Women, Children s and Sexual Health Division, Maternity Services. Guideline: Hyperemesis Gravidarum

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1 1 Introduction: Women, Children s and Sexual Health Division, Maternity Services Guideline: affects 1-2% of pregnant women, who can lose up to 30% of their body weight if severely affected. Ambulatory care has been shown to be both successful and cost effective, and avoids admission in the vast majority of suffers in units where it is offered. 2 Aims and objectives: The aim is to manage all women with hyperemesis gravidarum as outpatients with ad lib access to IV hydration and antiemetics on Stanway ward. 3. General Advice Nausea and vomiting in early pregnancy may not proceed to Hyperemesis, women should be advised to rest, eat small, frequent meals that are high in carbohydrate and low in fat; and avoid any foods or smells that trigger symptoms. 4 Criteria for Ambulatory Management 4.1 Inclusions: Unable to maintain hydration at home. Vomiting >5 times in 24 hours Unable to keep down more than 500mls of fluids in 24 hours. 4.2 Exclusions: Excluded women are those suffering from: Heart disease Diabetes Thyroid disease Those with abnormal liver function or thyroid function tests. 5. Process: Suitable women should be given information on our service, dietary advice and the Hyperemesis record. This will act as a hand held record of treatment. Women entered into the program should have their details entered into the hyperemesis book kept on Stanway ward. The Record will contain phone numbers for the ward, where women can be seen, as required, for fluids and antiemetics. 5.1 Duties, Responsibilities: The gynaecology SHO on call will review the woman at first presentation on Stanway ward. They will clerk and examine, request investigations as outlined below, and complete the VTE assessment. All details will be kept in the Record. Page 1 of 7

2 Medication will be prescribed and the medication record for each woman will be filed in the Ambulatory Hyperemesis Folder kept in the office on Stanway ward. Nursing staff on Stanway ward will administer fluids and antiemetics as prescribed. Gynaecology SHO or F1 will give the woman her completed record; prescribe TTO s and complete the discharge summary after each visit. Staff on Stanway ward will advise the staff on Lexden when Stanway is closed for the weekend, which will result in women seeking advice and support from Lexden. Women are advised that they may telephone the ward to attend as required. 5.1 The following investigations should be undertaken: Ultrasound scan to exclude multiple or molar pregnancy Urea and electrolytes Liver function Full blood count Thyroid function Random glucose Mid stream urine sample 6. Medication The following should be prescribed on the Medication record card will be attached to the Record. IV normal saline + 20mmol KCL 2 Litres the rate of 1 litre over 2-3hrs) Cyclizine 50mg max tds S/C, IV, IM Pabrinex Amp no.1 diluted in 100ml normal saline, infused IV over minutes If symptoms of gastritis prescribe, Ranitidine 50mg IV TDS or 150mg Oral BD. Women should be advised that meta analysis of 24 studies ( women with varying degrees of nausea and vomiting in pregnancy) has shown that anti-emetics, phenothiazines, (Prochlorperazine & Metoclopramide), and antihistamines (with or without Pyridoxine) were safe and efficacious. Subsequent fluids should be normal saline with Potassium (KCl) added, guided by urea and electrolyte levels. Dextrose saline should be avoided because of the risk of central pontine myelinolysis. 6.1 Second line antiemetics: Prochlorperazine 12.5mg IM tds or buccal 3 6mg BD Domperidone 30 60mg PR After administration of 2 litres of fluid and anti emetics, women should be allowed to go home and advised to phone the ward to return as required. 6.2 TTO s: Thiamine 50mg tds Folic acid 400mcg od Cyclizine 50mg tds Further rectal or buccal antiemetics as above if required Page 2 of 7

3 7. Inpatient Management Inpatient management should be considered for the following: Women who have been seen on 3 consecutive days (failing to respond) Abnormal liver or thyroid function, Women unable to tolerate oral antiemetics and vitamin supplements 7.1 Inpatient Medication Continuous IV fluids as point 6 Antiemetics and pabrinex as point 6 Low molecular weight heparin. Thromboembolic mechanical Stockings (TEDS) The use of corticosteroids should be limited to intractable cases and should be discussed with the responsible consultant. 8. Monitoring Compliance: A review of all women recruited will be undertaken and the outcomes reviewed. The findings will be presented to staff, to facilitate learning for future practice. 9. References: Successful outpatient management of nausea and vomiting in pregnancy. Kelly T, Ajala T. BMJ. 2011; Vol. 343 pp 4543 A risk-benefit assessment of pharmacological and non-pharmacological treatments for nausea and vomiting of pregnancy. Mazotta P, Magee LA. Drugs 2000; 59: Management of nausea and vomiting in pregnancy. Jarvis S, Nelson-Piercy C. BMJ 2011; 342: Dymphna Sexton-Bradshaw Barry Whitlow Associate Director of Women, Consultant Obstetrician Children's and Sexual Health Division /Gynaecologist / Head of Midwifery Lead Early Pregnancy Unit Anne Regan Lead Pharmacist Version Author (s) Date Circulation Comments One Two Barry Whitlow Consultant Obstetrician Anne Regan Pharmacist Sally Price Locum Consultant Khaled Khaled Professor in Obstetrics Anne Regan Lead Pharmacist Barry Whitlow Consultant Obstetrician Reviewed and revised Page 3 of 7

4 Appendix One Date Record Name.. Hospital No. NHS No DOB Address.. Post Code... LMP /../.. Gestation. Symptoms Nausea / Vomiting / Abdominal pain / Diarrhoea / Dysuria / Faint Pregnancy- Unique Quantification of Emesis (PUQE) Symptoms in 1 point 2 points 3 points 4 points 5 points Last 12 hours Duration of 0 < 1 hour 2-3 hours 4-6 hours > 6 hours nausea Number of vomits Number of dry retching > 7 PUQE < 6 = mild, 7-12 = moderate, > 13 = severe (Koren G, Boskovic R et al Motherisk-PUQE scoring system for nausea and vomiting of pregnancy. Americal J of Obstetrics and Gynaecology, vol 186, , 2002) Past Medical History Thyroid disease / Diabetes/ Heart Disease if yes not for OPD management VTE please complete VTE form and prescribe TEDS) Past Obstetric History. Medication Allergies Page 4 of 7

5 Examination Weight. Temperature. Urinalysis.. Abdomen Observations Time Pulse Lying Blood Pressure Standing Blood Pressure Ultrasound: Not performed / Awaited / IUP / Twins / Delayed Miscarriage / Mole Advised to ring EPU and return if unable to tolerate oral intake. Y / N Advised to book pregnancy with GP Y / N Signed Date PRINT NAME.. Designation: F1, F2, ST1-3, ST4-6, Other Page 5 of 7

6 Results TEST RESULTS Date Urea Creatinine Sodium Potassium Albumin Total protein AST ALT GGT Alk Phos Adjusted calcium HB Platelets WCC PCV T4 TSH Glucose MSU Page 6 of 7

7 Follow Up Visit Number.. Date Name Seen By Hospital No NHS No. Gestation. Examination Weight.. Pulse /minute Temperature Urinalysis Lying BP..mmHg Standing BP mmhg IV normal saline + 20 mmol KCL - 2 1L per 2-3 Hours Cyclizine (dose & administration route ) Stemetil (dose & administration route ) Medication Yes No Domeridone (dose & administration route ) Pabrinex(dose & administration route ) TTO s Follow Up Signed Date PRINT NAME.. Designation: F1, F2, ST1-3, ST4-6, Other Page 7 of 7