Clinical Guideline for Nausea and Vomiting in Pregnancy and ......Gravidarum Page 4 of 19 1. INTRODUCTION Nausea and/or vomiting in the first trimester of pregnancy (NVP) are very

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Clinical Guideline for Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum

Did you print this yourself? Please be advised the Trust discourages retention of hard copies of the procedural

document and can only guarantee that the procedural document on the Trust website is the most up to date version.

Version: V 2.0

Ratified by: Women's Health, Reproductive and Sexual Health Services Clinical Unit Business Meeting

Medicines Optimisation Group

Date ratified: By Division - December 2017

Medicines Optimisation Group – January 2018

Name of author and title: Dr Claire Ross, ST1 Obstetrics and Gynaecology Mr Dexter Pascal, Consultant Obstetrician and Gynaecologist

Mr David Chui, Consultant Obstetrician and Gynaecologist

Date Written: July 2014

Date Reviewed: July 2017

Name of responsible committee/individual: Chair of the Guideline Implementation Group for Maternity Services

Date issued: February 2018

Issue number: 2018238

Review date: July 2020

Target audience: Medical & Nursing/midwifery Staff in Obstetrics & Gynaecology

Compliance with CQC fundamental standards of care

Person Centred Care (Regulation 9)

Dignity and Respect (Regulation 10) Need for Consent (Regulation 11)

Safe Care and Treatment (Regulation 12)

Meeting Nutritional and Hydration Needs (Regulation 14)

Compliance with any other external requirements (e.g. Information Governance)

N/A

Associated Documents: Clinical Guideline for Anticoagulant Use in

Adults


Page 2 of 19

Version Control Table

Version number and

issue number

Date Author Reason for Change

Description of Changes Made

1.0 2014 Dr Claire Ross, Mr. Dexter Pascal, Mr. David Chui,

New guideline

2018238 V2.0 July 2017 Dr Claire Ross Clinical Review

Consultation Table

This document has been developed in consultation with the groups and/or individuals in this table:

Name of Individual or group

Title Date

Guideline Implementation Group

August 2014

Women's Health, Reproductive and Sexual

Health Services Clinical Unit Business Meeting

August 2014

Women and Children’s Guideline Implementation

Group

December 2017

Women and Children’s Governance and

accountability meeting

December 2017

Raisa Rampersad, Lead Pharmacist WC&SH

December 2017

Medicines Optimisation Group

January 2018

This information may be made available in alternative languages and formats, such as large print, upon request. Please contact the document author to discuss.


Page 3 of 19

Table of Contents Appendix A .......................................................................................................................... 3 Appendix b .......................................................................................................................... 3 1. Introduction .................................................................................................................. 4 2. Rationale....................................................................................................................... 4 3. Scope ............................................................................................................................ 4 4. Definitions .................................................................................................................... 4 5. Accountabilities ........................................................................................................... 4 6. Process ......................................................................................................................... 6

6.1 Diagnosis of Hyperemesis Gravidarum………………………………………………5 6.2 Risk Factors……………………………………………………………………………..6 6.3 Complications of Hyperemesis Gravidarum…………………………………………6 6.4 Symptom Assessment - The PUQE score ………………………………………….6 6.5 Initial Assessment of the patient on admission……………………………………..7 6.6 Acute management…………………………………………………………………….8 6.7 Ongoing inpatient Management………………………………………………………8 6.8 What to do if treatment measures fail………………………………………………..11 6.9 Discharge criteria………………………………………………………………………12

7. Special Considerations ............................................................................................. 13 8. Evidence Base/References........................................................................................ 13 9. monitoring table ................................................................ Error! Bookmark not defined. Appendix A ...................................................................................................................... 166 Appendix B………………………………………………………………………………………….17 Appendix C EHRA Form …………………………………………………………………………18 Appendix A

HYPEREMESIS GRAVIDARUM MANAGEMENT ALGORITHM (PAGE 1)12

Appendix b



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1. INTRODUCTION Nausea and/or vomiting in the first trimester of pregnancy (NVP) are very common, affecting up to 80% of women1, 2. Few of these will require regular medication or admission.

