American Journal of Emergency Medicine xxx (2015) xxx–xxx

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Original Contribution

Comparison of antiemetics for nausea and vomiting of pregnancy in an emergency department setting☆ Elizabeth A. Mayhall, MD, Robyn Gray, DO, Vrishali Lopes, MS, Kristen A. Matteson, MD, MPH ⁎ Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, RI

a r t i c l e

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Article history: Received 25 February 2015 Received in revised form 12 March 2015 Accepted 15 March 2015 Available online xxxx

a b s t r a c t Objective: To compare time from medication administration to disposition from the Emergency Department (ED) between women treated for nausea and vomiting of pregnancy with different antiemetic agents. Design: We performed a retrospective cohort study of women 13 weeks gestation or less treated in our Women and Infants Hospital ED for nausea and vomiting of pregnancy between 2009 and 2011. Data was collected on patient demographics, antiemetics used, and time to disposition. We analyzed time of administration of the antiemetic used first line (ondansetron versus metoclopramide versus promethazine or prochlorperazine) to time the discharge order was placed. Results: We analyzed data from 439 women treated in the ED for nausea and vomiting of pregnancy. Forty-four percent received ondansetron alone, 47% received any other antiemetic alone, and 9% received more than one agent first line. Antiemetic agent selected did not differ by patient age, parity, current treatment for nausea and vomiting in pregnancy, orthostatics, ketonuria or disposition. We found no difference in time from medication administration to disposition between women who received ondansetron and women who received any other antiemetic (metoclopramide, prochlorperazine or promethazine). Adjusting for potential confounders, compared to patients who received any other first line therapy, patients who received ondansetron had 2.09 times the odds of having a time to disposition at or above the 75th percentile (95% CI 1.31-3.34). Conclusions: The use of ondansetron in the ED for nausea and vomiting of pregnancy was associated with similar mean time from administration to disposition as other antiemetics. © 2015 Elsevier Inc. All rights reserved.

1. Introduction Nausea and vomiting of early pregnancy is one of the most common pregnancy-associated morbidities, affecting 50-80% of all pregnancies [1]. Severity of symptoms range from mild to severe, with approximately 0.5-2% of pregnant women experiencing extreme nausea and vomiting consistent with hyperemesis gravidarum [2]. Although one goal of early treatment of nausea and vomiting of pregnancy is to decrease the need of the patient to seek urgent setting care for their symptoms, many women seek emergency department care for this common problem [3,4]. Approximately 10% of women who experience nausea and vomiting of pregnancy will require medication for symptom management [5,6]. To date, no studies have directly compared different antiemetics for the treatment of acute exacerbations of nausea and vomiting of pregnancy among women presenting for treatment in an emergency department. However, antiemetics have been extensively studied in other settings and for nausea and vomiting in the nonpregnant population, including patients presenting to emergency rooms, patients in the

postoperative time period, and patients receiving radiation and/or chemotherapy with ondansetron shown to have equivalent if not improved efficacy to other antiemetics [7-9,12]. Currently, ondansetron is not the recommended in general as a first line agent for treatment of nausea and vomiting of pregnancy but specific guidelines for treatment in an ED are lacking [2]. Treating patients effectively and efficiently in the emergency room setting is a major priority to lessen the burden on our emergency health care system nationally [13]. At our institution, there is no one standard antiemetic medication given first line to patients presenting to our emergency room with nausea and vomiting of pregnancy. The goal of this study was to compare ondansetron to other antiemetic agents in terms of time from medication administration to emergency room discharge in a population of women presenting with nausea and vomiting of pregnancy. We hypothesized that in this population, compared to other antiemetics the use of ondansetron as the first-line antiemetic would be associated with the shortest time from medication administration to discharge. 2. Materials and methods

☆ Financial Support: Dr. Matteson was supported by K23HD057957 from the NIH/NICHD ⁎ Corresponding author at: Department of Obstetrics and Gynecology, Women & Infants Hospital, 101 Dudley Street, Providence RI, 02905. Tel.: +1 401 274 1100x48562; fax: +1 401 276 7871. E-mail address: [email protected] (K.A. Matteson).

