{"id":14135,"date":"2023-02-23T11:05:14","date_gmt":"2023-02-23T11:05:14","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/?page_id=14135"},"modified":"2024-12-27T14:01:14","modified_gmt":"2024-12-27T14:01:14","slug":"hyperemesis-gravidarum","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/pregnancy\/hyperemesis-gravidarum\/","title":{"rendered":"Hyperemesis Gravidarum"},"content":{"rendered":"\n<p><strong>NAUSEA &amp; VOMITING OF PREGNANCY (NVP) \/ HYPEREMESIS GRAVIDARUM<\/strong><\/p>\n\n\n\n<p><strong>INFORMATION<\/strong><\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<p><strong>M.A. &amp; A.B. 23-02-23<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p>Women with <strong>severe symptoms, signs of dehydration +\/- ketonuria (2+ or more) <\/strong>and<strong> those who do not improve with advice and oral antiemetics after 3 days<\/strong>, should be referred to Obstetric Triage.<\/p>\n\n\n\n<p>There should be a lower threshold for referring women with diabetes or other co-morbidities.<\/p>\n\n\n\n<p>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.<\/p>\n\n\n\n<p><strong>Additional considerations<\/strong><\/p>\n\n\n\n<p>If women planning TOP, assessment and management will be arranged through Gynaecology triage\/Ward 210 at RIE and Ward 12 at SJH, where possible.<\/p>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p>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\u2019 gestation. Consider using PUQE-24 score.<\/p>\n\n\n\n<p>Full clinical examination to assess for signs of dehydration<\/p>\n\n\n\n<p>Perform relevant investigations \u2013 urinalysis, MSU, weight, maternal observations (BP, pulse, temperature).<\/p>\n\n\n\n<p><strong>Mild symptoms and no ketonuria<\/strong><\/p>\n\n\n\n<p>Reassure (90% resolve by 16 weeks), and offer advice about dietary changes and coping strategies:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Drink little and often, take small bland meals high in carbohydrate<\/li>\n\n\n\n<li>Avoid fatty\/spicy\/triggering foods<\/li>\n\n\n\n<li>Get plenty of rest and ask people around you for extra support and help<\/li>\n\n\n\n<li>Eat foods or drink containing ginger; alternative ginger capsules (1 g daily in divided doses)<\/li>\n\n\n\n<li>Consider acupuncture\/pressure, aromatherapy and massage, or seasickness\/pregnancy wristbands<\/li>\n<\/ul>\n\n\n\n<p><strong>Moderate symptoms +\/- ketonuria (1+ or less)<\/strong>, or persistent symptoms despite advice<\/p>\n\n\n\n<p>Offer a trial of oral antiemetics as follows:<\/p>\n\n\n\n<p><em>1<sup>st<\/sup> LINE<\/em>:&nbsp; &nbsp;&nbsp;Cyclizine 50mg three times daily <strong>OR<\/strong>Prochlorperazine 10mg three times daily<\/p>\n\n\n\n<p><em>2<sup>nd<\/sup> LINE<\/em>:&nbsp; &nbsp;If ineffective after 24 hrs, switch above agents or combine for further 24-48 hrs<\/p>\n\n\n\n<p>Consider anti-reflux medication especially if associated with heartburn typically seen in in later pregnancy, e.g. omeprazole 20mg daily.<\/p>\n\n\n\n<p>If recurrent symptoms in same pregnancy, add folic acid 5mg + thiamine 100mg daily.<\/p>\n\n\n\n<p>Consider gradually reducing dose when symptoms improve or at 12-16 weeks\u2019 gestation.<\/p>\n\n\n\n<p><em>3<sup>rd<\/sup> LINE<\/em>:&nbsp;&nbsp; Ondansetron 8mg twice daily for 5 days may be considered for women in moderate group who do not improve or tolerate above options. Women <strong>must<\/strong> be counselled regarding a small increased risk of orofacial clefts with ondansetron use before 10 weeks\u2019 gestation and it should only be prescribed where benefits are considered to outweigh potential fetal risks.