: In this retrospective cohort study, the authors reviewed the medical records of 129 patients admitted and treated for hyperemesis gravidarum at two urban tertiary care centers in Utah during a five-year period. Of these patients, 35 were excluded from analysis because of incomplete information, maternal gastrointestinal illness, or use of feeding tubes and PICCs. Of the remaining 94 patients, 33 (35 percent) received a PICC, 19 (20 percent) received a nasogastric/nasoduodenal feeding tube, and 42 (45 percent) received only intravenous antiemetic medications. The groups were similar in respect to maternal demographics and health status, neonatal weight, gestational age at delivery, and Apgar scores. Outcomes were expressed in odds ratios (ORs) and were controlled for maternal age, parity, and smoking status; gestational age; and fetal weight.
Results: Neonatal complications, such as small size for gestational age and admission to the neonatal intensive care unit, were increased in the PICC group, but this did not achieve statistical significance. Maternal complications were uncommon in the medication-only and feeding tube groups. However, maternal complications were significantly more common in the PICC group (adjusted OR = 34.51, P < .001) and included thrombosis (eight patients), pulmonary embolus (one patient), localized cellulitis (five patients), and bacteremia or sepsis (five patients).
Conclusion: More than one half of patients who received a PICC experienced a serious or potentially life-threatening complication directly related to the treatment. Because there were no differences in neonatal outcomes, the authors conclude that PICCs should be avoided in the treatment of hyperemesis gravidarum; enteral feeding through a nasogastric/nasoduodenal feeding tube likely is a safer method when medical management alone is insufficient.
Holmgren C, et al. Hyperemesis in pregnancy: an evaluation of treatment strategies with maternal and neonatal outcomes. Am J Obstet Gynecol. January 2008;198(1):56.e1–56.e4.
Copyright © 2008 by the American Academy of Family Physicians.
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