Pantoprazole (Protonix)b Lansoprazole (Prevacid)b Omeprazole (Prilosec, Zegeridr Dexlansoprazole (Dexilant)C 400 mg 4 times daily for up to 12 wks 800 mg twice daily for up to 12 wks 150 mg twice daily 20 mg twice daily up to 6 wks 40 mg daily for up to 8 wks 15 mg daily for up to 8 wks 20 mg daily for 4-8 wks 30 mg daily for up to 4 wks aFood and Drug Administration category A. bFood and Drug Administration category B. (Food and Drug Administration category C.
to moderate symptoms respond as outpatients to any of several irst-line antiemetic agents (Clark, 2014; Matthews, 2014). One that is becoming a mainstay is Diclegis-a combination of doxylamine (10 mg) plus pyridoxine (10 mg). It has been proven safe and efective (Briggs, 2015; Koren, 2014). The usual dose is two tablets orally at bedtime. If relief is insufficient, then additional doses, first in the morning, and then in the morning and midafternoon can be added each day to the bedtime dose. At our institution, for cost savings, we prescribe these two agents individually: Unisom (doxylamine) Y2 of a 50-mg tablet plus a 25-mg vitamin B6 tablet. The same graduated dosing is used but does not exceed three total daily doses.
Ondansetron (Zofran) also does not appear to be teratogenic.
It was slightly more eicacious than a combination of doxylamine and pyridoxine in a randomized trial (Oliveira, 2014; Pasternak, 2013). Its drawbacks include potential maternal efects from prolonged QT-interval and serotonin syndrome (Koren, 2014).
When simple measures fail, intravenous crystalloid solutions are given to correct dehydration, ketonemia, electrolyte deicits, acid-base imbalances, and hypokalemia. No benefits are gained by infusing 5-percent dextrose along with crystalloids (Tan, 20l3). Thiamine, 100 mg, is given to prevent Wernicke encephalopathy (Giugale, 2015; Niebyl, 2010). his is usually diluted in 1 L of the selected crystalloid and infused at the maintenance rate desired for patient hydration.
If vomiting persists after rehydration and failed outpatient management, hospitalization is recommended (American College of Obstetricians and Gynecologists, 2015). Day care has also been shown to be efective in one randomized study (McCarthy, 2014). Intravenous hydration is continued and antiemetics such as promethazine, prochlorperazine, chlorpromazine, or metoclopramide are given parenterally (Table 54-3). The bulk of evidence is that treatment with glucocorticosteroids is not efective (Yost, 2003). Because of their putative teratogenicity, they are not routinely recommended (American College of Obstetricians and Gynecologists, 2015).