MANAGEMENT OF NAUSEA AND VOMITING OF PREGNANCY (NVP ) AND HYPEREMESIS GRAVIDARUM ( HG)
Summary of GTG 69

NVP- Diagnose when onset is in FIRST TRIMESTER and other causes have been excluded.

HG– Protracted NVP with triad of
more than 5% pre pregnancy weight loss
dehydration and
electrolyte imbalance

Differential diagnoses-
GI Conditions( peptic ulcers, cholecystitis, gastroenteritis, hepatitis, pancreatitis)
Genitourinary conditions( E.g urinary tract infection or pyelonephritis)
Metabolic conditions
Neurological conditions
Drug-induced nausea and vomiting.


HISTORY- Points to be noted in history-
Past history of NVP/ HG
Exclude other causes- abdominal pain, urinary symptoms, infection, drug history, chronic Helicobacter pylori infection
PUQE Score to quantify severity.
Is she able to keep any fluid/ food down
Validate her symptoms and psychological issues
Any adverse reaction to any antiemetic in the past
Pain- Severe abdominal or epigastric pain is unusual in NVP.
Calculate PUQE score ( PUQE Score is used to classify NVP as mild , moderate or severe- It is not used to diagnose HG)
Link to PUQE Scoring system


EXAMINATION- Pulse, BP, Temperature, Respiratory Rate, Oxygen saturation, Weight , Signs of Dehydration, Abdominal Examination, Other examination as Guided by History.
Refer her to sources of psychosocial support.
Advise to rest as needed for alleviation of symptoms.

INITIAL INVESTIGATIONS
Urine dipstick- Ketones ( 1+ or more is ketonuria) , Infection
Full blood count- For infection, anemia, haematocrit( raised in dehydration)
Urea and electrolytes- Hyponatremia, Hypo/hyperkalemia, dehydration, renal disease.
Blood glucose- Exclude diabetic ketoacidosis if diabetic.
Ultrasound- Viability, intrauterine , multiple pregnancy, molar pregnancy ( Urgent scan not needed if NVP resolves with treatment) .

Usual findings- hyponatraemia, hypokalaemia, low serum urea, raised
Haematocrit, ketonuria with a metabolic hypochloraemic alkalosis. Metabolic acidemia in severe cases.

The level of ketones should not be relied upon over and above clinical symptoms.




Investigations in REFRACTORY CASES– LFT( abnormal in about 40% with HG) , TFT, Amylase, Calcium, Phosphate, ABG ( Metabolic disturbance, severity) .
Biochemical thyrotoxicosis may occur- no need to treat – resolves as HG improves.


Treatment-

PUQE Score 3 to 12 , No complications- – Manage in community (oral antiemetics, rehydration, dietary advice, support, reassurance)

PUQE 13 or above, No complications, Not refractory to anti emetics- Ambulatory day care management until no ketonuria. – Fast i.v hydration, Antiemetics, Thiamine

Any PUQE Score, But with Complications, or failed ambulatory daycare management- Inpatient management.

Choice of i.v fluid- Normal saline with additional potassium ( according to daily electrolyte level) . ( There is no data- but because most women are hyponatremic, hypokalemic, hypochloremic, and ketotic)


Before giving dextrose infusion- ensure that
1. Sodium is normal
2. Thiamine has been given
( To prevent Wernicke’s encephalopathy) .

Criteria for inpatient treatment-
Continued nausea and vomiting and inability to keep down oral antiemetics
Hyperemesis Gravidarum, with continuous Nausea and vomiting despite oral antiemetics
Confirmed or suspected comorbidity (E.g UTI and inability to tolerate oral antibiotics).



Thromboprophylaxis– to be given while she is inpatient.

Antiemetics of choice- Phenothiazines and antihistamines( H1 receptor blockers) should be the first choice.
If no response to one drug- combination can be used.
Persistent HG or recurrent HG- Parenteral or rectal drugs can be used.

1. First line ( Mnemonic- 2C 2P )
Cyclizine 50 mg PO, IM or IV 8 hourly
Prochlorperazine 5–10 mg 6–8 hourly PO; 12.5 mg 8 hourly IM/IV; 25 mg PR daily
Promethazine 12.5–25 mg 4–8 hourly PO, IM, IV or PR
Chlorpromazine 10–25 mg 4–6 hourly PO, IV or IM; or 50–100 mg 6–8 hourly PR

2. Second line
Metoclopramide 5–10 mg 8 hourly PO, IV or IM (maximum 5 days’ duration)
Domperidone 10 mg 8 hourly PO; 30–60 mg 8 hourly PR
Ondansetron 4–8 mg 6–8 hourly PO; 8 mg over 15 minutes 12 hourly IV

3. Third line
Corticosteroids: hydrocortisone 100 mg twice daily IV → after clinical improvement →
Change to prednisolone 40–50 mg daily PO
Then taper to the lowest dose needed to maintain symptoms.


Complementary therapies- Ginger, Acupressure.
Consider avoiding iron preparations if these increase the NVP symptoms.

Proton pump inhibitors / H2 pump blockers can be given.

If managed as ‘in patient’– Urea and electrolyte daily. Thromboprophylaxis. Consider steroids. Multidisciplinary management.

Multidisciplinary team management –
Mental health services- Mental health issues can result from HG.
Dietary advice. Some women may need enteral or Total parenteral nutrition- Involve Gastroenterologist and nutritionist.

Termination of a wanted pregnancy due to HG-
When HG has lead to life-threatening illness and termination of the pregnancy is seen
as the only option.
Full range of treatment options to be offered before considering this option. The decision should be multidisciplinary.


On Discharge- make individualized plan.
If NVP continues into late 2nd or 3rd trimester- Offer serial Growth scans (repeated admissions for NVP are associated with18% incidence of small-for-gestational-age babies and significantly
lower birthweights)

Future pregnancy- Counsel about risk of recurrence.




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