2.1. Study population and variables We conducted a retrospective cohort study of women who were seen in the Women and Infants Emergency Department and had a

http://dx.doi.org/10.1016/j.ajem.2015.03.032 0735-6757/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Mayhall EA, et al, Comparison of antiemetics for nausea and vomiting of pregnancy in an emergency department setting, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.032

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E.A. Mayhall et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx

discharge diagnosis of “nausea and vomiting of pregnancy” between December 2009 and December 2011. This study was conducted with approval from the Institutional Review Board (IRB# 12–0061). We reviewed the electronic medical records of all women with nausea and vomiting of pregnancy as identified by ED discharge diagnosis codes during the above mentioned time frame. For this study, we included women who were given ondansetron, metoclopramide, prochlorperazine or promethazine during their emergency room visit. Because we were investigating uncomplicated nausea and vomiting of early pregnancy, we excluded from the study population women with a gestational age greater than 13 weeks, documented history of colitis, allergies to antiemetics, abnormal liver function tests, Addison’s disease, head trauma, appendicitis, fever, peptic ulcer disease, pyelonephritis, diabetic keto-acidosis, thyroid disorder, documented migraine, or molar pregnancy. Specifically for the analyses of antiemetic use, we additionally excluded women who were admitted to the hospital and women who received more than one antiemetic agent simultaneously for first line treatment as we were interested in the cohort of women who presented for treatment but eventually met criteria for discharge to home and planned to compare administration of single antiemetic agents. Trained chart abstractors collected data on patient age, parity, multifetal gestation, history of nausea and vomiting in pregnancy, anxiety, current treatment of nausea and vomiting of pregnancy, place of disposition (home versus inpatient), orthostatics, presence of hypotension, presence of ketonuria, smoking, first-line antiemetic medication selected, time that antiemetic orders were placed, time that antiemetic medications were administered, use of additional antiemetics (defined as administration N 20 minutes from the first line agent) before disposition, and time that disposition order was placed. The independent variable, first- line antiemetic medication, was defined as the antiemetic agent which was used first during the patient’s emergency room visit and was grouped as ondansetron, metoclopramide, and prochlorperazine/promethazine. Our dependent variable, “time to disposition” was defined as time from medication administration to disposition order. This was chosen as a proxy for medication effectiveness because patients had to show signs of improvement to meet ED criteria for discharge. 2.2. Outcome The primary outcome for this study was time to disposition. We set a 2-sided α = 0.05 and power = 80% and determined that in order to detect a minimum of a 30-minute difference in mean time to disposition from administration of drug with an anticipated standard deviation of 1.5 hours we needed a total of 142 patients who received ondansetron first line and 142 patients who received any other antiemetic agent. To ensure a sufficient number of patients meeting inclusion criteria, we included women who presented with nausea and vomiting of pregnancy over a 2 year time frame. 2.3. Statistical analyses Data were analyzed using SAS V 9.2 (Cary, NC). Relationships between antiemetic used and various clinical and demographic variables were examined using Chi-square, Fisher’s exact test, ANOVA, and Kruskal Wallis test where appropriate. P-Values are two sided with a P b 0.05 considered statistically significant. For the multivariable analyses, we collapsed time to disposition into two categories, b 75th percentile and ≥75th percentile (≥168 minutes). We performed multivariable logistic regression to determine odds of being in the ≥75th percentile for length of emergency room visit and the odds of needing a second agent. We calculated both crude and adjusted odds ratios, adjusting for factors that could potentially confound the relationship between antiemetic administered and time to disposition and patient characteristics that were significantly associated in the univariate analyses with first line antiemetic received (p b 0.05).

3. Results 3.1. Demographic findings During the study period, 439 patients received the diagnosis of “nausea and vomiting of early pregnancy” in the Women’s ED and met study eligibility criteria. Baseline patient characteristics are shown in Table 1. The mean age of patients was 25.6 years and the median gestational age at presentation was 8 weeks. Most pregnancies were singleton gestations (97.8%). Twelve percent of patients (n = 59) had a history or nausea/vomiting in a prior pregnancy and 40.6% of patients were currently being treated for nausea/vomiting of pregnancy. Almost 50% of patients were orthostatic (46.2%) or had ketones in their urine (47.8%). Almost 24% of patients had previously presented to the ED for nausea and vomiting of pregnancy prior to 13 weeks gestation and only 4% of women who presented to the ED were admitted to the hospital. Among the women discharged to home, 48% (n = 209) received ondansetron as a first line agent, 38% (n = 169) received metoclopramide, 13% (n = 56) received promethazine, and 1% (n = 5) received prochlorperazine (Figure). Nine percent (n = 41) received more than one antiemetic agent simultaneously. 3.2. Main findings We examined the association between patient characteristics and the first-line antiemetic that was administered to the patient. (Table 2) For these analyses we combined patients treated with promethazine and prochlorperazine (n = 61). Women treated first with ondansetron were less likely to have a history of nausea and vomiting in a prior pregnancy and were more likely to have prior emergency room visits for nausea and vomiting in the index pregnancy than women treated with metoclopramide or promethazine/prochlorperazine (8.6% vs. 13% vs. 20% P = 0.05 and 25.8% vs. 16.6% vs. 11.5%, p = 0.01, respectively). We found no difference between women who were and were not on current outpatient treatment for nausea and vomiting in terms of the first line antiemetic agent received in the emergency room (39.7% vs. 33.1% vs. 47.5%, p = 0.12). Similarly, we found no association between patient age, parity, gestational age at presentation, multifetal gestations, tobacco use, orthostatic hypotension, history of anxiety or ketonuria and the first line antiemetic given. The median time to disposition (defined as the difference in time from first line antiemetic given to time of disposition order) for this population was 111 minutes (range: 4–446). We found similar Table 1 Patient Characteristics (n = 500) N (%)a