For some women (in approximately 0.3 – 1%1,3), persistent and severe nausea and vomiting may lead to Hyperemesis Gravidarum (HG). In this case treatment of dehydration and electrolyte disturbance is often indicated as a day case or in-patient.

While the cause of Hyperemesis is unclear, there are several physiological changes of

pregnancy which are thought to be linked1,3,5,6.

- Placental Causes (rising βHCG levels coincide with the peak of symptoms)

- Higher Oestrogen and Progesterone levels

- Reduced GI motility and gastric emptying due to rising progesterone levels

- Increased vestibular sensitivity

2. RATIONALE There are over 25,000 admissions per year for severe nausea and vomiting in pregnancy or hyperemesis gravidarum4. Poor and inconsistent management can lead to poor patient experience, delayed discharges and unnecessary NHS costs. This guideline has been developed in an attempt to improve and standardise care we offer in East Sussex Healthcare Trust.

3. SCOPE

These guidelines apply to women experiencing nausea and vomiting in early pregnancy. Senior clinicians involved in early pregnancy care; including consultants, trainees and specialist and senior nursing staff have reviewed these guidelines. These guidelines and algorithms (appendix A & B) are aimed to assist in decision-making. They are not designed to be prescriptive and you are expected to use them alongside professional judgment and discussion with senior colleagues where appropriate.

Evidence used to inform these guidelines had been drawn from the references quoted. The guideline has been updated in 2017 using new evidence from the RCOG green top guideline No.69; The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum.

4. DEFINITIONS

The term ‘Hyperemesis Gravidarum’ is often used to describe symptoms of persistent and severe and nausea and vomiting in early pregnancy. See section 6.1 for more details. 5. ACCOUNTABILITIES

5.1 Midwives, Nurses & Obstetricians:

To access, read, understand and follow this guidance


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To use their professional judgment in application of this guidance 5.2 Management:

To ensure the guideline is reviewed as required in line with Trust and National recommendations

To ensure the guideline is accessible to all relevant staff 6. PROCESS

6.1 DIAGNOSIS OF HYPEREMESIS GRAVIDARUM (HG):

No standard definition of HG exists, but, the following features are often present and used as diagnostic and admission criteria.

Ketonuria and High specific Urine Gravity

Triad of:

o Dehydration and inability to maintain adequate fluid intake

o Weight loss >5% and nutritional deficiency

o Fluid and electrolyte disturbance

Other Clinical Features

Onset in the first trimester

(Usually between 4-7 weeks, resolving spontaneously by 16 weeks in 90%)

Nausea and vomiting despite oral antiemetic therapy

Ptyalism (inability to swallow saliva)

Weight loss and muscle wasting

Clinical features of dehydration with postural hypotension

Symptoms are often worse in multiple pregnancies or molar pregnancies

Look out for symptoms to suggest other causes (e.g. UTI, see full list below)

OTHER CAUSES OF NAUSEA AND VOMITTING TO BE EXCLUDED: (Note: Do not delay treatment if hyperemesis gravidarum is suspected)

GU (UTI / pyelonephritis / renal colic / ovarian accident)

Endocrine (Thyrotoxicosis / DKA / Addisons / hypercalcaemia)

GI causes (Peptic ulcer / Gastritis / pancreatitis / bowel

obstruction / hepatitis / cholelithiasis / appendicitis / Constipation)

Neurological and ENT (Migraine / vestibular causes / Meniere’s)

Psychological (Eating disorder / Depression)

Other pregnancy related (Multiple pregnancy / Molar pregnancy.

