Nausea and Vomiting in pregnancy/ Hyperemesis Gravidarum

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Dr Judith Kundodyiwa MRCOG / Dr Funmi Odusoga MRCOG

Nausea and vomiting affects up to 80% of pregnant women
Typically starts between 4 – 7 weeks, peaks in the 9^th week and resolves at 14weeks – 16 weeks, by 20weeks it would have resolved in 90% of women
Hyperemesis gravidarum is the severe form of Nausea and vomiting characterised as severe and persistent vomiting, potentially leading to at least 5% weight loss, dehydration, electrolyte imbalance, vitamin deficiency, acid base abnormality and, in some cases, adverse psychological effects.
Incidence of hyperemesis gravidarum is around 1 in 100 women

Full history – gestation, frequency and duration of vomiting.
A risk assessment of should be undertaken to exclude any known high risk factors e.g.: Multiple pregnancy.
Any significant medical history should be noted together with symptoms of UTI.
Any medication, particularly iron preparations.
Urinalysis to confirm pregnancy, determine the presence of ketones and exclude UTI – if leucocytes/nitrates present, obtain Mid Stream Urine for microscopy culture and sensitivity.
Abdominal palpitation if appropriate.
Obtain bloods for FBC, U&Es, LFTs and TFTs.

NO KETONES

Either:

If the woman is unable to tolerate oral medication the anti-emetics may be given intramuscularly prior to discharge.

Cyclizine 50 mg im or
Prochlorperizine 12.5 mg im
Reassure the woman that the medication should improve her symptoms and that most cases of hyperemesis resolve by 12 weeks gestation.
Give the following advice:
- To take a small, regular, dry snack.
- Avoid fatty, highly spiced and fried foods.
- Carbohydrate snacks at bedtime and before rising can prevent hypoglycaemia which is often implicated as a cause of nausea and vomiting.
- Iron therapy should be discontinued until the hyperemesis resolves.
- To try ginger products.
- Acupressure bands such as “sea bands” worn around the wrists may also be beneficial.
Midwife will ensure that the GP is aware of the woman’s condition so that (s)he can:

Assessment by clinician/ midwife, midwife will obtain IV access and commence IV fluids. Doctor to prescribe the following:

IV fluids:
Hartmann’s solution 1 litre over 1 hour then
Sodium Chloride 0.9% 1 litre over 2 hours
If potassium levels are <3.5mmol/L the above should be replaced with a solution of normal saline and potassium (0.15%

Potassium Chloride/0.9% Sodium Chloride) 1 litre over 2 hours

Administer anti-emetic:
Cyclizine 50 mg im or
Prochlorperizine 12.5 mg im
Arrange USS to exclude multiple pregnancy or hydatidiform mole.
After 3 hours rehydration and medication the woman’s condition should be reassessed and her blood results reviewed.
The woman’s urine should be rechecked for the presence of ketones.
If the woman’s condition has improved and her blood and urine results are normal, discharge the woman with an appointment to attend for follow up in two days if necessary.
Discharge the patient with a TTO for:
Cyclizine 50mg TDS and
Thiamine 50mg BD.
(Prochloperazine Buccal 3mg 1-2 tablets bd is an alternative to Cyclizine.)
If the woman’s condition has not improved and/or her blood results are abnormal, midwife/nurse should arrange for her to be seen by medical team and admitted to the ward.
If admitting, REMEMBER THROMBOPROPHYLAXIS!
In intractable cases consider Ondansetron 4mg three time daily, oral/IV/IM
Severe cases may require corticosteroids