Title of Guideline (must include the word

Guideline (not protocol, policy, procedure

etc.)

GUIDELINE ON MANAGEMENT OF
HYPEREMESIS GRAVIDARUM

Contact Name and Job title (author)

Dr. Shilpa Deb

Consultant Gynaecologist

Katherine Shorter
Gynaecology Nurse Specialist
Dr Corah Ohadike
ST7 Obstetrics and Gynaecology
Directorate and Speciality

Family Health
Obstetrics and Gynaecology

Date of submission

October 2014

Date on which guideline must be reviewed

(this should be 1 3 years)

October 2017

Explicit definition of patient group to which it

applies (e.g. inclusion and exclusion criteria,
diagnosis)
Abstract

Patients with hyperemesis gravidarum 20

weeks gestational age

Key words

Hyperemesis, vomiting, pregnancy, steroids

Statement of the evidence base of the

guideline has the guideline been peer
reviewed by colleagues?
Consultation process

Literature review, evidence ranging from 1- 5

Target audience

All medical, nursing and administrative

staff involved in emergency gynaecology.

This guideline is aimed at management of

women with hyperemesis gravidarum.

Risk Management Group

Consultant Gynaecologists
Ward Sisters
Gynaecology Nurse Specialists
Practice Development Matron

This guideline has been registered with the trust. However, clinical guidelines are guidelines
only. The interpretation and application of clinical guidelines will remain the responsibility of
the individual clinician. If in doubt, contact a senior colleague or expert. Caution is advised
when using guidelines after the review date.

SD_Hyperemesis Gravidarum_January 2014

HYPEREMESIS GRAVIDARUM
INTRODUCTION
Nausea and vomiting affect at least 50% of women in the first trimester of pregnancy.
Hyperemesis Gravidarum is persistent vomiting in pregnancy, associated with dehydration,
ketonuria and weight loss (>5% of pre-pregnancy weight). It affects 0.1-1% of pregnant
women and can be severe enough to warrant hospital admission and require intravenous
fluid therapy. It is a diagnosis of exclusion wherein other causes of severe vomiting are
excluded. Onset is always in the first trimester. This may result in fluid and electrolyte
imbalance as well as affecting the nutritional status.

CLINICAL FEATURES

Persistent vomiting or Severe nausea Adequate hydration not maintained

Ptyalism - inability to swallow saliva leading to spitting

Dehydration loss of skin turgor, furry tongue, ketotic breath, postural hypotension,
tachycardia

Muscle wasting/weakness

DIFFERENTIAL DIAGNOSES

**CONSIDER DIFFERENTIAL DIAGNOSES IT MUST BE A DIAGNOSIS OF EXCLUSION**

Urinary tract infection

Hepatitis

Enteric infections

Peptic ulceration

Reflux oesophagitis

Pancreatitis

Hypercalcaemia

Addisons disease

Benign Intracranial Hypertension

Rare causes of raised intracranial pressure

SD_Hyperemesis Gravidarum_January 2014

EXAMINATION

Assess for signs of dehydration- dry mucous membranes, concentrated urine,

ketonuria

Record Temperature, Pulse rate, Blood pressure

Weigh the patient

Perform a full examination including fundoscopy

INVESTIGATIONS

Urinalysis ketonuria / evidence of UTI; MSU for culture-sensitivity if positive for

nitrites, leucocytes or protein.

If glycosuria and ketonuria consider diabetes and measure a blood glucose

Full Blood count (FBC)-Haematocrit usually raised

Urea and electrolytes (U&E) -in severe hyperemesis hyponatraemia, hypokalaemia

and, raised serum urea may be seen

Liver function tests (LFT) -up to 50% have moderately increased transaminases and
may resolve in time. They require surveillance by performing LFTs every 2 weeks

Thyroid function tests (TFT)-biochemical hyperthyroidism Clinically euthyroid with

a raised free thyroxine, suppressed TSH but absence of thyroid antibodies; resolves
with improvement in hyperemesis gravidarum

Calcium (Ca) hypercalcaemia is a rare but potentially treatable cause of vomiting. If

left untreated it can progress to severe early onset pre-eclampsia like illness with
substantial maternal and neonatal morbidity and mortality

Pelvic Ultrasound (USS) rule out multiple pregnancy / molar pregnancy

Serum Human Chorinic Gonadotrophin (HCG) levels as baseline if molar pregnancy

suspected on USS

TREATMENT

Aims of treatment

Rehydration

Correction of electrolyte imbalance

Prevention of complications

SD_Hyperemesis Gravidarum_January 2014

I. Correction of dehydration and electrolyte abnormalities

Compound sodium lactate (Hartmanns) solution for the initial rapid hydration and
slow hydration. Intravenous (IV) 0.9% sodium chloride can be used for slow
hydration (over 6-8 hours)