Consider Pre-eclampsia / Fatty Liver if ongoing vomiting after

20wks)


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6.2 RISK FACTORS - First degree relative with HG - Previous admission - Previous HG - Multiple pregnancy - Molar Pregnancy

- Young maternal age - Primigravida - Obesity - Stress - H.Pylori seropositivity

6.3 COMPLICATIONS OF HYPEREMESIS GRAVIDARUM

Disturbance of acid balance and electrolytes (acidosis or alkalosis, hyponatraemia, hypokalaemia, hypomagnaesaemia)

Abnormal LFTs 40% (raised Transaminases and Bilirubin are markers of severe vomiting - they should resolve once vomiting is controlled)

Abnormal Thyroid function tests (due to the similarity between bHCG and

TSH); raised T4, Low TSH (self limiting)5

Nutritional and vitamin deficiencies (Folate, B6, B12, Thiamine)

Wernicke’s encephalopathy / central pontine myelinolysis8

Mallory Weiss tear / Oesophageal rupture / Retinal Haemorrhage

Increased VTE risk (Pregnancy / Reduced mobility / Dehydration)9

Psychological and occupational effects1,4,10

Rarely causes IUGR5 / miscarriage / termination due to severity of symptoms

Maternal death5,9

6.4 SYMPTOM ASSESSMENT – THE PUQE SCORE Quantification of symptoms can help differentiate between women that are suitable for discharge and those that require further admission. The Pregnancy Unique Quantification of Emesis and Nausea (PUQE) score, developed by clinician-researchers at the Canadian Motherisk Program11. It consists of only three questions which can be used at admission, and every subsequent 24 hours. The treatment goal is to achieve a ‘mild’ score prior to discharge2,11.


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QUANTIFICATION OF EMESIS AND NAUSEA SCORE

1. In the last 12 hours, for how long have you felt nauseated?

1 2 3 4 5

Not at all Less than 1 hour

2 – 3 Hours 4 – 6 hours More than 6 hours

2. In the last 12 hours, how many times have you vomited?

1 2 3 4 5

None 1-2 3-4 5-6 More than 7

3. In the last 12 hours how often have you had dry heaves / wretching without actually vomiting?

1 2 3 4 5

None 1-2 3-4 5-6 More than 7

SYMPTOM SEVERITY (BASED ON SCORE)

Mild Moderate Severe

Score 12

6.5 INITIAL ASSESSMENT OF THE PATIENT ON ADMISSION: Examination:

The following should be recorded as a minimum in the initial clinical assessment

PULSE / BLOOD PRESSURE / TEMPERATURE / RESP RATE / O2 SATS

HYDRATION ASSESSMENT: e.g. Mucous Membranes / CRT / Skin Turgor / JVP

ABDOMINAL EXAMINATION

WEIGHT (Repeat at every re-admission or weekly if long-term in patient)

Baseline Investigations

Baseline bloods - FBC / U+E / creatinine / LFTs

Other bloods based on symptoms (e.g. CRP if features of infection)

URINALYSIS (Record ketone levels daily during admission)

Early Pregnancy Ultrasound (if not already performed during this pregnancy)

Additional Investigations in refractory cases / multiple admissions:

TSH / TFTs

Amylase

Re-feeding bloods (Mg2+, Ca2+, PO4, Glucose) if: >5% body weight is lost

Consider ABG to exclude severe metabolic disturbances

Viral hepatitis screen (if liver transaminases >200)


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H.pylori antibodies may be considered. Chronic H.pylori can exacerbate HG.

