This document provides guidelines for the management of nausea and vomiting during pregnancy (NVP) and hyperemesis gravidarum (HG). It discusses diagnosing and assessing severity, treating symptoms with antiemetics and rehydration, preventing complications, and follow up care. NVP affects most pregnant women, while HG is a more severe form affecting 0.3-3.6% of pregnancies. Treatment involves antiemetics as first line therapy, with ondansetron and corticosteroids as subsequent options if needed. Complications like dehydration and nutritional deficiencies are prevented through rehydration and supplementation. Termination of pregnancy is only considered if all medical therapies have failed and the condition threatens the

1. Management of
Nausea and Vomiting
of Pregnancy
and
Hyperemesis
Gravidarum
Green-top Guideline, 2016
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt
ABOUBAKR ELNASHAR

2. CONTENTS
INTRODUCTION
I. DIAGNOSIS AND ASSESSMENT
II. TREATMENT
III. PREVENTION OF COMPLICATIONS
IV. FOLLOW-UP
SUMMARY
ABOUBAKR ELNASHAR

3. INTRODUCTION
NVP
up to 80% of pregnant women
one of most common indications for hospital
admission
Defined as
Nausea and/or vomiting
during early pregnancy
where there are no other causes.
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4. HG
Severe form of NVP
0.3–3.6% of pregnant women.
Recurrence rates
15% up to 80%
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5. I. DIAGNOSIS AND ASSESSMENT
NVP should only be diagnosed when
onset in 1st trimester of pregnancy
other causes of N and V have been excluded.
HG diagnosed when there is
Protracted* NVP with
The triad of
1. Weight loss ≥ 5% prepregnancy
2. Dehydration
3. Electrolyte imbalance.
*Prolonged ABOUBAKR ELNASHAR

6. Severity of NVP classified
Pregnancy-Unique Quantification of Emesis (PUQE)
score
An objective and validated index of N and V
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7. ABOUBAKR ELNASHAR

