This document addresses services for pregnancy complications such as treatment of antepartum thromboembolytic disease and treatment of hyperemesis gravidarum.

Thromboembolytic Disease

Medically Necessary:
Continuous and/or intermittent subcutaneous or intravenous anti-coagulant (e.g., unfractionated, low molecular weight heparin) therapy is considered medically necessary for treatment of antepartum thromboembolytic disease.

Hyperemesis Gravidarum 

Medically Necessary:

• Continuous and/or intermittent subcutaneous, intravenous and/or enteral anti-emetic/hydration/nutrition therapy is considered medically necessary for treatment of hyperemesis gravidarum when the following interventions have failed:
  1. Diet and activity modification (e.g., clear liquid diet in conjunction with bedrest, temporarily discontinuing prenatal vitamins and/or iron); and
  2. Oral, rectal and/or intramuscular medication (e.g., promethazine, prochlorperazine, diphenhydramine or trimethobenzamide); then
• When hyperemesis is not responding to the above, the following order of treatment may be used: 
  1. IV hydration; then
  2. Subcutaneous/Intravenous therapy with metoclopramide; then
  3. Subcutaneous/Intravenous therapy with ondansetron.
• Continuous and/or intermittent enteral or total parenteral nutrition therapy is considered medically necessary when nutritional needs are compromised and the above therapies have been ineffective.
• Based on the American College of Obstetricians and Gynecologists, Clinical Management Guidelines: Nausea and Vomiting of Pregnancy, corticosteroids may be considered as a last resort in individuals who will require enteral or parenteral nutrition because of weight loss. (ACOG, 2004)

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 

Future ICD-10 coding (effective 10/01/2013)
A draft of ICD-10 Coding related to this document, as it might look today, is available for reference and comments at: Appendix 1: Future ICD-10 coding

Antepartum complications can compromise the mother and fetus. Maternal-fetal evaluation, early identification of problems, and ongoing care can contribute to an optimal birth outcome. Complications that are frequently seen in the antepartum period are:

• Hyperemesis gravidarum (nausea and vomiting of pregnancy);
• Thromboembolytic disease;

Previously, individuals were hospitalized for some of these complications, dependent upon their severity.  Advances in technology and medication use have allowed a reduction of hospital admissions, a decrease of inpatient days (if admitted) and continuation of care in the home setting. Frequently, home nursing care, pharmacy services and durable medical equipment are utilized to provide care in the home setting. Home infusion therapies generally consist of home nursing visits for maternal care and education. These services are considered skilled care and are administered by an agency licensed and in accordance to state and local laws. Examples of these therapies are:

• Anti-coagulant therapy for deep vein thrombosis (DVT): administration of anti coagulant medication (e.g., heparin) generally by the subcutaneous route to prevent further clot formation;
• Hydration/medication/total parenteral nutrition (TPN) for hyperemesis gravidarum (nausea and vomiting of pregnancy): administration of intravenous fluids for hydration or specialty fluids that provide total nutrition requirements;
• Enteral tube nutrition for hyperemesis gravidarum: feeding through a nasogastric tube with liquid nutrition products.  

Although 70-85% of all pregnant women experience some nausea, vomiting, hyperemesis gravidarum is the severe and intractable form of nausea and vomiting in pregnancy. This becomes evident when the nausea and vomiting are refractory to first line therapy. At this point controlling the nausea and vomiting with more invasive therapy may be necessary. Intractable vomiting may also compromise the mother's nutritional status. TPN or enteral therapy might be utilized concurrently with antiemetic therapy.

During pregnancy, women have an increased risk of deep vein thrombosis. This is due most often to the reduced venous flow or stasis in the lower extremities. Anticoagulant therapy during pregnancy is limited to parenteral therapy as oral medications cross the placenta impacting the fetus. Both unfractionated and low molecular weight heparin are effective anticoagulant medications. Low molecular weight heparin may have fewer complications in the way of thrombopenia and osteoporosis.

Peer Reviewed Publications:

1. Bates SM, Ginsberg JS. How we manage venous thromboembolism during pregnancy. Blood. 2002; 100(10):3470-3478.
2. Buttino L Coleman SK, Bergauer NK, et al. Home subcutaneous metoclopramide therapy for hyperemesis gravidarum. J Perinatol. 2000; 20(6):359-362.
3. Davis SM, Branch DW. Thromboprophylaxis in pregnancy: who and how? Obstet Gynecol Clin North Am. 2010; 37(2):333-343.
4. Fell DB, Dodds L, Joseph KS, et al. Risk factors for hyperemesis gravidarum requiring hospital admission during pregnancy. Obstet Gynecol. 2006; 107(2 Pt 1):277-284.
5. Goodwin TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am. 2008; 35(3):401-417.
6. Greer IA. Anticoagulants in pregnancy. J Thromb Thrombolysis. 2006; 21(1):57-65.
7. Hamaoui E, Hamaoui M. Nutritional assessment and support during pregnancy. Gastroenterol Clin North Am. 2003; 32(1):59-121.
8. James AH. Prevention and management of venous thromboembolism in pregnancy. Prevention and management of venous thromboembolism in pregnancy. Am J Med. 2007; 120(10 Suppl 2):S26-34.
9. Phillips OP. Venous thromboembolism in the pregnant woman. J Reprod Med. 2003; 48(11 Suppl):921-929.

Government Agency, Medical Society and Other Authoritative Publications:

1. American College of Obstetricians and Gynecologists (ACOG) Clinical Management Guidelines: Nausea and Vomiting of Pregnancy. 2004; Number 52. Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=10939.  Accessed on January 11, 2011.
2. American College of Obstetricians and Gynecologists (ACOG) Clinical Management Guidelines: Prevention of deep vein thrombosis and pulmonary embolism. 2007; Number 84. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=11429&nbr=5947. Accessed on January 11, 2011.
3. Diphenhydramine. In: DrugPoints System [Internet database]. Greenwood Village, Co: Thomson Healthcare. Updated periodically. Available at: http://www.thomsonhc.com.   Accessed on: January 12, 2011.
4. Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2002; (1): CD000145.
5. Gates S, Brocklehurst P, Davis LJ. Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period. Cochrane Database Syst Rev. 2002; (2):CD001689.
6. Metoclopramide. In: DrugPoints System [Internet database]. Greenwood Village, Co: Thomson Healthcare. Updated periodically. Available at: http://www.thomsonhc.com.   Accessed on: January 12, 2011.
7. Ondansetron. In: DrugPoints System [Internet database]. Greenwood Village, Co: Thomson Healthcare. Updated periodically. Available at: http://www.thomsonhc.com.  Accessed on: January 12, 2011.
8. Prochlorperazine. In: DrugPoints System [Internet database]. Greenwood Village, Co: Thomson Healthcare. Updated periodically. Available at: http://www.thomsonhc.com.   Accessed on: January 12, 2011.
9. Promethazine. In: DrugPoints System [Internet database]. Greenwood Village, Co: Thomson Healthcare. Updated periodically. Available at: http://www.thomsonhc.com.   Accessed on: January 12, 2011.

Hyperemesis Gravidarum
Pregnancy Complications
Thromboembolytic Disease