Further imaging (e.g. Abdominal ultrasound if GI cause suspected)

6.6 ACUTE MANAGEMENT The following management refers to that required in the first 6 hours. STOP ANY EXACERBATING MEDICATIONS until symptoms are controlled (e.g. iron supplementation) IV ACCESS - preferably green (18G) or above IV / IM ANTIEMETIC (Cyclizine 50mg to be given first line - see below for alternatives) ADEQUATE FLUID RESUSCITATION Aim for 2L of fluid within the first 4 hours of admission

0.9% Sodium Chloride + Potassium Chloride 20mmol (FIRST LINE) Or

Hartmann’s solution Potassium containing fluids should be given via a suitable pump at a MAXIMUM RATE no greater than 250ml/hr for 40mmol/L and 500ml/hr for 20mmol/L potassium chloride. The majority of women admitted for hyperemesis are young with few co-morbidities; they will tolerate aggressive fluid resuscitation well. Caution in women with co-morbidities such as cardiac or renal pathologies.

6.7 ONGOING INPATIENT MANAGEMENT

FLUID MANAGEMENT

Prescribe adequate fluid replacement aiming for approximately 4-6L in the first 24 hours (including acute fluid rehydration) and 2-4L in subsequent 24 hour periods – consider adjusting for oral intake / weight.

All women given acute treatment should be reviewed within 6 hours to check response to initial treatment and assess suitability for rapid discharge

(See discharge criteria and algorithm appendix b).

Women who do not respond will require admission and further management.


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A FLUID BALANCE CHART IS MANDATORY Urine output should be more than 30ml/hr (0.5ml/kg/hr) Appropriate fluids to choose:

For resuscitation purposes avoid dextrose containing fluids where possible. These may increase the risk of central pontine myelinosis and Wernicke’s encephalopathy. Dextrose containing fluids may be necessary in diabetics or women with sickle cell disease, but glucose may worsen hypokalaemia. ANTIEMETIC CHOICES

The order of proven fetal safety is documented above10. First line treatment should include regular cyclizine unless contraindicated. Women should be prescribed one regular and one PRN antiemetic (minimum). Reviewed every 24 hours - add alternative antiemetics as indicated. Side effects include drowsiness, extrapyramidal effects (dyskinesias and dystonias) and rarely oculogyric crisis (with metoclopramide and phenothiazines).

FIRST LINE

0.9% sodium chloride + Potassium Chloride 40mmol/L or 20mmol/L (Sodium content 150mmol/L) HG women are prone to hypokalaemia and hyponatraemia Saline with added potassium is usually most appropriate

SECOND LINE

Hartmann’s Solution (Sodium content 131mmol/L, K+ 5mmol/L)

FIRST LINE:

1. Cyclizine 50mg TDS / Promethazine 20-25mg nocte(H1 receptor

antagonists)

2. Prochlorperazine PO 5mg TDS / Buccal 3mg TDS (phenothiazines)

SECOND LINE:

3. Metoclopramide 10mg TDS / Domperidone 10mg TDS(Dopamine

antagonists)

(Metoclopramide max = 30mg/24hour or 0.5mg/kg/24hour if lower)

4. Ondansetron 4mg TDS


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Do not prescribe both dopamine antagonists and phenothiazines simultaneously)15 Emergency treatment for extra-pyramidal effects is procyclidine 5mg IV injection or IM

VITAMIN SUPPLEMENTATION

Should be given to reduce the risk of Wernicke’s encephalopathy and fetal neural tube abnormalities2,5,16

Women with weight loss >5% should be referred to a dietician. THROMBOPROPHYLAXIS

Women admitted with Hyperemesis Gravidarum should be offered thromboprophylaxis with low-molecular-weight heparin unless there are specific contraindications such as active bleeding. Thromboprophylaxis can be discontinued upon discharge. Please see ESHT document Clinical Guideline for Anticoagulant Use in Adults. A formal VTE assessment score should be completed. OTHER ORAL MEDICATION CONSIDERATIONS

Analgesia

- Paracetamol 1g QDS (if >50Kg), Co-codamol 30/500mg 2 tablets QDS,

Codeine 30-60mg QDS and Dihydrocodeine 30-60mg QDS.

- AVOID NSAIDs due to the risk of congenital malformations.