1 Litre (L) over 2 hours followed by 1L over 4 hours followed by 1L over 6 hours and
1 L over 8 hours.

Consider adding 20mmol potassium chloride to fluids tailor to electrolytes

Avoid Dextrose containing fluids as these can precipitate Wernickes

encephalopathy and avoid rapid administration of Normal saline as can result in
too rapid a correction in Sodium levels and may cause central pontine myelinolysis

II. Antiemetics
*Unless known allergies, use stepwise and prescribe each regularly for 24 hours before
moving to next line treatment. It would be advisable to add the 2nd line anti-emetic to the
first line and trying the combination before proceeding to the third line ant-emetics and
steroids. Commonly, women will require combination of anti-emetics to control their
symptoms.
1st line Promethazine orally (PO)/intramuscular (IM) 25 milligrammes (mg) three times a
day (t.d.s.) and / or
Cyclizine PO/IM/IV 50mg t.d.s.
2nd Line Prochlorperazine IM 12.5mg t.d.s. / PO 10mg t.d.s. / buccal 3-6 mg b.d. and/or
Metoclopramide PO/IM/IV 10mg t.d.s.

Please Note:

Metoclopramide and prochloperazine can cause extrapyramidal side effects

(acute dystonic reactions, oculogyric crisis)

Emergency treatment is IV PROCYLIDINE 10MG STAT which can be repeated

after 20minutes if necessary.

3rd line Ondansetron IM/ slow IV 4-8mg then PO 4-8mg b.d.

SD_Hyperemesis Gravidarum_January 2014

Chlorpromazine IM 25 mg t.d.s. / PO 10-25 mg t.d.s.

4th line- Steroids

Consider in severe hyperemesis Resistant to antiemetics, 3+ ketonuria with 3 or

more inpatient admissions

Consultant decision

Steroid flow chart

Diagnosis of Severe Hyperemesis
(Resistant to anti-emetics, 3+ketonuria with 3 or more inpatient admissions)

If unable to tolerate orally

Hydrocortisone 50mg IV
twice a day for
24-48 hours

If unable to tolerate orally

Hydrocortisone 50mg IV
three times a day for
24-48 hours

If unable to tolerate orally

Hydrocortisone 75mg IV
three times a day for
24-48 hours

Prednisolone 5mg TDS

orally
No/minimal response in 24 hrs

Prednisolone 10mg TDS

orally
No/minimal response in 24 hrs

Prednisolone 15mg TDS

orally

Once vomiting is controlled and food intake has resumed, continue the required dose of
Prednisolone for 7 days, then advise decrease every week thereafter by 5mg depending on
the degree of wellbeing. If vomiting recurs, go back to the immediately previous dose.

III. Vitamin supplementation

Thiamine and high dose folic acid supplementation is required in cases of severe
hyperemesis or women requiring repeated (more than 2) hospital admissions to
prevent Wernickes encephalopathy.

Thiamine 50mg b.d orally or IV Pabrinex I and II in 100 millilitres (ml) of 0.9% sodium
chloride infused over 30-60 minutes once a week until the parenteral need for

SD_Hyperemesis Gravidarum_January 2014

hydration is required. Commonly, severity of hyperemesis settles by 12-14 weeks of

gestational age.

Folic Acid 5mg daily once able to tolerate orally

IV. Anti-reflux measures

1st line-Alginates (e.g. Peptac, Gaviscon)

2nd line- Ranitidine IV 50mg t.d.s. then PO 150mg b.d.

3rd line- Omeprazole 20mg od

V. Thromboprophylaxis

Document Venous Thromboembolism risk score

Thromboembolic deterrent stockings

Subcutaneous Enoxaparin if VTE score dictates

VI. Other management

Psychological support

Dietary advice on discharge

o

Eat dry biscuits, bread or cereal before getting up in the morning; get out of
bed slowly and avoid sudden movements

Drink fluid between meals rather than with meals to reduce volume of
intake

Avoid large greasy or spicy meals

Keep rooms well ventilated and odour free

COMPLICATIONS OF SEVERE HYPEREMESIS

Wernickes encephalopathy

Electrolyte disturbance

Central pontine myelinolysis

Other vitamin deficiencies B12 and B6

Mallory-Weiss tears

Malnutrition

Spontaneous oesophageal rupture

Pneumothorax

SD_Hyperemesis Gravidarum_January 2014

Splenic avulsion

Acute tubular necrosis

Depression

Venous thromboembolism

Coagulopathy

SD_Hyperemesis Gravidarum_January 2014

DAYCASE AND OUTPATIENT MANAGEMENT

Patients suitable for outpatient management

Ketonuria of 3+ or less

Diagnosis of hyperemesis gravidarum established

Patients unsuitable for outpatient management

Significantly abnormal urea and electrolytes

Loss of 10% body weight

Haematemesis

Persistent vomiting after day case hydration

Persistent ketonuria after day case hydration

3 previous attendances for day case hydration

Suspected other cause for vomiting

Diabetes Mellitus

Severe hyperemesis

Assessment

History and examination including fundoscopy

Investigations Urinalysis, FBC, U&Es, Ca, LFTs, TFTs, MSU, USS (if not
previously had a scan)

Treatment

Antiemetics First dose IM/IV Cyclizine, Prochlorperazine, Metoclopramide (see

doses above)

Rehydration - IV Hartmans 1L over 2 hours then 1L over 4 hours

Reassessment in 6 hours review blood results. Registrar review if bloods

abnormal.

