NAUSEA & VOMITING OF PREGNANCY (NVP) / HYPEREMESIS GRAVIDARUM
INFORMATION
Nausea and vomiting affects up to 80% of pregnant women, with typical onset in the first trimester. Hyperemesis is characterised by severe, protracted symptoms associated with the triad of weight loss (more than 5% from pre-pregnancy weight), dehydration and electrolyte abnormalities.
Women with severe symptoms, signs of dehydration +/- ketonuria (2+ or more) and those who do not improve with advice and oral antiemetics after 3 days, should be referred to Obstetric Triage.
There should be a lower threshold for referring women with diabetes or other co-morbidities.
Out-of-hours, consider single dose IM cyclizine 50mg or IM prochlorperazine 12.5mg with planned daytime attendance to Obstetric Triage for assessment and ambulatory management.
Additional considerations
If women planning TOP, assessment and management will be arranged through Gynaecology triage/Ward 210 at RIE and Ward 12 at SJH, where possible.
Take a history to assess symptom severity and exclude other causes (abdominal pain, UTI symptoms, infection, chronic H pylori), particularly if atypical presentation e.g. onset after 11 weeks’ gestation. Consider using PUQE-24 score.
Full clinical examination to assess for signs of dehydration
Perform relevant investigations – urinalysis, MSU, weight, maternal observations (BP, pulse, temperature).
Mild symptoms and no ketonuria
Reassure (90% resolve by 16 weeks), and offer advice about dietary changes and coping strategies:
- Drink little and often, take small bland meals high in carbohydrate
- Avoid fatty/spicy/triggering foods
- Get plenty of rest and ask people around you for extra support and help
- Eat foods or drink containing ginger; alternative ginger capsules (1 g daily in divided doses)
- Consider acupuncture/pressure, aromatherapy and massage, or seasickness/pregnancy wristbands
Moderate symptoms +/- ketonuria (1+ or less), or persistent symptoms despite advice
Offer a trial of oral antiemetics as follows:
1st LINE: Cyclizine 50mg three times daily ORProchlorperazine 10mg three times daily
2nd LINE: If ineffective after 24 hrs, switch above agents or combine for further 24-48 hrs
Consider anti-reflux medication especially if associated with heartburn typically seen in in later pregnancy, e.g. omeprazole 20mg daily.
If recurrent symptoms in same pregnancy, add folic acid 5mg + thiamine 100mg daily.
Consider gradually reducing dose when symptoms improve or at 12-16 weeks’ gestation.
3rd LINE: Ondansetron 8mg twice daily for 5 days may be considered for women in moderate group who do not improve or tolerate above options. Women must be counselled regarding a small increased risk of orofacial clefts with ondansetron use before 10 weeks’ gestation and it should only be prescribed where benefits are considered to outweigh potential fetal risks.
Pregnancy-Unique Quantification of Emesis (PUQE-24) index for assessing symptom severity:
| In the past 24 hours, how long have you felt nauseated or sick to your stomach? | Not at all (1) | 1 hour or less (2) | 2-3 hours (3) | 4-6 hours (4) | More than 6 hours (5) |
| In the past 24 hours have you vomited or thrown up? | I did not throw up (1) | 1-2 times (2) | 3-4 times (3) | 5-6 times (4) | 7 or more times (5) |
| In the past 24 hours how many times have you had retching or dry heaves without bringing anything up? | No time (1) | 1-2 times (2) | 3-4 times (3) | 5-6 times (4) | 7 or more times (5) |
Pregnancy Sickness Support charity – www.pregnancysicknesssupport.org.uk
Best use of medicines in pregnancy (BUMPS) patient information on antiemetics – www.medicinesinpregnancy.org/Medicine–pregnancy/Morning-Sickness
UKTIS monograph for healthcare professionals on ondansetron use in pregnancy – https://uktis.org/monographs/use-of-ondansetron-in-pregnancy/
NICE CKS Nausea/vomiting in pregnancy – https://cks.nice.org.uk/topics/nausea-vomiting-in-pregnancy/
RCOG Green-top Guideline No. 69 (2016). The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum.
