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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

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


Patient information and support charity Pregnancy Sickness Support

NHS Information for patients

RCOG Guideline -information on NVP

Patient Information Support from Hyperemesis Gravidarum Australia

Tommys org -patient support site

HER Foundation USA

American College of Obstetricians and Gynaecologists -patient information

ACOG Practice Bulletin on NVP – access needed

Internation Collaboration on Hyperemesis Gravidarum



  1. The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum Royal College of Obstetrician & Gynaecologists Green-top Guideline No 69 June 016
  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
  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
  5. Hyperemesis Gravidarum Goodwin, T. Murphy Obstetrics and Gynecology Clinics, Volume 35, Issue 3, 401 – 417
  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.
  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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