Heartburn / Gastritis

- Peptac liquid 5-10ml after meals and at bedtime, Ranitidine 150mg BD,

Omeprazole 20mg once a day

Constipation

Thiamine (Vitamin B1) Hydrochloride 25-50mg three times daily. Hold

whilst on Pabrinex.

Pabrinex I and II (dilute in 100ml 0.9% sodium chloride, give IV over 30-60minutes) to be given weekly to those not tolerating any oral tablets. Commence oral thiamine 1 week after last dose of IV pabrinex.

Folic Acid 5mg once daily – high dose folic acid should be continued while oral intake is suboptimal.


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- Lactulose 15ml BD, Laxido 1 sachet 1-3 times a day, Ispaghula husk

(fybogel) 1 sachet BD in water after food, Senna 7.5-15mg nocte

Treatment of UTI or other infection

- Cefalexin, Amoxicillin and Nitrofurantoin are safe in the first trimester

- AVOID Trimethoprim as it acts as a folate antagonist

- Use local antibiotic policies and urine sensitivities to guide choice

Alternative therapies

- Ginger, acupuncture and acupressure may be beneficial2,10.

PSYCHOLOGICAL SUPPORT

It is rare to remove all symptoms of hyperemesis with medical treatment and women should be aware of this risk. Be aware of the quality of life impact and mental health status. Support and refer if necessary.

6.8 WHAT TO DO IF TREATMENT MEASURES FAIL

Women who show no improvement after 24 hours of treatment should be discussed and reviewed by a registrar or above

Women who show no improvement after 72 hours should be discussed with and reviewed by a consultant for consideration of steroid therapy20.

- Prednisolone 40mg – 50mg OD

(Gradually taper to the lowest dose that controls symptoms)

Or

- Hydrocortisone 100mg IV BD (convert to oral prednisolone once tolerating oral intake)

Stop corticosteroids if no improvement within 24 hours. Titrate corticosteroids down according to clinical and symptomatic improvement. All women who require corticosteroid therapy should be reviewed by a consultant in antenatal clinic on discharge. When all other medical therapies have failed, enteral or parenteral nutrition should be considered with a multidisciplinary approach.


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6.9 DISCHARGE CRITERIA

Prescribe a 2 week supply with advice to discontinue only when a normal diet is resumed. A Discharge letter addressed to the GP should be written so that any medications required after this 2 week period can be continued. All women who are discharged should receive an information leaflet or be directed to appropriate websites with information on hyperemesis.

- For example

- NHS Choices http://www.nhs.uk/conditions/pregnancy-and-baby/pages/morning-sickness-nausea.aspx#close

- Pregnancy Sickness Support https://www.pregnancysicknesssupport.org.uk/help/hyperemesis-gravidarum/

- NICE Guidelines http://www.nice.org.uk/Guidance/CG62

- BUMPS (Best Use of Medicines in Pregnancy)

http://www.medicinesinpregnancy.org/medicine--pregnancy/NV/

All women should be encouraged to seek medical advice early if symptoms become unmanageable on discharge.

The following criteria should be met before women are discharged:

Improving urine ketones

Tolerating adequate oral fluids

No clinical evidence of dehydration

Mild severity PUQE score or alternative

Discharge medications should include:

Folic acid 5mg OD

Thiamine 50mg TDS

Regular Oral antiemetic

http://www.nhs.uk/conditions/pregnancy-and-baby/pages/morning-sickness-nausea.aspx#closehttp://www.nhs.uk/conditions/pregnancy-and-baby/pages/morning-sickness-nausea.aspx#closehttps://www.pregnancysicknesssupport.org.uk/help/hyperemesis-gravidarum/http://www.nice.org.uk/Guidance/CG62http://www.medicinesinpregnancy.org/medicine--pregnancy/NV/


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7. Special Considerations Nil 8. Evidence Base/References Policy updated in 2017 with additional reference to: RCOG Green top guideline 69; The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum. June 2016 https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdf Original Citations from 2014

1. R Gadsby, AM Barnie-Adshead, C Jagger. A prospective study of nausea and vomiting during pregnancy. Br J Gen Pract. 1993 Jun;43(371):245-8.