Characteristic b

Age Mean (SD) Age Median (Min-Max)b Parity Median (Min-Max) Gestational age (Median)c Multifetal gestation History of N/V prior pregnancy Currently being treated for N/V History of anxiety Current tobacco use Orthostatic hypotension Ketonuria Previous ER visit Admitted to the hospital Simultaneous administration of N1 antiemetic first line

25.6 (5.8) 25 (15–43) 1 (0–7) 8 (4–12) 11 (2.2) 59 (11.8) 203 (40.6) 33 (6.6) 25 (11.9)d 231 (46.2) 238 (47.8) 118 (23.6) 20 (4.0) 44⁎ (8.8)

a

Data presented as N (column %) unless otherwise noted. Data presented in years. Data presented in weeks; Our criteria included women up to 13 weeks gestational age, however no patients exceeded 12 weeks. d N = 210: Of the 500 patients only 210 had whether or not they used tobacco recorded in their medical record. ⁎ Note: This number differs from the 41 patients listed in Figure because in Figure, admissions are excluded first, whereas in Table 1, 44 patients received N1 antiemetic but 3 patients were admitted and received more than 1 agent. b c

Please cite this article as: Mayhall EA, et al, Comparison of antiemetics for nausea and vomiting of pregnancy in an emergency department setting, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.032

E.A. Mayhall et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx

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Patients with discharge diagnosis of nausea/vomiting pregnancy prior to 13 weeks gestation N = 932

Patients with “uncomplicated”* nausea/vomiting early pregnancy N = 500 Admitted to the hospital and excluded from additional analyses, N = 20 Received a single agent first line N = 439

Received more than one agent first line N = 41

Ondansetron N = 209

Ondansetron+ Metoclopramide N = 26

Metoclopramide N = 169

Ondansetron+ Promethazine or prochlorperazine N = 13

Promethazine N = 56

Metoclopramide + promethazine or prochlorperazine N=2

Prochlorperazine N=5

*Weexcluded from the study population women with a gestational age greater than 13 weeks, documented history of colitis, allergies to antiemetics, abnormal liver function tests, Addison’s disease, head trauma, appendicitis, fever, peptic ulcer disease, pyelonephritis, diabetic keto-acidosis, thyroid disorder, documented migraine, or molar pregnancy. The remaining patients comprised our “uncomplicated” nausea/vomiting early pregnancy population. Figure. Patient selection and antiemetic use flow chart.

median times to disposition between women treated with ondansetron first line (117 minutes), metoclopramide (103 minutes), and either promethazine or prochlorperazine (103 minutes). (p = 0.07). We found no difference in administration of an additional antiemetic agent between women first with the different antiemetics. We performed multivariate analyses and controlled for factors that could potentially confound the relationship between antiemetic administered and time from medication administration to disposition. We included in our model history of nausea/vomiting in a prior pregnancy, previous visits to the emergency room, already on antiemetic therapy for nausea/vomiting of pregnancy, and orthostatic hypotension based on the association of these patient characteristics with first line antiemetic received. (Table 3) Adjusting for these factors, we found that compared to patients who received any other first line therapy, patients who received ondansetron first line had 2.09 times the odds of having a time to disposition at or above the 75th percentile (164 minutes) (95% CI 1.31-3.34). We found no difference between ondansetron and other antiemetic agents in terms of odds of requiring a second antiemetic agent [aOR = 1.42 (95% CI 0.92-2.17)]. Because representation to the ED for nausea and vomiting was clearly associated with first antiemetic medication chosen and could be associated with time to disposition, we repeated these analyses removing this group of patients (n = 89) and found the association between ondansetron administration first line and increased time to disposition remained (aOR 1.84; 95% CI 1.11-3.05).