Admission if vomiting persists in spite of hydration and parenteral antiemetic

Oral antiemetics if vomiting settles Promethazine, Cyclizine, Prochloperazine,

Metoclopramide (see doses above)

Discharge if vomiting stopped, give prescription for regular oral anti-emetics

Reassurance and GP follow up as needed

Offer review on emergency ward if symptoms persist

Pregnancy Sickness Support - LINK

SD_Hyperemesis Gravidarum_January 2014

SD_Hyperemesis Gravidarum_January 2014

Outpatient Management of vomiting in pregnancy

(Hyperemesis) up to 14 weeks

Assessment Diagnosis suggests hyperemesis

Ketonuria 3+ or less

Ketonuria 1+ or less

Ketonuria 3+

Investigations MSU, U&E,

FBC, LFT,TFT, Ca, USS (if not
already completed).

Hydration(Hartmanns) 1
litre stat followed by 1 litre
over 2 hours

Anti-emetic

Cyclizine 50mg IM/IV (1st

line)
or
Prochlorperazine
12.5mg IM (2nd line) or
metoclopramide 10mg IM/IV
(2nd line)

Check for urine

ketones and
review blood
results

SD_Hyperemesis Gravidarum_January 2014

Discharge with

Outpatient prescription for oral

antiemetics

1st Line cyclizine 50mg TDS

and/or
2nd line Prochlorperazine 12.5mg
TDS or metoclopramide 10mg
TDS

Diet advice

Patient advised to call emergency

ward if vomiting persists beyond
24 hours and be called in for
hydration and review of antiemetics.
Alternatively,
can
arrange to see GP

Information Pregnancy Sickness

Support group

If urine ketones 2+ or more

or patient unwell Admit to
hospital

INPATIENT MANAGEMENT

Criteria for ward admission

Significantly abnormal urea and electrolytes

Loss of 10% body weight

Haematemesis

Persistent vomiting after day case hydration

Persistent ketonuria after day case hydration

3 previous attendances for day case hydration

Suspected other cause for vomiting

Diabetes Mellitus

Severe hyperemesis

General management

Fluid Input output chart

Urinalysis of all samples

Alternate day U&Es

Adapt IV fluids daily and titrate against fluid balance charts and results of U&Es

Weigh twice weekly

Anti-emetics (see above)

Antacids / Histamine receptor blockers/proton pump inhibitors (see above)

Thiamine and folic acid (see above)

Emotional and Psychological support

Nurse in a side room if possible

Diabetics with Hyperemesis Gravidarum

Inpatient management only

Consider use of sliding scale insulin

Discuss with Diabetic/Obstetric team

SD_Hyperemesis Gravidarum_January 2014

References

Bottomley C, Bourne T. Management strategies for hyperemesis. Best Practice& Research

Clinical Obstetrics and Gynaecology 23 (2009) 549-564

Nelson-Piercy C, de Swiet M. Corticosteroids for the treatment of hyperemesis gravidarum.

BJOG 1994;101:1013-15

Nelson-Piercy C, Fayers P, de Swiet M. Randomised, double blind placebo-controlled trial of

corticosteroids for the treatment of hyperemesis gravidarum. BJOG 2001;108:9-15

Nelson-Piercy, C., de Swiet, M. Corticosteroids for the treatment of hyperemesis gravidarum.

BJOG 2005; 111:1013-1015
Al-Ozairi E, Waugh J J S, Taylor R. Termination is not the treatment of choice for severe
hyperemesis gravidarum: Successful management with corticosteroids (CASE REPORT)
Journal of Obstetric Medicine 2009;2: 34-37

Bergin PS and Harvey P. Wernickes encephalopathy and central pontine myelinolysis

associated with gravidarum. British Medical Journal 1992;Aug 305 page 518

Taylor R. Successful management of hyperemesis gravidarum using steroid therapy. QJM

1996; 89: 103-107

Chesterfield Royal Hospital NHS Foundation Trust Hyperemesis Gravidarum outpatient

policy.

Leeds Teaching Hospitals NHS Trust Guidleine- Guideline for management of nausea and
vomiting in Early Pregnancy

Royal Cornwall Hospitals NHS Trust Guideline- Inpatient guideline for hyperemesis
gravidarum in pregnancy

SD_Hyperemesis Gravidarum_January 2014