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Nausea-vomiting in pregnancy ( NVP )

Typically begins by 4th week and disappears by the 16th Peaks at approx 9 th week 75-80 % of pregnant ♀ experience this
♦ varying intensity
♦ various length of time Symptoms subside by 20th week in 90 % cases About 0.3 % – 1 % develop hyperemesis gravidarum ( HG )

Hyperemesis Gravidarum is severe form of NVP- requires hospital admission. Diagnosis is on basis of the triad -

♦ 5 % pre-pregnancy weight loss
♦ dehydration
♦ electrolyte imbalance

HG can be life threatening if not treated promptly and can ↑ the 
risk of fetal loss , preterm birth , LBW

Previous HG- advice risk of recurrence in future pregnancies
 NVP can have sig impact on physical and emotional health- impact can be comparable to those undergoing cancer chemotherapy Hospitalization for hyperemesis occurs in less than 1 % of pregnant
 women

Aetiology- Fetoprotective ( embryoprotection ) Genetic Biochemical Immunological Biosocial

Rising levels of hCG- ie conditions with ↑↑ levels of hCG as
♦ trophoblastic dis
♦ multiple pregnancy

are associated with ↑ severity of NVP
 Ongoing work to study interaction of TSH suppression and hCG
○ hCG is the thyroid stimulator of pregnancy and biochemical hyperthyroidism is seen commonly in HG Link between hCG and estradiol Female gender of the fetus associated with ↑ severe HG Role of H Pylori

Risk factors – hyperemesis- Hyperthyroid disorders psychiatric illness previous molar pregnancy pre-existing diabetes gastro-intestinal disorders asthma multiple pregnancies

History- Previous h/o NVP / HG / LMP date Quantify severity
♦ nausea
♦ vomiting
♦ hypersalivation
♦ spitting
♦ loss of weight
♦ inability to tolerate food and fluids
♦ effect on quality of life
 History to exclude other causes
♦ abdominal pain
♦ urinary symptoms
♦ infection
♦ drug history
♦ chronic H pylori infection

Examination –Temp Pulse BP Saturation Resp rate Abdominal examination Weight Signs of dehydration Signs of muscle wasting Other exam as guided by hx

Differentials – Genito-urinary – UTI , uraemia , pyelonephritis Drug induced – iron , antibiotics, opioids Neurological – vestibular disease , migraine Pregnancy related conditions 
○ acute fatty liver ○ pre-eclampsia ( if onset in 2nd 1/2 of pregnancy ) Psychological – e.g eating disorders Metabolic / endocrine e.g
○ hypercalcaemia ○ thyrotoxicosis ○ DKA ○ Addison’s disease Gastrointestinal e.g
○ gastroenteritis
○ peptic ulcer
○ pancreatitis
○ bowel obstruction
○ hepatitis
○ cholelithiasis , cholecystitis
○ appendicitis 
○ H pylori infection


Investigations – Urine dipstick 
○ quantify ketonuria as + 1 ketones or > MSU Us and Es FBC Bl glucose US scan Refractory cases or h/o previous admissions
○ TFTs
○ LFTs
○ Calcium and phosphate
○ Amylase. Changes – Biochemical changes in NVP/ HG

 Hyponatraemia Hypokalaemia Low serum urea ↑ Haematocrit Ketonuria with met hypochloraemic alkalosis Abnormal TSH ↑ Transaminases in HG Slightly raised bil and amylase

Complications – ↑ risk of low birth weight ↑ risk pre-term birth metabolic complications nutritional deficiencies Wernicke encephalopahy ( severe HG ) loss of productivity psychological impact thrombosis esophageal injuries vasospasm of cerebral arteries risk of recurrence

Management – Mild NVP should be managed in the community with oral anti-emetics Support Reassurance Oral hydration Dietary advice.

Cyclizine 50 mg tds Promethazine 25 mg nocte upto 25 mg qds Cinnarizine Doxylamine

Phenothiazines as
 Prochlorperazine ( Stemetil ) 5-10 mg tds or 3-6 mg bd buccal ( PCP is considered 2nd line in some guidelines ) Chlorpromazine Perhenazine

Safety and efficacy data for 1st line anti-emetics 
( H-1 receptor antagonists ) and phenothiazines is available & established Combination of different drugs can be used – if one drug is not effective alone Check previous response to antiemetic Rx Phenothiazines and Metoclopramide can cause extrapyramidal SEs and oculogyric crisis

