Aboubakr Elnashar

1. Management of
Nausea and Vomiting
of Pregnancy
and
Hyperemesis
Gravidarum
Green-top Guideline, 2016
Prof. Aboubakr Elnashar
Benha University Hospital, Egypt
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2. CONTENTS
INTRODUCTION
I. DIAGNOSIS AND ASSESSMENT
II. TREATMENT
III. PREVENTION OF COMPLICATIONS
IV. FOLLOW-UP
SUMMARY
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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.
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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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