Treatment of Severe Nausea and Vomiting of Pregnancy with Subcutaneous Medications

ABSTRACT

We examined treatment outcomes in women with severe nausea and vomiting of pregnancy (NVP) receiving outpatient nursing support and either subcutaneous metoclopramide or subcutaneous ondansetron via a microinfusion pump. Among women receiving outpatient nursing services, we identified those diagnosed with severe NVP having a Pregnancy-Unique Quantification of Emesis (PUQE) score of greater than 12 at enrollment and prescribed either metoclopramide (n = 355) or ondansetron (n = 521) by their physician. Maternal characteristics, response to treatment, and start versus stop values were compared between the medication groups. Allocation to group was based on intention-to-treat protocol. Maternal characteristics were similar between the groups. Days to reduction in PUQE score levels were similar (median 2 days, metoclopramide; 3 days, ondansetron; p = 0.206). Alteration from metoclopramide to ondansetron (31.8%) was more frequent than alteration from ondansetron to metoclopramide (4.4%; p < 0.001). Improvement of NVP symptoms and reduced need for hospitalization was noted with both medications. Treatment with either metoclopramide or ondansetron resulted in significant improvement of NVP symptoms with half of women showing a reduction from severe symptoms to moderate or mild symptoms within 3 days of treatment initiation. Alteration in treatment was significantly greater in patients initially prescribed metoclopramide.

NVP - nausea and vomiting of pregnancy - subcutaneous metoclopramide - subcutaneous ondansetron

REFERENCES

• 1 Jueckstock J K, Kaestner R, Mylonas I. Managing hyperemesis gravidarum: a multimodal challenge. BMC Medicine 2010;8:46. Available at: http://www.biomedcentral.com/1741-7015/8/46 Accessed November 24, 2010
• 2 Miller F. Nausea and vomiting in pregnancy: the problem of perception—is it really a disease?.  Am J Obstet Gynecol. 2002;  186 (5, Suppl Understanding) S182-S183
• 3 Eliakim R, Abulafia O, Sherer D M. Hyperemesis gravidarum: a current review.  Am J Perinatol. 2000;  17 207-218
• 4 Goodwin T M. Hyperemesis gravidarum.  Obstet Gynecol Clin North Am. 2008;  35 401-417 viii
• 5 Attard C L, Kohli M A, Coleman S et al.. The burden of illness of severe nausea and vomiting of pregnancy in the United States.  Am J Obstet Gynecol. 2002;  186 (5, Suppl Understanding) S220-S227
• 6 Lacasse A, Rey E, Ferreira E, Morin C, Bérard A. Nausea and vomiting of pregnancy: what about quality of life?.  BJOG. 2008;  115 1484-1493
• 7 Koren G, Boskovic R, Hard M, Maltepe C, Navioz Y, Einarson A. Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy.  Am J Obstet Gynecol. 2002;  186 (5, Suppl Understanding) S228-S231
• 8 Niebyl J R. Clinical practice. Nausea and vomiting in pregnancy.  N Engl J Med. 2010;  363 1544-1550
• 9 American College of Obstetrics and Gynecology . ACOG (American College of Obstetrics and Gynecology) Practice Bulletin: nausea and vomiting of pregnancy.  Obstet Gynecol. 2004;  103 803-814
• 10 Naef III R W, Chauhan S P, Roach H, Roberts W E, Travis K H, Morrison J C. Treatment for hyperemesis gravidarum in the home: an alternative to hospitalization.  J Perinatol. 1995;  15 289-292
• 11 Buttino Jr L, Coleman S K, Bergauer N K, Gambon C, Stanziano G J. Home subcutaneous metoclopramide therapy for hyperemesis gravidarum.  J Perinatol. 2000;  20 359-362
• 12 Lombardi D G, Istwan N B, Rhea D J, O'Brien J M, Barton J R. Measuring outpatient outcomes of emesis and nausea management in pregnant women.  Manag Care. 2004;  13 48-52
• 13 Drugs.com. Ondansetron side effects. Available at: http://www.drugs.com/sfx/ondansetron-side-effects.html Accessed May 23, 2011
• 14 Matok I, Gorodischer R, Koren G, Sheiner E, Wiznitzer A, Levy A. The safety of metoclopramide use in the first trimester of pregnancy.  N Engl J Med. 2009;  360 2528-2535
• 15 Berkovitch M, Mazzota P, Greenberg R et al.. Metoclopramide for nausea and vomiting of pregnancy: a prospective multicenter international study.  Am J Perinatol. 2002;  19 311-316
• 16 Sørensen H T, Nielsen G L, Christensen K, Tage-Jensen U, Ekbom A, Baron J. Euromap Study Group . Birth outcome following maternal use of metoclopramide. The Euromap study group.  Br J Clin Pharmacol. 2000;  49 264-268
• 17 Tan P C, Khine P P, Vallikkannu N, Omar S Z. Promethazine compared with metoclopramide for hyperemesis gravidarum: a randomized controlled trial.  Obstet Gynecol. 2010;  115 975-981
• 18 Einarson A, Maltepe C, Navioz Y, Kennedy D, Tan M P, Koren G. The safety of ondansetron for nausea and vomiting of pregnancy: a prospective comparative study.  BJOG. 2004;  111 940-943
• 19 Matthews A, Dowswell T, Haas D M, Doyle M, O'Mathúna D P. Interventions for nausea and vomiting in early pregnancy.  Cochrane Database Syst Rev. 2010;  CD007575
• 20 Wennberg D E, Marr A, Lang L, O'Malley S, Bennett G. A randomized trial of a telephone care-management strategy.  N Engl J Med. 2010;  363 1245-1255
• 21 Altavela J L, Jones M K, Ritter M. A prospective trial of a clinical pharmacy intervention in a primary care practice in a capitated payment system.  J Manag Care Pharm. 2008;  14 831-843