Metaclopramide -can be used safely as an adjunctive therapy 10 mg tds
 Ondansetron -can be used an adjunctive therapy for management of severe NVP when other anti-emetic combinations have failed 
( can cause severe constipation ) 4-8 mg bd-tds 
Corticosteroids – should be avoided during the 1st trimester 
( ↑ ed risk of oral clefting ) and should be restricted to refractory cases


Ginger – may be beneficial up to 1gm/day Pyridoxine ( Vit B6 ) in combination with Doxylamine is available OTC in several countries and has been shown to be effective
Pyridoxine is not recommended by RCOG P6 wrist Acupressure – may help some women Herbal , homeopathy , hypnosis , hynotherapy , psychotherapy – limited or lack of evidence in NVP

Seek help if –very dark urine or no urine for 8 hrs abdominal pain or fever severe weakness – feels faint vomiting blood repeated unstoppable vomiting inability to keep food or fluids down for 24 hrs any symptoms of pre-eclampsia as
○ severe headache
○ visual problems
○ severe pain below ribs
○ sudden swelling of face , hands or feet

Consider admission if –suspected HG 
○ is she dehydrated 
○ ketonuria
○ weight loss 5 % BW despite treatment not coping previous history of hyperemesis unable to keep down liquids or oral anti-emetics confirmed co-morbidity e.g UTI she has an underlying illness for e.g diabetes PUQE score > 13

LINKS and RESOURCES

Patient information and support charity Pregnancy Sickness Support https://www.pregnancysicknesssupport.org.uk/treatments/

NHS Information for patients https://www.nhs.uk/conditions/pregnancy-and-baby/morning-sickness-nausea/

RCOG Guideline -information on NVP https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg69/

Patient Information Support from Hyperemesis Gravidarum Australia https://www.hyperemesisaustralia.org.au/resources

Tommys org -patient support site https://www.tommys.org/pregnancy-information/im-pregnant/early-pregnancy/morning-sickness-information-and-support

HER Foundation USA http://www.hyperemesis.org/

American College of Obstetricians and Gynaecologists -patient information https://www.acog.org/Patients/FAQs/Morning-Sickness-Nausea-and-Vomiting-of-Pregnancy?IsMobileSet=false

ACOG Practice Bulletin on NVP – access needed https://journals.lww.com/greenjournal/Abstract/2018/01000/ACOG_Practice_Bulletin_No__189__Nausea_And.39.aspx

Internation Collaboration on Hyperemesis Gravidarum https://www.hgresearch.org/

 

References

  1. The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum Royal College of Obstetrician & Gynaecologists Green-top Guideline No 69 June 016 https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf
  2. Nausea and Vomiting of Pregnancy Jeffrey D Quinlan et al Am Fam Physician 2003;68:121-8
  3. Nause and Vomiting of Pregnancy APGO Continuing Series on Women Health Education via http://www.nationalperinatal.org/Resources/APGO%20Educational%20Series%202011.pdf
  4. The Management of Nausea and Vomiting of Pregnancy Campbell, KimRowe, HilaryAzzam, HussamLane, Carolyn A. et al. Journal of Obstetrics and Gynaecology Canada , Volume 38, Issue 12, 1127 – 1137 https://www.jogc.com/action/showCitFormats?pii=S1701-2163%2816%2939464-6&doi=10.1016%2Fj.jogc.2016.08.009
  5. Hyperemesis Gravidarum Goodwin, T. Murphy Obstetrics and Gynecology Clinics, Volume 35, Issue 3, 401 – 417 https://www.obgyn.theclinics.com/article/S0889-8545(08)00044-2/abstract
  6. Einarson, Adrienne et al. “Treatment of nausea and vomiting in pregnancy: an updated algorithm.” Canadian family physician Medecin de famille canadien vol. 53,12 (2007): 2109-11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231543/
  7. Nottinghamshire Area Prescribing Committee Primary Care Management of Nausea & Vomiting in Early Pregnancy November 2018
  8. Gabra A (2018) Complications of Hyperemesis Gravidarum; A Disease of Both Mother and Fetus, Review Article. Crit Care Obst Gyne. Vol.5 No.1:1.
  9. Risk Factors for Hyperemesis Gravidarum Requiring Hospital Admission During Pregnancy Fell, Deshayne B. MSc1; Dodds, Linda PhD1; Joseph, K S. MD, PhD1; Allen, Victoria M. MD, MSc2; Butler, Blair MD2 Obstetrics & Gynecology: 
 February 2006 – Volume 107 – Issue 2 – p 277-284

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