Nausea and vomiting in pregnancy and hyperemesis gravidarum

Further guidance on the management of nauseas and vomiting in pregnancy can be accessed from the Royal College of Obstetricians and Gynaecologists or NICE CKS.

For advice on when and how to refer to specialist services, consult the local clinical referral guideline.

Women with mild to moderate nausea and vomiting in pregnancy (PUQE score 3-12 (see below) and no dehydration or ketonuria) should be managed in primary care.

  • Reassure – 90% resolve by 16 weeks, nausea and vomiting are not usually associated with a poor pregnancy outcome
  • Rest – fatigue exacerbates symptoms, support from family and friends with household chores and childcare can be helpful
  • Diet – drinking little and often, small meals high in carbohydrate and low fat, avoid triggering foods/smells
  • Acupressure at wrist (P6) – some randomised controlled trials (RCT) and systematic reviews have suggested a beneficial effect
  • Ginger – was superior to placebo in some studies, and may be effective

Do not use diazepam, pyridoxine, herbal treatments, homeopathy, hypnotherapy, hypnosis, or psychotherapy.

Where rest and dietary advice have been unsuccessful, use of oral anti-emetics is recommended; these may reduce the risk of developing hyperemesis gravidarum.

1st line

Promethazine hydrochloride

  • Initially 25mg at night; can be increased to 25mg morning and evening

See 3.4.1 antihistamines

OR

Cyclizine

  • 50mg up to three times daily

See 4.6 Drugs used in nausea and vertigo

Note: these may cause sedation and other antimuscarinic side effects.

Review after 24 hours and if response is good, continue treatment and reassess weekly thereafter. It may be possible to stop anti-emetics at 12-16 weeks, using clinical judgement.

Consider combinations of different drugs in women who do not respond to a single anti-emetic.

If 1st line anti-emetics are not effective and the woman is not dehydrated or ketonuric, consider 2nd line anti-emetics.

2nd line

Metoclopramide

  • 5-10mg three times a day for a maximum of 5 days (not for patients under 20 years old)

OR

Prochlorperazine

  • Oral tablets: 5-10mg up to three times a day
  • Buccal tablets: 3-6mg twice daily

See 4.6 Drugs used in nausea and vertigo

Note: there is an increased risk of extrapyramidal side effects and oculogyric crises with both metoclopramide and prochlorperazine.

Review patients regularly.

Consider combinations of different drugs in women who do not respond to a single anti-emetic.

3rd line

Ondansetron (unlicensed indication) (preferably not in first trimester)

  • 4mg up to twice daily

See 4.6 Drugs used in nausea and vertigo

Note: There is less safety data with ondansetron and studies are mixed. For this reason, the Royal College of Obstetricians and Gynaecologists recommends the use of ondansetron should be limited to patients who are not adequately managed on the aforementioned anti-emetics and preferably used after the first trimester of pregnancy. For further information, refer to RCOG guidance, or BUMPS.

Ondansetron must not be used in patients with any history suggestive of prolonged QT.

Review patients regularly.

Consider combinations of different drugs in women who do not respond to a single anti-emetic

If oral anti-emetics are unsuccessful, or cannot be kept down, consider referral.

Secondary care management usually takes the form of outpatient visits, rather than inpatient care, and may include daily saline infusions for dehydration.

Pregnancy Unique Quantification of Emesis (PUQE) index

Severity of symptoms can be quantified using the Pregnancy Unique Quantification of Emesis (PUQE) index:

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?7 or more times (5)5-6 times (4)3-4 times (3)1-2 times (2)I did not throw up (1)
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)

PUQE-24 score: Mild ≤ 6, Moderate = 7-12, Severe = 13-15

 

Home > Formulary > Chapters > 7. Obstetrics, gynaecology, and urinary-tract disorders > Nausea and vomiting in pregnancy and hyperemesis gravidarum

 

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