Hyperemesis Gravidarum (HG) is diagnosed when there is intractable nausea and vomiting of pregnancy associated with weight loss, dehydration, and electrolyte imbalance. Guidelines recommend outpatient management for mild cases using antihistamines and phenothiazines as first-line antiemetics. Hospitalization is indicated for HG with continued vomiting and signs of dehydration or ketosis. Inpatient treatment involves IV hydration with normal saline and potassium, supplementation with thiamine, and thromboprophylaxis with low molecular weight heparin. Second-line therapies include metoclopramide, ondansetron, corticosteroids, and ginger may be used as complementary therapy.

1. Management of
Hyperemesis Gravidarum
-Guidelines
Dr Meenakshi Sharma
MD (AIIMS), FICMCH
Consultant Obs & Gynae,
Yashoda Superspeciality Hospital
Shanti Mukund Hospital

2. RCOG Guidelines 2016
Definition
• Nausea vomiting of pregnancy (NVP) – NVP should
only be diagnosed when onset is in first trimester
of pregnancy and other causes have been ruled
out.
• Hyperemesis Gravidarum (HG)- HG can be
diagnosed when there is intractable NVP with
triad of more than 5% prepregnancy weight loss,
dehydration and electrolyte imbalance.

3. Hyperemesis Gravidarum
• NVP affects 80% of pregnant women
• HG affects 0.3-3.6% of pregnant women
• Etiology - rising levels of beta hCG, higher
levels associated with multiple or molar
pregnancy associated with more severity
of NVP
• NVP starts 4-7 weeks, peaks 9 weeks and
resolves by 20 weeks in 90% of women
RCOG 2016

4. Hyperemesis Gravidarum
• Symptoms
• Nausea
• Vomiting
• Enhanced
olfactory senses
• Food and/or
fluid intolerance
• Lethargy
• Signs
• Dehydration
• Weight loss
• Ketonuria
• Anaemia
• Tachycardia

5. Pregnancy Unique Qualification of
Emesis (PUQE) score
• Developed by Motherisk programme an NVP
helpline Canada
• PUQE Score is used to classify the severity of NVP
and response to therapy (C), evidence 2+

7. NVP/HG - Evaluation
History
• Previous H/o NVP/HG
• Quantify severity using
PUQE score
• History to exclude other
causes
• Abdominal pain
• Urinary symptoms
• Infection
• Drug history
• Chronic H. pylori
infection
Examination
• Temperature
• Pulse
• Blood pressure
• Oxygen saturation
• Respiratory rate
• Abdominal examination
• Weight
• Signs of dehydration
• Signs of muscle wasting

9. Differential diagnosis
Differential Diagnosis
System
Diagnosis
Genitourinary UTI
Uraemia
Molar pregnancy
Gastrointestinal Gastritis/ peptic ulcer
Reflux/ oesophagitis
Cholecystitis
hepatitis
Pancreatitis
Bowel obstruction
Endocrine Addison’s disease
Hyperthyroidism
Diabetes ketoacidosis
CNS Intracranial tumours
Vestibular disease

10. Complications
• Maternal
• Hypokalemia
• Hyponatremia and central pontine myelinosis
• Wernickie’s encephalopathy
• Vitamin B6/B12 deficiency
• Malnutrition
• Mallory- Weiss esophageal tears
• Venous thromboembolism
• Psychological morbidity
• Fetal
• Growth restriction
• Wernicke’s encephalopathy is associated with 40% fetal
death

11. Management (RCOG 2016)
• Women with mild NVP should be managed in
community with antiemetics (D)
• Ambulatory day care management should be used for
suitable patients when Primary care measures have
failed and where PUQE score less than 13 (C)
• Inpatient management -if there is atleast one of
following
• Continued NVP and inability to keep down oral
antiemetics
• Continued NVP associated with ketonuria and/or weight
loss (>5% body weight) despite oral antiemetics
• Confirmed or suspected comorbidities (UTI) or inability to
tolerate oral antibiotics

12. Management of HG
• Provision of symptomatic relief
• Correction of dehydration and electrolyte
imbalance
• Prophylaxis against recognized complications
• Admit if
• Symptom are severe despite 24 hrs of medication
• Evidence of dehydration and ketosis
• Admit earlier if coexisting conditions eg diabetes

13. Pharmacological Group of
Antiemetics
Class of drugs Antiemetic
Phenothiazine Prochlorperazine (stemetil/
buccastem)
Chlorpromazine
Antihistamines
(H1 receptor antagonist)
Doxylamine
Cyclizine
Promethazine (phenergan)
Meclozine
Dopamine antagonists Metoclopramide
Domperidone
5-HT3 (serotonin) antagonist Ondansetron

14. Antiemetic therapy (RCOG 2016)
• There are safety and efficacy data for first-line
antiemetics such as antihistamines (H1 receptor
antagonists) and phenothiazines and they should
be prescribed when required for NVP and HG (c)
• Combinations of different drugs should be used
in women who do not respond to a single
antiemetic.
• For women with persistent or severe HG, the
parenteral or rectal route may be necessary and
more effective than an oral regimen.

