WOMEN AND NEWBORN HEALTH SERVICE

King Edward Memorial Hospital

CLINICAL GUIDELINES
SECTION C: GYNAECOLOGY GUIDELINES

ABNORMALITIES OF EARLY PREGNANCY

MANAGEMENT OF HYPEREMESIS GRAVIDARUM

AIM
To provide information on the care of a woman with hyperemesis gravidarum.

BACKGROUND
Many women are affected by nausea (801-85%)2 and vomiting (52%) in the first
trimester of pregnancy.2 Severe vomiting requiring hospitalisation occurs in 0.3-20%
of all pregnant women, however hospital admission rates fall from 8 weeks2. The
peak severity for hyperemesis is around 12 weeks,1 and whilst most will resolve by
20 weeks,1, 2 10% will continue throughout pregnancy.2
Hyperemesis gravidarum is a severe form of nausea and vomiting which occurs in
0.3%1 to 1.5% of pregnancies.2 Excessive vomiting of both solid food and liquids
may lead to dehydration, ketosis, electrolyte imbalance, thyrotoxicosis and rarely
vitamin deficiency in pregnancy.
The term “hyperemesis” however, should be used only where one or more of the
following exist:
 persistent symptoms that have led to attendance at the hospital, and the need
for intravenous (IV) therapy;
 weight loss of > 4 kg (or >5%1) since conception associated with persistent
vomiting/anorexia;
 lack of response to usual antiemetic and other medications.
Other causes of severe nausea and vomiting need to be excluded. 1, 3 Most cases
have other causes for symptoms and must be evaluated fully for serious obstetric
and medical complications.

KEY POINTS
1. Therapeutic interventions are mainly supportive in conjunction with anti-emetic
medication. Non-pharmacologic interventions are used frequently, whilst
prescribed treatment is usually not indicated unless the symptoms are severe.2, 3
The safety and effectiveness of anti-emetics should then be discussed with
women with severe symptoms.2 Cessation of hyperemesis may result in superior
perinatal outcomes.4
2. Consultation with a Dietitian is very useful to obtain an accurate dietary history,
elucidate possible nutritional avenues to pursue, and to counsel the woman.
Dietary and lifestyle changes should be encouraged. Women should be advised
about appropriate foods and fluids to prevent dehydration and minimise
aggravation of symptoms. Refer all repeat admissions to the Dietitian.
3. Clinical Psychologists and Social Workers are also available to provide multi-
disciplinary care for this condition.
4. Complementary therapies have been used including ginger3 (Zingiber officinale –
not stocked in pharmacy) and acupuncture / acupressure.2 However, there is

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 currently insufficient high quality evidence to support a particular choice of
complementary therapy.2, 5 See Clinical Guideline Minor Symptoms or Disorders
of Pregnancy.
5. Iron supplementation may worsen symptoms.2 Discontinuing iron-containing
multivitamins (where appropriate) may improve hyperemesis symptoms.2
6. Women admitted with hyperemesis should be considered for thromboprophylaxis
with LMWH and can discontinue thromboprophylaxis when the hyperemesis
resolves10.

COMPLICATIONS
 Whilst nausea and vomiting do not directly have a harmful effect on pregnancy,
and no studies link nausea and vomiting with teratogenicity, it does affect the
woman’s quality of home and work life, relationships and use of healthcare
resources.2
 Depression is common, either preceding or resulting from hyperemesis.3
 Dehydration increases the risk of Diabetic Ketoacidosis in those with Type 1
diabetes.
 Electrolyte disturbances as seen in any patient with persistent vomiting –
hypochloraemic alkalosis, hypokalaemia and hyponatraemia.
 Protein-calorie malnutrition and accompanying ketosis, anaemia,
hypoalbuminaemia.
 Vitamin / mineral deficiencies and accompanying problems – e.g. Wernicke’s
encephalopathy from thiamine deficiency, folate deficiency, iron deficiency.
 Thyroid dysfunction – e.g. “pseudothyrotoxicosis” – suppressed TSH with high
free thyroxine resulting from thyroid stimulation by HCG.
 Renal dysfunction3 – (reversible) elevated urea and creatinine.
 Hepatic dysfunction accompanying hyperemesis3 – elevated ALT, AST, low
albumin, elevated bilirubin, subsequent to malnutrition and catabolic changes.
 Ulcerative oesophagitis.
 Sialorrhoea – constant salivation (“ice-cream bucket syndrome”).

MANAGEMENT

ASSESSMENT

Gynaecological / Obstetric history

1. Obtain details of current pregnancy.
 Determine first day of the last menstrual period.
 Check whether an ultrasound has been performed in this pregnancy, at what
gestation and where this was performed. If this was performed outside KEMH,
arrange for the report to be faxed to KEMH and following review & initialling, a
copy filed in the woman's hospital notes.
 Confirm the gestation.
 Determine whether there has been any vaginal bleeding.

