April 1, 2025

Case Discussion: Management of Severe Nausea and Vomiting in a Pregnant Woman with Bipolar Disorder

Bipolar Disorder, Psychiatric Disorders During Pregnancy

This article explores the case of a woman with bipolar disorder who develops HG associated with severe anxiety and sleep disruption, and discusses various treatment options.

Ruta Nonacs, MD PhD

Hyperemesis gravidarum (HG) is a severe form of nausea and vomiting during pregnancy, affecting up to 2% of pregnant women. It can significantly impact both physical and mental health, particularly for those with pre-existing psychiatric illness. HG is associated with several adverse fetal outcomes including preterm delivery, low birthweight, small for gestational age, low Apgar scores, and neurodevelopmental delay.

In addition, many women with HG consider pregnancy termination; one study found that 52.1% of women had considered terminating their pregnancy due to HG. A significant number of women with HG do elect to terminate their pregnancy; the exact frequency varies across studies but ranges from 5% to 15%.

This article explores the case of a woman with bipolar disorder who develops HG associated with severe anxiety and sleep disruption, and discusses various treatment options.

Case Presentation

Meet Sarah, a 28-year-old woman with a history of bipolar disorder. She has been stable on a regimen of aripiprazole 5 mg and citalopram 20 mg for the past five years and elected to continue these medications during her pregnancy. She is now at 9 weeks of gestation. She began to have severe nausea and vomiting at 5 weeks of gestation and was diagnosed with hyperemesis gravidarum. Sarah’s symptoms include persistent nausea and frequent vomiting, which have led to dehydration and significant weight loss. She has received intravenous hydration in the emergency room on two occasions. Additionally, in the setting of experiencing these severe symptoms over the course of the past month, she now reports severe anxiety which has interfered with her sleep and has negatively impacted her mood.

Treatment Options

Antiemetic Agents

Antiemetic agents are a cornerstone in managing HG. Commonly used medications include metoclopramide, ondansetron, and prochlorperazine. For Sarah, these medications metoclopramide and ondansetron were not effective.

Benzodiazepines

Benzodiazepines, such as lorazepam and diazepam, have been used in the treatment of HG to help manage anxiety and reduce nausea. Lorazepam and diazepam can be administered intravenously, which may be useful in those with severe vomiting. In addition, lorazepam can be administered sublingually.

Olanzapine

Olanzapine, an atypical antipsychotic, has been proposed as a potential treatment for HG resistant to standard care. Its antiemetic properties and favorable safety profile make it an option for managing severe nausea and vomiting, especially in cases with psychiatric comorbidities. For Sarah, olanzapine could be considered if her symptoms persist despite conventional treatments. In addition, olanzapine may be helpful for managing her anxiety and sleep disruption.

Typically a daily dose of 2.5 to 5 mg is used. In addition, there is a dissolving wafer formulation of olanzapine (Zydis) that may be especially useful in those with severe vomiting.

Gabapentin

In a small double-blind, randomized controlled trial, oral gabapentin (1800-2400 mg/day) was more effective than standard-of-care therapy (oral ondansetron or metoclopramide) for reducing nausea and vomiting and increasing oral nutrition in in outpatients with hyperemesis gravidarum. This could be another option for Sarah, given that it is unlikely to cause mood instability and may also help with sleep and anxiety.

Mirtazapine

Mirtazapine, an antidepressant with antiemetic properties, has shown promise in treating severe HG that is unresponsive to conventional antiemetics. However, given Sarah’s diagnosis of bipolar disorder, mirtazapine’s antidepressant effects may increase risk for hypomania or mania, and careful monitoring is essential due to its potential impact on mood stability.

Management Strategy

Managing hyperemesis gravidarum in a woman with bipolar disorder requires a thoughtful and multidisciplinary approach. Persistent vomiting may impact a woman’s ability to sustain oral treatment, which increases risk for relapse. In addition, the anxiety and sleep disruption that often accompany HG may further increase risk for relapse.

By considering a range of treatment options, including antiemetic agents, benzodiazepines, olanzapine, gabapentin and mirtazapine, healthcare providers can tailor care to meet the unique needs of each patient, addressing both the physical symptoms of HG and the psychological challenges associated with bipolar disorder.