Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum

Objectives

To guide management of women with Nausea and Vomiting in pregnancy or Hyperemesis Gravidarum

Audience

Community and Hospital Maternity Team

Initial Assessment

Use of ketones in no longer advised to determine severity PUQE score is a helpful tool

Total score is sum of replies to each of the three questions.

PUQE-24 Score: Mild 6; Moderate 7-12; severe 13-15

Motherisk PUQE-24 scoring system
In the last 24 hours, for 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 last 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 last 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)

Antiemetic Choice

Recommended antiemetic therapies and dosages

First line

Doxylamine and Pyridoxine (vitamin B6) 20/20mg PO at night, increase to additional 10/10mg in morning and 10/10mg at lunchtime if required

Cyclizine 50mg PO, IM or IV 8 hourly

Prochlorperazine 5-10mg 6-8 hourly PO (or 3mg buccal);12.5mg 8 hourly IM/IV; 25mg PR daily

Promethazine 12.5mg 4-8 hourly PO, IM or IV

Chlorpromazine 10-25mg 4-6 hourly PO IM or IV

Second Line

Metoclopramide 5-10mg 8 hourly PO IV/IM/SC

Domperidone 10mg 8 hourly PO;30mg 12 hourly PR

Ondansetron 4mg 12 hourly PO; 8mg over 15 minutes 12 hourly IV; 16mg daily PR (women taking ondansetron may require laxatives if constipation develops)

Third line

Hydrocortisone 100mg twice daily IV and once clinical improvement occurs, convert to prednisolone 40-50 mg daily PO, with the dose gradually tapered (by 5-10mg per week) until the lowest maintenance dose that controls the symptoms is reached (Corticosteroids should be reserved for cases where standard therapies have failed; when initiated they should be prescribed in addition to previously started effective antiemetics. Women takin corticosteroids should have their blood pressure monitored and a screen for diabetes mellitus)

IM intramuscular; IV intravenous; PO by mouth; PR by rectum

Management in the Community/outpatient

Community Out Patient Hyperemesis Gravidarum

Management as a day case in the antenatal ward

Day Case Hyperemesis Gravidarum

Inpatient Management

Inpatient Hyperemesis Gravidarum

Next review date: 31/08/2028

Author(s): Darlow K.

Version: 1.0

Approved By: CMT for maternity team

References

RCOG Guideline

The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69) Feb 2024