8. Initial clinical assessment and baseline investigations
1. History
1. Previous history of NVP/HG
2. Quantify severity using PUQE score:
 N, V,
 Hypersalivation, spitting
 Loss of weight
 Inability to tolerate food and fluids
 Effect on quality of life
3. History to exclude other causes:
 abdominal pain
 urinary symptoms
 infection
 drug history
 chronic Helico bacter pylori infection
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9. 2. Examination
 General
 T, P, BP, RR
 Oxygen saturations
 Weight
Signs of dehydration
Signs of muscle wasting
Abdominal
Other examination
as guided by history
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10. 3. Investigation
Urine
1. Dipstick:
quantify ketonuria as 1+ ketones or more
2. MSU
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11. Blood:
1. Urea and electrolytes:
– hypokalaemia/hyperkalaemia
– hyponatraemia
– dehydration
– renal disease
2. Full blood count:
– infection
– anaemia
– haematocrit
3. Blood glucose monitoring:
– exclude diabetic ketoacidosis if diabetic
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12. Ultrasound scan:
– confirm viable intrauterine pregnancy
– exclude
multiple pregnancy
trophoblastic disease
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13. Refractory cases OR
History of previous admissions:
1. TFTs:
Exclude hypothyroid/hyperthyroid
2. LFTs:
Exclude hepatitis or gallstones, monitor
malnutrition
3. Calcium and phosphate
4. Amylase:
Exclude pancreatitis
5. ABG:
Exclude metabolic disturbances to monitor severity
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14. Other pathological causes should be excluded by
clinical history, focused examination and investigations.
1. GIT:
Cholecystitis, peptic ulcer, gastroenteritis
hepatitis, pancreatitis
2. Genitourinary:
urinary tract infection or pyelonephritis
3. Metabolic:
4. Neurological
5. Drug-induced
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15. Severe abdominal or epigastric pain
unusual in NVP and HG
may warrant further investigation of
serum amylase levels
abdominal ultrasound
possibly oesophageal gastroduodenoscopy,which
is considered safe in pregnancy.
Chronic infection with Helicobacter pylori
can be associated with NVP and HG
testing for H. pylori antibodies may be considered.
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16. II. TREATMENT
Place
Community management
Mild NVP
managed with antiemetics.
Ambulatory daycare management
Community/primary care measures have failed
PUQE score is less than 13.
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17. Inpatient management
1. Continued N and V and inability to keep down oral
antiemetics
2. Continued N and V associated with
1. ketonuria and/or
2. weight loss (≥5%of body weight), despite oral
antiemetics
3. Confirmed or suspected comorbidity
1. urinary tract infection
2. inability to tolerate oral antibiotics.
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18. LINES OF TREATMENT
1. Antiemetics
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19. First-line antiemetic
Safe and effective
should be prescribed when required for NVP and HG
Antihistamines (H1 receptor antagonists)
Phenothiazines
Risk of oculogyric crises
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20. First drug is not effective.
drugs from different classes
Combinations of different drugs
Persistent or severe HG:
Parenteral or
Rectal route
Ask about previous adverse reactions
If adverse reaction: prompt cessation
use antiemetics with which you are familiar
Women with previous or current NVP or HG
Avoid iron-containing preparations
if these exacerbate the symptoms.
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21. 2nd line antiemetics
Metoclopramide
safe and effective
Risk of
extrapyramidal effects
oculogyric crises
Short-term use (maximum dose of 30 mg in 24 hours or
0.5 mg/kg body weight in 24 hours [whichever is lowest]
and maximum duration of 5 days)
IV doses should be administered by slow bolus
injection over at least 3 minutes to help minimise these
risks.
(Regan et al, 2009)
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22. Ondansetron use in NVP and HG
5-HT3 receptor antagonist
US FDA pregnancy category B:
Animal studies: failed to demonstrate F risk
No adequate and well-controlled studies in
pregnant women.
Safe and effective
(RCOG, 2016)
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23. Ondansetron use in NVP&HG
increased to 13%
No increase of specific birth defects with first-
trimester use
(Parker et al, 2018)
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24. 3rd line antiemetics
Corticosteroids
should be reserved for cases where standard
therapies have failed.
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25. Not recommended
Pyridoxine
1. no association between the degree of NVP and
vit B6 levels
2. Cochrane SR: lack of consistent evidence that
pyridoxine is effective
3. RCT: did not demonstrate any improvement in
nausea
Diazepam
addition reduced nausea
no difference in vomiting
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26. 2. Rehydration
Normal saline
Add potassium chloride in each bag
guided by daily monitoring of electrolytes
The most appropriate IV hydration.
Dextrose infusions
Not appropriate unless
serum sodium levels are normal
Thiamine has been administered.
 Urea and serum electrolyte levels
should be checked daily in women requiring IV fluids.
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27. III. PREVENTION OF COMPLICATIONS
1. Severe NVP or HG
Multidisciplinary team
midwives, nurses
dieticians, pharmacists
endocrinologists, gastroenterologists,
psychiatrist.
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28. 2. Histamine H2 receptor antagonists or
proton pump inhibitors
may be used for women developing
gastro-oesophageal reflux disease
oesophagitis or
gastritis.
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29. 2. Thiamine supplementation (vit B1)
either oral or IV
should be given to all women admitted with
prolonged vomiting, especially
before administration of dextrose or parenteral
nutrition.
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30. Wernicke’s encephalopathy
due to vitamin B1 (thiamine) deficiency
Sym:
blurred vision, unsteadiness and
confusion/memory problems/drowsiness
Signs:
nystagmus, ophthalmoplegia, hyporeflexia or
areflexia, gait and/or finger–nose ataxia.
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31. Episodic and of slow onset.
Potentially fatal but reversible medical emergency.
Association with IV dextrose and parenteral nutrition.
Complete remission: 29%
Permanent residual impairment: common.
Pregnancy loss: IUFD and terminations: 48%.
(Chiossi et al, 2006)
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32. 3. Women admitted with HG
Thromboprophylaxis:
low-molecular-weight heparin
unless there are specific contraindications such
as active bleeding.
can be discontinued upon discharge.
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33. 4. Enteral and parenteral nutrition
When all other medical therapies have failed
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34. 5. Termination of pregnancy
Occasionally, HG or its treatment may lead to life-
threatening illness
termination of the pregnancy is seen as the only
option.
Initiation of a prompt and responsive treatment plan
may reduce this.
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35. All therapeutic measures
should have been tried before offering termination
of pregnancy.
10% of pregnancies complicated by HG
Many of these women have not been offered the full
range of treatments available
10% had been offered steroids.
(Al-Ozairi et al, 2009)
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36. Treatment options before deciding that the only option
is termination of the pregnancy
Antiemetics
Corticosteroids
Enteral and parenteral feeding
Correction of electrolyte or metabolic disturbances
Decision
multidisciplinary,
psychiatric opinion
with documentation of therapeutic failure.
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37. 808 women who terminated their pregnancies
secondary to HG
(Poursharif et al, 2007)
Prominent reasons
Inability to care for the family and self: 66.7%
Fear that they or their baby could die: 51.2%
Fear the baby would be abnormal: 22%
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38. V. FOLLOW-UP
1. ANTENATAL
 An individualised management plan
 Severe NVP or HG who have continued symptoms
into the late second or the third trimester:
serial scans to monitor fetal growth.
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39. 2. Postnatal
A woman’s quality of life can be adversely affected
Assess a woman’s mental health status during
the pregnancy and postnatally
Refer for psychological support if necessary.
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40. 3. Future pregnancies
Women with previous HG should be advised that
there is a risk of recurrence in future pregnancies.
Early use of
lifestyle/dietary modifications
Antiemetics
that were found to be useful in the index
pregnancy to reduce the risk of NVP and HG in
the current pregnancy.
ABOUBAKR ELNASHAR

41. SUMMARY
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42. You can get this lecture and 392
lecture from:
1.My scientific page on Face book:
Aboubakr Elnashar Lectures.
https://www.facebook.com/groups/2277
44884091351/
2.Slide share web site
3. elnashar53@hotmail.com
4.My clinic: Althwara st, Mansura, Egypt
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