4. Conclusions Comparisons of antiemetic medications for nausea and vomiting of pregnancy in an emergent care setting are lacking, despite the fact that nausea and vomiting in pregnancy is an extremely common problem for which women seek ED care [6]. We found that, among women who were treated in the ED for nausea and vomiting of early pregnancy and discharged home, the use of ondansetron first line was associated with similar mean time from administration to disposition as other antiemetics but associated with increased odds of being in the highest quartile for duration of stay in the emergency room. Only 4% of patients presenting to our ED for nausea and vomiting of early pregnancy were subsequently admitted the hospital. This result isn’t to suggest that the symptoms of nausea and vomiting of pregnancy are minimal; One study that subjectively assessed the severity of nausea and vomiting of pregnancy found that it was comparable to nausea and vomiting caused by moderately nausea-producing chemotherapy, which is commonly regarded as the most severe type [5]. Our inpatient admission rate suggests that although the symptoms of nausea and vomiting of early pregnancy can be quite severe, they can be effectively treated in an ED setting and that more research on how to best treat this population of women is needed. Much of the research on antiemetics has been conducted on nausea and vomiting from chemotherapy. In these studies, ondansetron has shown superior efficacy to other antiemetics with the lowest side effect

Please cite this article as: Mayhall EA, et al, Comparison of antiemetics for nausea and vomiting of pregnancy in an emergency department setting, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.032

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E.A. Mayhall et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx

Table 2 Patient characteristics and patient outcomes based on first line antiemetic received (n = 439) Antiemetic Used First Linea Variable c

Age [Mean (SD)] Age [Median (min-max)]c Parity [Median (min-max)] Gestational age [Median (min-max)]f Multifetal gestation Yes No History of N/V prior pregnancy Yes No Currently being treated for N/V Yes No History of anxiety Yes No Current tobacco use Yes No Orthostatic hypotension Yes No Ketonuria Yes No Additional antiemetic given N20 minutes after first Yes No Time to disposition (minutes) a b c d e f g h i

O (N = 209)b

M (N = 169)b

P (N = 61)b,i

P-value O vs M vs P

25.6 (5.9) 25 (15–43) 1 (0–7) 8 (5–12)

24.8 (5.5) 23 (15–43) 1 (0–7) 8 (5–12)

26.2 (5.8) 25 (16–43) 1 (0–6) 8 (4–12)

0.22d 0.48e 0.19e

6 (2.9) 203 (97.1)

2 (1.2) 167 (98.8)

0 (−−) 61 (100)

0.37g

18 (8.6) 191 (91.4)

22 (13.0) 147 (87.0)

12 (20.0) 48 (80.0)

0.05h

83 (39.7) 126 (60.3)

56 (33.1) 113 (66.9)

29 (47.5) 32 (52.5)

0.12h

15 (7.2) 194 (92.8)

12 (7.1) 157 (92.9)

2 (3.3) 59 (96.7)

0.53h

13 (13.1) 86 (86.9)

6 (9.8) 55 (90.2)

3 (13.6) 19 (86.4)

0.80h

109 (52.2) 100 (47.8)

68 (40.2) 101 (59.8)

27 (44.3) 34 (55.7)

97 (46.9) 110 (53.1)

72 (42.6) 97 (57.4)

30 (49.2) 31 (50.8)

69 (33.0) 140 (67.0) 117.0

39 (23.1) 130 (76.9) 103.0

21 (34.4) 40 (65.6) 103.0

0.06h 0.58h

0.07h 0.07e

O = ondansetron, M = metoclopramide, P = prochlorperazine + promethazine Data presented as N (column %) unless otherwise noted Data presented in years Anova Kruskal Wallis test Data presented in weeks Fisher’s exact test Chisquare Although 61 patients received P has a first line antiemetic, under “History of N/V prior pregnancy” there are only 60 patients listed because we were missing one data point from this field.