2. A Matthews, DM Haas, DP O’Mathuna, T Dowswell, M Doyle. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2014 Mar 21;3; CD007575. doi: 10.1002/14651858.CD007575.pub3.

3. RC Boeling, V Berghella, AJ Kelly, SJ Barton, SJ Edwards. Interventions for treating hyperemesis gravidarum (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD010607. DOI: 10.1002/14651858.CD010607

4. R Gadsby, T Barnie-Adshead. Severe nausea and vomiting of pregnancy: should it be treated with appropriate pharmacotherapy? The Obstetrician & Gynaecologist 2011;13:107–111.

5. A Neill, C Nelson-Piercy. Hyperemesis Gravidarum. The Obstetrician & Gynaecologist. 2003;5:204-7

6. National Institute for Health and Clinical Excellence – NICE clinical Knowledge Summaries (CKS) Nausea and Vomiting in Pregnancy. 2013 June. Available at: http://cks.nice.org.uk/nauseavomiting-in-pregnancy#!topicsummary

7. MA Klebanoff, PA Koslowe, R Kaslow, GG Rhoads. Epidemiology of vomiting in early pregnancy. Obstet Gynaecol. 1985 Nov;66(5):612-6

8. PS Bergin, P Havey. Wernicke’s encephalopathy and central pontine myelinosis associated with hyperemesis gravidarum. BMJ 1992; 305:517-518

9. Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives: Reviewing maternal deaths to make motherhood safer: 2006–2008. BJOG: An International Journal of Obstetrics & Gynaecology, 2011 March. 118: (s1)1–203.

10. Society of Obstetricians and Gynaecologists of Canada (SOGC) Clinical Practice Guideline. The management of Nausea and Vomiting of Pregnancy. J Obstet Gynaecol Can. October 2002;24(10):817-23

11. G Koren, R Boskovic, M Hard, C Maltepe, Y Navioz, A Einarson. Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy. Am J Obstet Gynaecol. 2002 May;186(5 Suppl Understanding):S228-31

12. Brighton and Sussex University Hospitals. GP002 – Vomiting in pregnancy and Hyperemesis Gravidarum Clinical Guidelines. May 2011.

13. UK Teratology Information Service (UKTIS) and TOXBASE UK. Treatment of Nausea and vomiting in pregnancy. 2012. Available at: www.toxbase.org

14. Best use of Medicines in Pregnancy (BUMPS)/UKTIS. Treating Nausea and Vomiting in Pregnancy. Factsheet. 2013. Available at: http://www.medicinesinpregnancy.org/Medicine--pregnancy/NV/

15. Electronic Medicines Compendium (eMC). Summary of product characteristics for Maxalon Tablets 10mg. 2013. Available at: http://www.medicines.org.uk/emc/medicine/20690/SPC/Maxolon+Tablets+10mg/

https://www.rcog.org.uk/globalassets/documents/guidelines/green-top-guidelines/gtg69-hyperemesis.pdfhttp://cks.nice.org.uk/nauseavomiting-in-pregnancy#!topicsummaryhttp://www.toxbase.org/http://www.medicinesinpregnancy.org/Medicine--pregnancy/NV/http://www.medicines.org.uk/emc/medicine/20690/SPC/Maxolon+Tablets+10mg/


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16. I Greer. Obstetrician’s perspective- therapeutic trial and error. BMJ, 2004:328 p504.