9.6 Management of Hyperemesis Gravidarum King Edward Memorial Hospital

Clinical Guidelines -Section C Perth Western Australia

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  Seek information regarding the woman’s anxiety about progress of her
pregnancy – some cases require ultrasound to confirm fetal viability.
2. Obtain a dietary history to ascertain state of nutrition and recent intake. Ask
specifically about the nausea and vomiting.
 What is being kept down after ingestion?
 Does anything precipitate the nausea?
 Is the appetite normal / decreased?
3. Determine the presence of other symptoms. The following factors predispose to
or aggravate hyperemesis:
 Multiple pregnancy3, 6  Gastro-oesophageal  Dyspepsia
3, 4
reflux
 Molar pregnancy 3
 Peptic ulcer disease  Pyelonephritis
 Previous hyperemesis  Urinary tract infection  Gastro-enteritis
 Pre-existing eating disorders  Gastro-intestinal atony  Hepatitis
 Depression or anxiety
3 4
 Reflux oesophagitis  Appendicitis
 Rejecting or unplanned
3
 Inflammatory bowel  Cholelithiasis
pregnancy disease
 Greater weight4  Younger age4  Allergies4
 Restrictive diet (e.g. lactose-free, vegetarian,4 or nutritional  Helicobacter
deficiency3 pylori3, 7, 8
 Financial and other situational stresses  Sialorrhoea4
 Cultural isolation, removal from country of origin, separation from spouse/family.
4. Ask about:
 Bowel habits and the presence of diarrhoea and/or constipation.
 Urinary symptoms such as dysuria, frequency and suprapubic pain.
 Presence of abdominal/pelvic/back pain.
 Past surgical, medical and psychiatric history.
 The dose and frequency of use of alcohol, smoking and other recreational
drugs.
 Incidence of any rigors or shivering.
 Social circumstances.
 Current medications and allergies.
5. Exclude any symptoms suggestive of thyrotoxicosis.

Examination
A full history and examination are required as there is always a lengthy differential
diagnosis.
In addition to the disorders mentioned above, papilloedema must be excluded,
surgical and medical abdominal disorders, urinary infection, gastrointestinal infection
(such as giardiasis, acute helicobacter gastritis) neurological states such as recurrent
migraine, benign recurrent and positional vertigo, and vestibular neuronitis, severe
hypercalcaemia should be considered.
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Clinical Guidelines -Section C Perth Western Australia

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 Investigations
 Urine testing: To ascertain the degree of ketosis and identify any other
abnormalities.
 Blood tests: FBC, U & E’s, LFT’s, TFT’s.
 Ultrasound Scan: Arrange if this has not already been performed to exclude
molar or multiple pregnancies which precipitate hyperemesis.
 Other investigations:
 Ketosis
 Bicarbonate level
 Blood gases if required.
 Women with diabetes should be monitored carefully as dehydration increases
the risk of diabetic ketoacidosis.
Note: BHCG can cause gestational thyrotoxicosis through cross reaction with the
TSH receptor. BHCG is a glycoprotein similar in structure to TSH thus the circulating
levels of free T4 and T3 are elevated at this stage of pregnancy and more so in
hyperemesis gravidarum. This is usually self-limiting but occasionally anti thyroid
medication is required.

MANAGEMENT
1. Admit if the woman continues to be dehydrated after treatment in EC/HITH for
IV fluid resuscitation and electrolyte restoration with Sodium Chloride 0.9%.
Hartmann’s has no advantage. Do not give Dextrose containing fluids as they
may precipitate encephalopathy and may also worsen hyponatraemia. Where
possible, providing warmed fluids and blankets reduces caloric loss from
shivering3.
 See also Clinical Guideline Management in the Home.
2. If hypokalaemic, the woman may require potassium (Oral route preferred).
3. Reassure the woman. Nausea and vomiting can have a profound effect on a
woman and her family’s health and quality of life.2, 3
4. Fast the woman until the mode of treatment has been determined. If she is
not to be fasted, offer dry crackers, lemonade and ginger beer. Provide advice
on oral hygiene as vomiting affects oral health.2
5. Administer IV fluids and medications as prescribed.3
6. Commence a fluid balance chart.
7. Perform a daily ward urine test for ketones.
8. Do not rush oral intake. It may help to keep the woman fasted or suck ice
cubes for the first 24 hours until the anti-emetics become effective.
9. Provide dietary education.3 Provide the woman with a copy of the booklet
Nutritional Fitness in Pregnancy and Morning Sickness”, available from Ward
6 and the Emergency Centre.

MEDICATIONS
To reduce possible risk of neonatal withdrawal symptoms, drug therapies should
cease two weeks before planned birth.3

9.6 Management of Hyperemesis Gravidarum King Edward Memorial Hospital

Clinical Guidelines -Section C Perth Western Australia

C 9.6 All guidelines should be read in conjunction with the Disclaimer at the beginning of this manual Page 4 of 6
 First Line Drug Therapy
 Prescribe anti emetics:
 Prochlorperazine (Stemetil)
 Metoclopramide (Maxalon) 10mg.
These should not be administered more frequently than every 8 hours.
 Prescribe Pyridoxine3 (Vitamin B6) 25mg every 8 hours.
 Limited evidence supports use and toxicity may occur at high doses. 2
 Consider prescribing:
 Antihistamines to reduce the nausea.2, 3 Prescribe 8 hourly in the
interval between the administration of the antiemetic.
 Thiamine (Vitamin B1) 100mg once daily to prevent Wernicke’s
encephalopathy.
 Folic acid and multivitamins3.