15. Antiemetic therapy (RCOG 2016)
• Women should be asked about previous adverse reactions
to antiemetic therapies. Drug-induced extrapyramidal
symptoms and oculogyric crises can occur with the use of
phenothiazines and metoclopramide. If this occurs, there
should be prompt cessation of the medications. (B)
• Metoclopramide is safe and effective, but because of the
risk of extrapyramidal effects it should be used as second-
line therapy. (B)
• There is evidence that Ondansetron is safe and effective,
but because data are limited it should be used as second-
line therapy. (C) Some studies report increased risk of
cleft palate and cardiac defects
• Pyridoxine is not recommended for NVP and HG. (C)

16. Antiemetic therapy (RCOG 2016)
• Corticosteroids should be reserved for cases
where standard therapies have failed. (A)
• I/V Hydrocortisone 100 mg BD for 48 hrs
• Oral prednisolone 30 – 40 mg/day -1 week then
tapered gradually 5mg reduction every week
• Diazepam is not recommended for the
management of NVP or HG. (B)

18. Management – Rehydration
therapy ( RCOG 2016)
• Normal saline with additional potassium chloride in
each bag, with administration guided by daily
monitoring of electrolytes, is the most appropriate
intravenous hydration. (D)
• Dextrose infusions are not appropriate unless the
serum sodium levels are normal and thiamine (100mg
thiamine) has been administered. (D)
• Dextrose solution can precipitate Wernicke’s
encephalopathy
• Avoid double strength saline even in cases of severe
hyponatraemia

19. Thromboprophylaxis
• Increased risk of VTE due to dehydration and
immobilization in hospitalized pts.
• Clexane should be given if the risk factor score
for VTE is 3 or more

20. Pre-existing risk factors Score
Previous recurrent VTE 3
Previous unprovoked or
estrogen related
3
Previous VTE provoked 2
Family history of VTE 1
Known thrombophilia 2
Medical comorbidity 2
Age (> 35 years) 1
Obesity 1 or 2 *
Parity (≥ 3) 1
Smoker 1
Gross varicose vein 1
Obstetric risk factors 1
Pre-eclampsia 1
Dehydration/ Hyperemesis/
OHSS
1
Multiple pregnancy or ART 1
Transient risk factors
Current systemic infection 1
Immobility 1
Surgical procedure in
pregnancy
2
Total score
Risk assessment for
Venous
Thromboembolism
(VTE)
*Score 1 for BMI >30
*Score 2 for BMI >40

21. Complementary Therapy - Ginger
• Ginger may be used by women wishing to avoid
antiemetics in mild to moderate NVP. (A)
• Three systematic reviews addressed effectiveness of
ginger in NVP –1 review- 4 RCT all found ginger more
effective than placebo for NVP
• Another review 10 RCT, Ginger compared with placebo
(5), Vitamin B6, (4), dimenhydramine (1). Ginger
superior to placebo and equal to Vitamin B6 and
dimenhydramine in improving NVP
• Ginger was superior to placebo but less effective than
metoclopramide in a RCT, 102 patients with NVP.
• One review highlighted potential maternal adverse
effects-anticoagulant effect, stomach irritation and a
potential interaction with beta blockers and
benzodiazepines.
Tiran D, Complement Ther Clin Pract 2012

22. Complementary Therapy –
Acustimulation
• Women may be reassured that acustimulations are safe in
pregnancy. Acupressure may improve NVP (B)
• Acustimulations - acupuncture, acupressure and electrical
stimulation)
• Pericardium 6 point (PC6)- 2.5 finger breadths up from the
wrist crease on the inside of the forearm, between the
tendons of palmaris longus and flexor carpi radialis
• Review of 14 studies and metanalysis demonstrated acupressure
applied by finger pressure or wristband and electrical stimulation
both reduced NVP, but acupuncture methods did not.
Helmreich RJ, Explore (NY) 2006
• A review of 6 RCT, 399 women, 5 RCT shows positive result of
acupressure including 2 RCT in patients with HG (102women)
Lee EJ, J Pain Symptom Manage 2011

24. Monitoring and Adverse effects
• Urea and serum electrolyte levels should be
checked daily in women requiring intravenous
fluids.
• H2 receptor antagonists or PPI may be used for
women developing GE reflux, oesophagitis or
gastritis. (D)
• Thiamine supplementation (either oral or
intravenous) should be given to all women
admitted with prolonged vomiting, especially
before administration of dextrose or parenteral
nutrition.

25. Monitoring and Adverse effects
• Women admitted with HG should be offered
thromboprophylaxis with LMHW unless there are
specific contraindications such as active
bleeding. Thromboprophylaxis can be
discontinued upon discharge. (C)
• When all other medical therapies have failed,
enteral or parenteral treatment should be
considered with a multidisciplinary approach. (D)
• All therapeutic measures should have been tried
before offering termination of a wanted
pregnancy. (D)

26. Monitoring and Adverse effects
• Women with severe NVP or HG who have
continued symptoms into the late second or the
third trimester should be offered serial scans to
monitor fetal growth.
• Early use of lifestyle/dietary modifications and
antiemetics that were found to be useful in the
index pregnancy is advisable to reduce the risk
of NVP and HG in the current pregnancy. (c)

27. Conclusions
• Women with mild NVP should be managed in the
community with antiemetics
• Antihistamines (H1 receptor antagonists) and
phenothiazines are first line antiemetics,
Metoclopramide and Ondensetron are second line
therapies
• Normal saline with KCL should be ideal iv fluid for
hydration
• Thiamine supplementation should be given to all
women admitted with prolonged vomiting
• Women with HG who are admitted to hospital should
receive thromboprophylaxis with LMHW unless
contraindicated