profile [10,11]. Given the efficacy of ondansetron in other clinical scenarios, we were expecting similar outcomes in pregnancy and were surprised by our finding that administration of ondansetron first line was not associated with the shortest durations of ED visit. However, a recently published randomized clinical trial of ondansetron versus metoclopramide among women hospitalized for hyperemesis gravidarum also found that ondansetron was not superior and reported similar

effectiveness of ondansetron and metoclopramide [14]. One possible explanation for these findings is that the nausea and vomiting of pregnancy may involve a different pathophysiologic emetic pathway than nausea and vomiting from chemotherapy. Studies evaluating antiemetics in cancer patients suggest antiemetics are more effective when chosen based on the pathophysiologic emetic pathway rather than administered empirically [11]. While the exact pathophysiologic

Table 3 Odds of increased duration of ED visit and receiving a second antiemetic agent

First line antiemetic treatment First line treatment Ondansetron All others Other variables N/V previous pregnancy Yes No Prior ED visit Yes No Already on treatment Yes No Orthostatic hypotension Yes No

≥75th percentile- time from medication to disposition

Received second antiemetic

Crude OR (95% CI)

Adjusted (95% CI)

Crude OR(95% CI)

Adjusted (95% CI)

2.11 (1.36-3.29) Ref Crude OR (95% CI)

2.09 (1.31-3.34) Ref

1.40 (0.92-2.11) Ref Crude OR (95% CI)

1.42 (0.92-2.17) Ref

1.89 (1.03-3.49) Ref

1.44 (0.79-2.65) Ref

2.75 (1.67-4.51) Ref

1.66 (1.02-2.70) Ref

2.39 (1.54-3.72) Ref

1.86 (1.23-2.83) Ref

1.43 (0.93-2.21) Ref

1.05 (0.69-1.58) Ref

a

All others = Metoclopramide, prochlorperazine, or promethazine.

Please cite this article as: Mayhall EA, et al, Comparison of antiemetics for nausea and vomiting of pregnancy in an emergency department setting, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.032

E.A. Mayhall et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx

mechanism of nausea and vomiting of pregnancy is not fully understood, it has been theorized that the human chorionic gonadotropin (hCG) secreted during pregnancy may stimulate estrogen production from the ovaries and the resulting hyperestrogenism may lead to the symptoms. It has also been suggested that vitamin B deficiency may play a role as the use of multivitamins containing vitamin B reduces the incidence of nausea and vomiting [6,15]. Complex signaling pathways mediate the symptoms of nausea and vomiting, which include dopamine, acetylcholine, histamine and 5hydroxytryptamine, with antiemetics classified by the receptors on which they act. Ondansetron is a serotonin 5-hydroxytryptamine receptor antagonist while metoclopramide is a dopamine receptor antagonist.7 While radiation and chemotherapy induced nausea and vomiting may be well managed by using medications that act at the level of the 5hydroxytryptamine serotonin receptor, nausea and vomiting of pregnancy may be better managed by other medications because it is not be mediated by the same neuropharmacologic mechanism [12]. Having access to data from an emergency room facility specifically designed for women’s emergent care presented us with a unique opportunity to compare antiemetic medications in a large population of women presenting with acute exacerbations of nausea and vomiting of pregnancy, and we collected data from all patients presenting with this problem over a 2 year period. Given our sample size, we were powered to detect a 30 minute difference in length of ED stay between the most commonly administered antiemetics at our institution (ondansetron and metoclopramide). Lastly, our main independent variables, first line antiemetic medication, and dependent variable (time to disposition in the ED) were clearly and objectively recorded within the medical record. Based on previous literature on treatment of nausea and vomiting in other clinical settings, we expected we would find that ondansetron was superior to metoclopramide for treatment of nausea and vomiting of pregnancy in the ED setting. Although our study findings were quite interesting, a single retrospective cohort study is unable to provide an absolute answer to this important treatment dilemma as to which antiemetic agent is superior for treating nausea and vomiting of pregnancy in the ED and future randomized clinical trials should be performed. Additionally, with increased interest in the cost of healthcare, a cost-benefit analysis could also better inform treatment strategies for nausea and vomiting of pregnancy in the emergency room. Limitations of our study include its retrospective design; we were limited to the data collected as part of the medical record and therefore cannot assess quality of life, patient-reported tolerance of the medications, and patient-reported change in symptoms pre and post medication. Although patient-reported tolerance and change in symptoms could not be assessed with this study design, our finding of a shorter time to disposition as well as need for fewer additional antiemetics suggest that administration of metoclopramide first line was well-tolerated and resulted in adequate change in symptoms for discharge. Finally, patient characteristics including history of nausea/vomiting in prior pregnancy, currently on therapy for nausea/vomiting and representations could affect both the provider’s choice of antiemetic and the patient’s response

