hyperemesis gravidarum

SD_Hyperemesis Gravidarum_January 2014

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)

Patients with hyperemesis gravidarum ≤ 20 weeks gestational age

Abstract

This guideline is aimed at management of women with hyperemesis gravidarum.

Key words

Hyperemesis, vomiting, pregnancy, steroids

Statement of the evidence base of the guideline – has the guideline been peer reviewed by colleagues?

Literature review, evidence ranging from 1- 5

Consultation process

Risk Management Group Consultant Gynaecologists Ward Sisters Gynaecology Nurse Specialists Practice Development Matron

Target audience All medical, nursing and administrative staff involved in emergency gynaecology. 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.


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

Addison’s disease

Benign Intracranial Hypertension

Rare causes of raised intracranial pressure


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


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 Wernicke’s

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.

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

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.


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

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 Wernicke’s 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

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

Prednisolone 5mg TDS 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


Hydrocortisone 75mg IV three times a day for

24-48 hours



No/minimal response in 24 hrs

No/minimal response in 24 hrs


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

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

intake

o Avoid large greasy or spicy meals

o Keep rooms well ventilated and odour free

COMPLICATIONS OF SEVERE HYPEREMESIS

Wernicke’s encephalopathy

Electrolyte disturbance

Central pontine myelinolysis

Other vitamin deficiencies – B12 and B6

Mallory-Weiss tears

Malnutrition

Spontaneous oesophageal rupture

Pneumothorax


Splenic avulsion

Acute tubular necrosis

Depression

Venous thromboembolism

Coagulopathy


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&E’s, Ca, LFT’s, TFT’s, MSU, USS (if not

previously had a scan)

Treatment

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

doses above)

Rehydration - IV Hartman’s 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


Outpatient Management of vomiting in pregnancy (Hyperemesis) up to 14 weeks

Assessment Diagnosis suggests hyperemesis Ketonuria 3+ or less

Ketonuria 3+

Investigations – MSU, U&E,

FBC, LFT,TFT, Ca, USS (if not

already completed).

Hydration–(Hartmann’s) 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)

Ketonuria 1+ or less

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 anti-

emetics. Alternatively, can

arrange to see GP

Information Pregnancy Sickness

Support group

Check for urine ketones and

review blood results

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&E’s

Adapt IV fluids daily and titrate against fluid balance charts and results of U&E’s

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


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. Wernicke’s 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

hyperemesis gravidarum

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