17. National Institute for Health and Clinical Excellence – NICE. CG92, Venous thromboembolism: reducing the risk: Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. Jan 2010. Available at: http://www.nice.org.uk/guidance/CG092

18. Royal College of Obstetricians and Gynaecologists (RCOG). Green top guideline number 37a. Reducing The Risk Of Thrombosis And Embolism During Pregnancy And The Puerperium. November 2009. Available at: http://www.rcog.org.uk/womens-health/guidelines

19. National Institute for Health and Clinical Excellence – NICE. CG62 Antenatal care: Routine care for the healthy pregnant woman. March 2008. Available at: http://www.nice.org.uk/guidance/CG62

20. C Nelson-Piercy, P Fayers, M De Swiet. Randomised, double-blind placebo-controlled trial of corticosteroids for the treatment of hyperemesis gravidarum. BJOG 2001; 108(1)p9-15

21. Pregnancy Sickness Support. Hyperemesis Gravidarum. 2013. Available at: https://www.pregnancysicknesssupport.org.uk/help/hyperemesis-gravidarum/

22. NHS Choices. Vomiting and Sickness in Pregnancy. 2013. Available at: http://www.nhs.uk/conditions/pregnancy-and-baby/pages/morning-sickness-nausea.aspx#clo

http://www.nice.org.uk/guidance/CG092http://www.rcog.org.uk/womens-health/guidelineshttp://www.nice.org.uk/guidance/CG62https://www.pregnancysicknesssupport.org.uk/help/hyperemesis-gravidarum/


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9. Document Monitoring Table

Element to be Monitored

Lead Tool for Monitoring

Frequency Responsible Individual/Group/ Committee for review of results/report

Responsible individual/ group/ committee for acting on recommendations/action plan

Responsible individual/group/ committee for ensuring action plan/lessons learnt are Implemented

Compliance with the guideline

Clinical Unit lead

notes Datix 3 yearly Consultant meeting, audit within women and children’s

Consultant meeting, audit within women and children’s

Clinical Unit lead, Audit Lead

Urea and electrolyte levels should be taken daily in women with HG when having IV fluids

Clinical Unit lead




Thiamine supplementation should be given to all women admitted with prolonged vomiting

Clinical Unit lead




Women with HG who are admitted to hospital should receive thromboprophylaxis with LMWH heparin, unless there are contraindications

Clinical Unit lead




Women with severe NVP or HG who have symptoms extending into the late 2nd trimester or beyond should have USS to assess fetal growth

Clinical Unit lead





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Baseline assessment:

clinical examination (weight, pulse and BP)

urinalysis (dipstick +/- MSU)

Baseline Blood tests (FBC, U&Es, LFTs)

Baseline symptom assessment / e.g PUQE

score

Pelvic ultrasound scan (if not already

performed in this pregnancy)

Acute management:

IV fluids: 2 litres 0.9% Saline (+20mmol KCL) over a total of 4 hours (2 hours per litre)

Intravenous anti-emetic: 50mg Cyclizine IV stat

Subjective improvement in symptoms at 6hour

review? Yes

Discharge with:

Thiamine 50mg po tds

Folic acid 5mg po od

Cyclizine 50mg po tds

Cytoprotection if required

All for 2 weeks initially

Patient information leaflet

Consider lower threshold for admission if PUQE score over 12 on admission or ALT

abnormal

No

Inpatient management:

Continue Intravenous fluids: aim for a total of 3 litres per 24 hours (adjust according to clinical need)

Regular anti-emetic: 1st line 50mg Cyclizine IV three times plus PRN antiemetic

Thiamine 50mg PO TDS / Pabrinex I+II weekly IV

Folic acid: 5mg orally once daily

Consider cytoprotection (ranitidine 50mg TDS IV or 150mg BD PO / Peptac 10ml QDS)

VTE prophylaxis (+ formal VTE assessment): 40mg Enoxaparin S/C

Strict fluid balance monitoring

Daily symptom scoring and adjustment of antiemetics

No

Yes

Clinically improving after 24 hours?

Add Metoclopramide

10mg IV three times a day

Change to oral Cyclizine

50mg three times a day

Further Clinical improvement after

further 12-24 hours and symptom score in mild

category?

