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Hyperemesis Gravidarum - obsolete Feb 2023

Checked: 23-03-2021 by Rob Adams Next Review: 22-03-2022

Overview

There are CKS guidelines on management of Nausea and vomiting in pregnancy (revised Feb 2020). The guidelines include advice on non-pharmacological measures as well as recommended medication and thresholds for referral for secondary care assessment.

Consider using a validated questionnaire to assess the severity of nausea and vomiting in pregnancy (for example the Pregnancy-Unique Quantification of Emesis [PUQE] score). This is described in more detail in Appendix II of the guideline from the Royal College of Obstetricians and Gynaecologists and reproduced below.

The UK teratology information service website Best Use of Medicines in Pregnancy (BUMPS) is also useful. The local Formulary options can be accessed here.

Women with mild to moderate nausea and vomiting in pregnancy (PUQE score 3-12 (see below) and no dehydration or ketonuria should be managed in primary care.

Severity of symptoms can be quantified using the Pregnancy Unique Quantification of Emesis (PUQE) index:

Motherisk PUQE-24 Scoring system

In the last 24 hours, for how long have you felt nauseated or sick to your stomach?	Not at all (1)	1 hour or less (2)	2-3 hours (3)	4-6 hours (4)	More than 6 hours (5)
In the last 24 hours have you vomited or thrown up?	I did not throw up (1)	1-2 times (2)	3-4 times (3)	5-6 times (4)	7 or more times (5)
In the last 24 hours how many times have you had retching or dry heaves without bringing anything up?	No time (1)	1-2 times (2)	3-4 times (3)	5-6 times (4)	7 or more times (5)

PUQE-24 score: Mild ≤ 6, Moderate = 7-12, Severe = 13-15

Referral Guidance

St Michael's Hospital

ICE referrals to the outpatient hyperemesis clinic at St Michael's that was previously available have been suspended. All referrals for patients with hyperemesis now need to go through to the on call gynae registrar via switchboard. This is due to restrictions in how they are able to manage these patients on the ward due to COVID social distancing restrictions.

NBT and Weston

For other hospitals please contact the appropriate on call team.

Red Flags

CKS list the following red flags:

Consider admitting to hospital if the woman has one of:

Continued nausea and vomiting and is unable to keep down liquids or oral antiemetics.
Continued nausea and vomiting with ketonuria and/or weight loss (greater than 5% of body weight), despite treatment with oral antiemetics.
A confirmed or suspected comorbidity (for example she is unable to tolerate oral antibiotics for a urinary tract infection).

Have a lower threshold for admitting to hospital or seeking specialist advice if the woman has a co-existing condition (for example diabetes) which may be adversely affected by nausea and vomiting.

Admission or specialist advice may also be required if there is suspicion of an alternative diagnosis or complication requiring specialist management.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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