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to antiemetic. Because of this, we took all of these identified potential confounders into consideration when we performed our analyses. However, with a cohort study design it is possible that unmeasured confounders inadvertently affected the association between exposure and outcome. In conclusion, we found similar times from medication administration to disposition in women with nausea and vomiting of pregnancy treated in the ED with ondansetron and with other agents. Our results suggest that, contrary to what we hypothesized, ondansetron may not be superior for this population of patients and that we should examine the external validity of research on treatment of nausea and vomiting when results are applied to different study populations, such as chemotherapy patients and healthy pregnant patients. Further investigation is needed in order to optimize care for this important population of patients seeking ED care for nausea and vomiting of pregnancy. References [1] Matthews A, Dowswell T, Haas DM, Doyle M, O’Mathuna DP. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev 2010:CD000145 [PubMed PMID: 24659261]. [2] Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 52. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;103:803–15. [3] Lombardi DG, Istwan NB, Rhea DJ, O'Brien JM, Barton JR. Measuring outpatient outcomes of emesis and nausea management in pregnant women. Manag Care 2004; 3(11):48–52 [PubMed PMID:15595402]. [4] Atanackovic G, Wolpin J, Koren G. Determinants of the need for hospital care among women with nausea and vomiting of pregnancy. Clin Invest Med 2001;24(2):90–3 [PubMed PMID:11368151]. [5] Lacroix R, Eason E, Melzack R. Nausea and vomiting during pregnancy: a prospective study of its frequency, intensity and patterns of change. Am J Obstet Gynecol 2000; 182(4):931–7 [PubMed PMID:10764476]. [6] Niebyl J. Nausea and vomiting in pregnancy. NEJM 2010;363(3):1544–50 [PubMed PMID:20942670]. [7] Patanwala AE, Amini R, Hays DP, Rosen P. Antiemetic therapy for nausea and vomiting in the emergency department. J Emerg Med 2010;39:330–6 [PubMed PMID:20022195]. [8] Ekinci O, Malat I, Isitmangil G, Aydin N. A randomized comparison of droperidol, metoclopramide, tropisetron, and ondansetron for the prevention of postoperative nausea and vomiting. Gynecol Obstet Invest 2011;71(1):59–65 [PubMed PMID:21160196]. [9] Talesh KT, Motamedi MHK, Kahnamouii S. Comparison of ondansetron and metoclopramide antiemetic prophylaxis in macillofacial surgery patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111(3):275–7 [PubMed PMID:20674417]. [10] Basch E, Prestrud AA, Hesketh PJ, Kris MG, Feyer PC, Somerfield MR, et al. Antiemetics: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol 2011;29:4189–98 [PubMed PMID:21947834]. [11] Glare P, Pereira G, Kristjanson LJ, Stockler M, Tattersall M. Systematic review of the efficacy of antiemetics in the treatment of nausea in patients with far-advanced cancer. Support Care Cancer 2004;12(6):432–40 [PubMed PMID:15108099]. [12] Salvo N, Doble B, Khan L, Amirthevasar G, Dennis K, Pasetka M, et al. Prophylaxis of radiation-induced nausea and vomiting using 5-hydroxytryptamine-3 serotonin receptor antagonists: a systematic review of randomized trials. Int J Radiat Oncol Biol Phys 2012;82:408–17 [PubMed PMID:21075553]. [13] Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press; 2007. [14] Abas MN, Tan PC, Azmi N, Omar SZ. Ondansetron compared with metoclopramide for hyperemesis gravidarum: a randomized controlled trial. Obstet Gynecol 2014; 123(6):1272–9 [PubMed PMID:24807340]. [15] Braunstein GD, Hershman JM. Comparison of serum pituitary thyrotropin and chorionic gonadotropin concentrations throughout pregnancy. J Clin Endocrinol Metab 1976;42:1123–6 [PubMed PMID:932175].

Please cite this article as: Mayhall EA, et al, Comparison of antiemetics for nausea and vomiting of pregnancy in an emergency department setting, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015.03.032

Comparison of antiemetics for nausea and vomiting of pregnancy in an emergency department setting.

To compare time from medication administration to disposition from the Emergency Department (ED) between women treated for nausea and vomiting of preg...
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