Yes

No Restart IV medication and review after a further 12-

24 hours

Go to page 2

Appendix A


Baseline assessments:

Observations and Weight

Abdominal exam / hydration assessment

Urinalysis (Ketones)

Baseline Blood tests (FBC, U&Es, LFTs)

Baseline PUQE score

Pelvic ultrasound scan


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Yes

Change to Oral antiemetics

Discharge with:



Regular effective

antiemetics +/- PRN drug

Cytoprotection if

required

All for 2 weeks

initially

Patient

information leaflet

Consider EPAC or

antenatal clinic

appointment if indicated.

Yes

Yes Further Clinical

improvement after further 12-24 hours and symptom score in mild

category?

No

Restart IV medication and review after further 12-24

hours

Further Clinical improvement after

further 12-24 hours and symptom score in mild

category?

Clinically improving after further 24 hours?

Continued from page 1

No Restart IV medication and review after further 12-24

hours

No

Stop Metoclopramide Add Ondansetron 4-8mg IV

Three times daily

Clinically improving after further 24 hours?

Yes

Change to oral Anti-emetics

No

Admission >72 hours requires consultant

review for consideration of Steroid / TPN therapy.

See Section 6.8.

Appendix B HYPEREMESIS GRAVIDARUM MANAGEMENT ALGORITHM (PAGE 2)

Discharge with:



Regular effective

antiemetics +/- PRN drug

Cytoprotection if required

All for 2 weeks initially

Patient information leaflet

Consider EPAC or ANC

appointment if indicated.


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Appendix C – EHRA Form A Due Regard, Equality & Human Rights Analysis form must be completed for all procedural documents used by East Sussex Healthcare NHS Trust. Guidance for the form can be found here on the Equality and Diversity Extranet page.

Due Regard, Equality & Human Rights Analysis

Title of document: Clinical Guideline Nausea and vomiting in pregnancy Hyperemesis Gravidarum

Who will be affected by this work? Women requiring support for Hyperemesis

Please include a brief summary of intended outcome:

These guidelines apply to women experiencing nausea and vomiting in early pregnancy. Senior clinicians involved in early pregnancy care; including consultants, trainees and specialist and senior nursing staff have reviewed these guidelines.

Yes/No Comments, Evidence & Link to main content

1.

Does the work affect one group less or more favourably than another on the basis of: (Ensure you comment on any affected characteristic and link to main policy with page/paragraph number)

Age No

Disability (including carers) No

Race No

Religion & Belief No

Gender No

Sexual Orientation (LGBT) No

Pregnancy & Maternity Yes This guideline applies to women who are pregnant

Marriage & Civil Partnership No

Gender Reassignment No

Other Identified Groups No

2.

Is there any evidence that some groups are affected differently and what is/are the evidence source(s)?

N/A

3. What are the impacts and alternatives of implementing / not implementing the work / policy?

N/A

4.

Please evidence how this work / policy seeks to “eliminate unlawful discrimination, harassment and victimisation” as per the Equality Act 2010?

N/A

5. Please evidence how this work / policy seeks to “advance equality of

N/A


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opportunity between people sharing a protected characteristic and those who do not” as per the Equality Act 2010?

6. Please evidence how this work / policy will “Foster good relations between people sharing a protected characteristic and those who do not” as per the Equality Act 2010?

N/A

7.

Has the policy/guidance been assessed in terms of Human Rights to ensure service users, carers and staff are treated in line with the FREDA principles (fairness, respect, equality, dignity and autonomy)

N/A

8.

Please evidence how have you engaged stakeholders with an interest in protected characteristics in gathering evidence or testing the evidence available?

N/A

9. Have you have identified any negative impacts or inequalities on any protected characteristic and others? (Please attach evidence and plan of action ensure this negative impact / inequality is being monitored and addressed).

No