Second Line Drug Therapy

 Commence antiemetics such as Ondansetron 4mg every 8 hours in cases of:
 Further refractory vomiting
 Failure to improve
 Recurrent hospital admissions.

Third Line Drug Therapy: Rarely used and only after consultation
 Prednisolone
Or
 Hydrocortisone
Note: Steroids may increase the risk for congenital malformations3 such as oral
clefts in the first 10 weeks of gestation.

ENTERAL FEEDING
 Consider enteral feeding in extreme cases of intractable vomiting that does not
respond to any of the above interventions.3
 Indications are :
 Significant weight loss or failure to achieve an appropriate gestational
weight gain
 Inability to tolerate oral feeding despite antiemetic treatment
 Multiple hospital admission for hyperemesis gravidarum
 Poor nutritional status
 Significant vitamin deficiencies
 Persistently abnormal LFTs.

NB: Maternal complications associated with PICC line placement are substantial and
the use of PICC lines for the treatment of hyperemesis gravidarum should not be
routinely used9 If a PICC is used consider VTE prophylaxis

9.6 Management of Hyperemesis Gravidarum King Edward Memorial Hospital

Clinical Guidelines -Section C Perth Western Australia

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 REFERENCES & STANDARDS

1. Boelig RC, Berghella V, Kelly AJ, Barton SJ, Edwards SJ. Interventions for treating hyperemesis
gravidarum (Protocol). Cochrane Database of Systematic Reviews. 2013 (6).
2. Australian Health Ministers' Advisory Council. Clinical practice guidelines: Antenatal care- Module 1.
Canberra: Australian Government Department of Health and Ageing; 2012. Available from:
http://www.health.gov.au/antenatal
3. Pairman S, Tracy S, Thorogood C, Pincombe J. Midwifery: Preparation for practice. 2nd ed. Chatswood,
NSW: Elsevier Australia; 2010.
4. Mullin PM, Ching C, Schoenberg F, MacGibbon K, Romero R, Goodwin TM, et al. Risk factors, treatments,
and outcomes associated with prolonged hyperemesis gravidarum. Journal of Matern Fetal Neonatal
Med. 2012 Jun;25(6):632-6.
5. Matthews A, Haas DM, O'Mathúna DP, Dowswell T, Doyle M. Interventions for nausea and vomiting in
early pregnancy (Review). Cochrane Database of Systematic Reviews. 2014 (3).
6. Edmonds DK, editor. Dewhurst's textbook of obstetrics & gynaecology. 8th ed. West Sussex: Wiley-
Blackwell; 2012.
7. Sandven I, Abdelnoor M, Nesheim BI, Melby KK. Helicobacter pylori infection and hyperemesis gravidarum:
A systematic review and meta-analysis of case-control studies. Acta Obstetr Gynecol Scand.
2009;88(11):1190-200.
8. Gungoren A, Bayramoglu N, Duran N, Kurul M. Association of Helicobacter pylori positivity with the
symptoms in patients with hyperemesis gravidarum. Arch Gynecol Obstet. 2013;288(6):1279-83.
9. Holmgren,C. Aaqaard-Tillery KM,Silver RM,Porter TF, Varner M. Hyperemesis in pregnancy: an evaluation
of treatment strategies with maternal and neonatal outcomes. Am J Obstet Gynecol. 2008;191(1):56.e1-4
10. Royal College of Obstetricians and Gynaecologists(RCOG).Green-top guideline No 37a.Reducing the
Risk of Venous Thromboembolism during Pregnancy and the Puerperium. April 2015

National Standards – 1.7.2 Clinical Care

Legislation - Nil
Related Policies – Nil
Other related documents –
 AHMAC National Evidence-Based Antenatal Care Guidelines: Module 1 (p.91-95).
 Clinical Guideline, Section B: Minor Symptoms or Disorders of Pregnancy
 Clinical Guideline, Section C, Hyperemesis: Management in the Home
 Clinical Guidelines, Section P: Folic acid; Hydrocortisone; Metoclopramide; Ondansetron; Prednisolone;
Prochlorperazine; Pyridoxine; Thiamine
 Nutritional Fitness in Pregnancy and Morning Sickness patient brochures.
RESPONSIBILITY
Policy Sponsor HoD Gynaecology
Initial Endorsement June 2002
Last Reviewed May 2014
Last Amended July 2015
Review date May 2017

Do not keep printed versions of guidelines as currency of information cannot be guaranteed.

Access the current version from the WNHS website.

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