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Hyperemesis Gravidarum
Scope
Nausea and vomiting are common symptoms in early pregnancy affecting up to 90% of pregnancies. It typically starts between the 4th and 7th week of pregnancy. Hyperemesis Gravidarum (HG) may cause volume depletion, electrolyte and acid-base imbalances, nutritional deficiencies and even death.
Hyperemesis Gravidarum occurs in 0.3-3.6% of women.
The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69)
History
- Previous history of Nausea and Vomiting of Pregnancy (NVP)/HG
- Quantify severity using PUQE score (please see Management section): nausea, vomiting, ptyalism (hypersalivation), spitting, weight loss, inability to tolerate food and fluids, effect on quality of life and ability to perform daily activities.
- Ask about self-reported nutritional status or rapid weight loss.
- Ask about co-morbidities which may be complicated by lack of oral intake of essential medications such as epilepsy, diabetes, HIV, psychiatric conditions and hypoadrenalism.
- Relevant surgical history such as gastric bypass, band or sleeve.
- History to exclude other causes:
- abdominal pain
- urinary symptoms
- infection
- drug history (prescription and/or recreational)
- chronic Helicobacter pylori infection
Examination
- Temperature
- Heart rate (tachycardia in dehydration)
- Blood pressure (hypotension in dehydration)
- Oxygen saturations
- Respiratory rate (tachypnoea in dehydration)
- Abdominal examination
- Weight
- Signs of dehydration such as sunken eyes, dry lips and mouth, oliguria or anuria, tachycardia and hypotension.
- Signs of malnutrition or rapid weight loss (equal to or greater than 5% pre pregnancy weight), and muscle wasting as measured by mid-arm circumference1.
- Neurological signs such as confusion, nystagmus or ataxia which could indicate Wernicke's encephalopathy.
Differential Diagnosis
| Infective
UTI, Pyelonephritis, Viral hepatitis, Gastroenteritis, Cholecystitis, Appendicitis |
| Metabolic
Addison’s disease, Hyperglycaemia, Uraemia, Thyrotoxicosis, Acute liver failure |
| Other
Raised intracranial pressure, Intestinal obstruction, Pancreatitis, Peptic ulcer |
- Severe dehydration
- Signs of malnutrition
- Rapid weight loss
- Neurological signs
- Co-morbidities complicated because of poor oral intake (diabetes, epilepsy, hypoadrenalism, psychiatric conditions, HIV)
- Urinalysis: Nitrites may indicate infection. The presence or absence of ketonuria in pregnancy is not an indicator of dehydration. Assessing urinary ketones does not have a use in the management of NVP or HG and may be misleading.
- MSU (if dipstick indicates signs of UTI)
If the patient is unwell enough to warrant further investigations with blood tests, she should be referred to gynaecology on the same day if under 16 weeks or maternity triage if 16 weeks and over.
Patients who have already had a dating scan will be able to contact maternity triage directly on 01752 430200 for advice, the midwifery team will direct patients under 16 weeks to the gynaecology nursing triage who will either advise the patient to come in or to seek support from primary care.
Women with mild/moderate nausea and vomiting in pregnancy (PUQE score 3-12) can often be managed in primary care. Most patients find that the symptoms resolve by 16 weeks. Rest is advised along with drinking little and often and eating a diet high in carbohydrate and low in fat.
| 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 brining anything up? | No time (1) | 1 -2 times (2) | 3 - 4 times (3) | 5 - 6 times (4) | 7 or more times (5) |
| The total score indicating severity of symptoms is the sum of the replies to each of the three questions: mild equal to or below 6, moderate 7-12, severe 13 - 15 |
Please Formulary guidance for drug treatment: Nausea and vomiting in pregnancy and hyperemesis gravidarum - South & West
Referral Criteria
CRITERIA FOR ADMISSION
- Severe persistent vomiting and unable to tolerate fluids or oral antiemetics. (PUQE score 13 or more)
- Clinical features of dehydration +/- electrolyte imbalance.
- Weight loss (equal to or greater than 5% body weight) despite oral antiemetics
- Confirmed or suspected comorbidity (such as urinary tract infection and inability to tolerate oral antibiotics).
N.B. Ketonuria is not a marker of dehydration in pregnancy and should not be used to assess severity.
Pre-existing mental health conditions may be exacerbated by HG particularly where prescribed oral medications are not being taken or kept down because of vomiting, therefore consideration to alternative routes of administration, proactive use of antiemetics and appropriate referrals should be considered. Have a low threshold to send in women with diabetes.
Referral Instructions
e-Referral Service Selection
Specialty: Not otherwise specified
Clinic Type: Gynaecology
Service: DRSS-Western-Gynaecology-Devon ICB-15N
Referral Form
GP Information
HELP Score - HER Foundation (hyperemesis.org) The HyperEmesis Level Prediction Score was developed by the HER Foundation to quantify HG symptoms into a score that can be trended over time to monitor progress and response to treatment.
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: December 24
