Is Mirtazapine an Effective Treatment for Nausea and Vomiting of Pregnancy?: A Case Series

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To the Editors
Case 1 is 34 years old, gravida 4, para 2. First pregnancy ended in premature labor at 25 weeks, and infant weighed 700 g and died at 3 days old. Second pregnancy, a normal healthy child delivered at 34 weeks. In third pregnancy, she experienced severe nausea and vomiting of pregnancy (NVP) as well as panic attacks and subsequently chose to terminate the pregnancy. Her fourth pregnancy, at the fifth-week of gestation, she experienced severe NVP accompanied by severe anxiety and decided to terminate this pregnancy. However, a week before the termination date, she was prescribed mirtazapine 15 mg/d and, within 2 days, both her anxiety and NVP subsided and she canceled the termination. Because she was feeling so much better, she decided that she did not require any further mirtazapine. However, each time the mirtazapine is tapered off, the NVP symptoms return almost immediately. The dose is subsequently stabilized at 15 mg, until the 17th week of gestation and tapered to 7.5 mg until delivery. She delivered at 36 weeks by cesarian section a healthy infant who is developing normally.
Case 2 is 31 years old, gravida 4, para 1. First pregnancy was terminated. Her second pregnancy was uneventful apart from having severe NVP with no treatment, and she delivered a normal healthy infant at 38 weeks. Third pregnancy ended in a miscarriage at 7 weeks. One year later, she became pregnant for the fourth time and was having severe NVP and mirtazapine was started at 7.5 mg per/d. The NVP diminished dramatically and had subsided completely within a few days. She was slowly tapered off the mirtazapine at 11 weeks with no further NVP. However, a routine ultrasound at 16 weeks detected severe malformations in her fetus, and she underwent an abortion, with subsequent analysis confirming a trisomy 18.
Case 3 is 32 years old, gravida 1, para 1. She presented at 15 weeks with severe NVP and severe depression with suicidal ideation, was prescribed mirtazapine 7.5 mg/d, and within a few days the NVP subsided. She tried several times to discontinue the mirtazapine, but each time she did, the severe NVP symptoms reappeared. She continued taking mirtazapine until late second trimester and delivered a healthy baby at 38 weeks who, upon follow-up, was developing normally.
Case 4 is age 31 years old, gravida 2, para 2. In the first pregnancy, a normal healthy infant was born at term. In the second pregnancy, she developed moderately severe NVP at 9 weeks but found the symptoms quite incapacitating relative to the moderate nature. Mirtazapine was prescribed at doses that she was instructed to titrate herself, to a maximum of 7.5 mg/d, of which she took 3.75 mg/d. The NVP subsided almost immediately and did not return after discontinuation, despite having taking it for less than a week. She delivered a healthy infant at term who was developing normally.
Case 5 is 37 years old, gravida 3, para 2. First pregnancy conceived by in vitro fertilization resulted in a normal healthy baby, born at term. Second pregnancy ended with a very early miscarriage. A few months later, she became pregnant spontaneously without in vitro fertilization. However, she was hospitalized at 8 weeks with severe NVP and had lost 5 kg. Oral doxylamine, intravenous chlorpromazine, and ondansetron were all tried without success and her severe NVP persisted. She was also prescribed high-dose anxiolytics in the form of intravenous clorazepate, 40 mg/d. She was then started on mirtazapine 15 mg/d, without apparent effect, as she continued to frequently vomit for the next several days.
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