<\/p>\n\n\n\n<p><strong>Pregnancy-Unique Quantification of Emesis (PUQE-24) <\/strong>index for assessing symptom severity:<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table><tbody><tr><td>In the past 24 hours, how long have you felt nauseated or sick to your stomach?<\/td><td>Not at all (1)<\/td><td>1 hour or less (2)<\/td><td>2-3 hours (3)<\/td><td>4-6 hours (4)<\/td><td>More than 6 hours (5)<\/td><\/tr><tr><td>In the past 24 hours have you vomited or thrown up?<\/td><td>I did not throw up (1)<\/td><td>1-2 times (2)<\/td><td>3-4 times (3)<\/td><td>5-6 times (4)<\/td><td>7 or more times (5)<\/td><\/tr><tr><td>In the past 24 hours how many times have you had retching or dry heaves without bringing anything up?<\/td><td>No time (1)<\/td><td>1-2 times (2)<\/td><td>3-4 times (3)<\/td><td>5-6 times (4)<\/td><td>7 or more times (5)<\/td><\/tr><\/tbody><\/table><figcaption class=\"wp-element-caption\">PUQE-24 score: Mild \u2264 6, Moderate = 7-12, Severe = 13-15<\/figcaption><\/figure>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<p>Pregnancy Sickness Support charity &#8211; <a href=\"http:\/\/www.pregnancysicknesssupport.org.uk\" target=\"_blank\" rel=\"noreferrer noopener\">www.pregnancysicknesssupport.org.uk<\/a><\/p>\n\n\n\n<p>Best use of medicines in pregnancy (BUMPS) patient information on antiemetics &#8211; <a href=\"http:\/\/www.medicinesinpregnancy.org\/Medicine--pregnancy\/Morning-Sickness\" target=\"_blank\" rel=\"noreferrer noopener\">www.medicinesinpregnancy.org\/Medicine&#8211;pregnancy\/Morning-Sickness<\/a><\/p>\n\n\n\n<p>UKTIS monograph for healthcare professionals on ondansetron use in pregnancy &#8211; <a href=\"https:\/\/uktis.org\/monographs\/use-of-ondansetron-in-pregnancy\/\" data-type=\"URL\" data-id=\"https:\/\/uktis.org\/monographs\/use-of-ondansetron-in-pregnancy\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/uktis.org\/monographs\/use-of-ondansetron-in-pregnancy\/<\/a><\/p>\n\n\n\n<p>NICE CKS Nausea\/vomiting in pregnancy &#8211; <a href=\"https:\/\/cks.nice.org.uk\/topics\/nausea-vomiting-in-pregnancy\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/cks.nice.org.uk\/topics\/nausea-vomiting-in-pregnancy\/<\/a><\/p>\n\n\n\n<p>RCOG Green-top Guideline No. 69 (2016). The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum.<\/p>\n\n\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>NAUSEA &amp; 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. M.A. &amp; A.B. 23-02-23<\/p>\n","protected":false},"author":6,"featured_media":0,"parent":4337,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"categories":[890],"class_list":["post-14135","page","type-page","status-publish","hentry","category-https-apps-nhslothian-scot-refhelp-hyperemesis-gravidarum"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"heatherlevy","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/heatherlevy\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/pregnancy\/https-apps-nhslothian-scot-refhelp-hyperemesis-gravidarum\/\" rel=\"tag\">Hyperemesis Gravidarum<\/a>","rttpg_excerpt":"NAUSEA &amp; 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. M.A. &amp; A.B. 23-02-23","_links":{"self":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/14135","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/comments?post=14135"}],"version-history":[{"count":4,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/14135\/revisions"}],"predecessor-version":[{"id":22241,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/14135\/revisions\/22241"}],"up":[{"embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/pages\/4337"}],"wp:attachment":[{"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/media?parent=14135"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/apps.nhslothian.scot\/refhelp\/wp-json\/wp\/v2\/categories?post=14135"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}