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The Management of Nausea - SOGC

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NAUSEA AND VOMITING OF PREGNANCY: TREATMENT ALGORITHM 12<br />

(If no improvement, go to next step)<br />

Give 10 mg <strong>of</strong> doxylamine combined with 10 mg <strong>of</strong> pyridoxine, up to four tablets a day<br />

(i.e., two at bedtime, one in the morning, and one in the afternoon).<br />

Adjust schedule and dose according to severity <strong>of</strong> symptoms.<br />

Add dimenhydrinate, 50 to 100 mg q4–6h po or suppository (pr)<br />

(up to 200 mg/d when taking four doxylamine/pyridoxine tablets/d)<br />

Add any <strong>of</strong> the following (in order <strong>of</strong> proven fetal safety):<br />

• chlorpromazine, 10 to 25 mg q4–6h po or intramuscular<br />

injection (IM), 50 to 100 mg q4–6h pr<br />

• prochlorperazine, 5 to10 mg q6–8h 1M or po or pr<br />

• promethazine, 12.5 to 25 mg q4–6h 1M or po<br />

• metoclopramide, 5 to 10 mg q8h IM or po<br />

• ondansetron, * 8 mg q12h po<br />

Notes:<br />

• <strong>The</strong> use <strong>of</strong> this algorithm assumes that other causes <strong>of</strong><br />

nausea and vomiting <strong>of</strong> pregnancy (NVP) have been ruled<br />

out.<br />

• At any time you may add any or all:<br />

pyridoxine 25 mg q8h<br />

ginger § 250 mg q6h<br />

P6 acupressure/acupuncture<br />

• At any step, when indicated, consider parenteral<br />

nutrition.<br />

* Safety, particularly in the first trimester <strong>of</strong> pregnancy, not yet<br />

determined.<br />

† No study has compared different fluid replacements for<br />

NVP.<br />

‡ Steroids may increase risk for oral clefts in first 10 weeks <strong>of</strong><br />

gestation.<br />

§ Safety <strong>of</strong> doses higher than 1000 mg/day not yet determined<br />

in pregnancy.<br />

or promethazine, 5 to 10 mg q6–8h po or pr<br />

No dehydration Dehydration<br />

Reproduced from Levichek Z, 12 by permission <strong>of</strong> the publishers.<br />

Start rehydration treatment:<br />

• intravenous (IV) fluid replacement † (per local protocol)<br />

• multivitamin IV supplementation<br />

• dimenhydrinate, 50 mg (in 50 mL <strong>of</strong> saline, over 20 min)<br />

q4–6h IV<br />

Add any <strong>of</strong> the following (in order <strong>of</strong> proven fetal safety):<br />

• chlorpromazine, 25 to 50 mg q4–6h IV<br />

• prochlorperazine, 5 to 10 mg q6–8h IV<br />

• promethazine, 12.5 to 25 mg q4–6h IV<br />

• metoclopramide, 5 to 10 mg q8h IV<br />

Add methylprednisolone, ‡ 15 to 20 mg q8h IV<br />

or ondansetron * 8 mg, over 15 min q12h IV or<br />

1 mg/h continuously up to 24 hours<br />

JOGC 4 OCTOBER 2002

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