CLINICAL GUIDELINE FOR

In-patient Guideline for Hyperemesis Gravidarum in pregnancy

1. Aim/Purpose of this Guideline

To inform midwives and obstetricians about the inpatient management of pregnant women
with hyperemesis gravidarum

2. The Guidance
Hyperemesis Gravidarum is an extreme form of nausea and vomiting in pregnancy.
Defined as persistent vomiting in pregnancy, it is associated with weight loss of greater than 5% of
pre-pregnancy weight and large ketonuria.

Criteria for Ward Admission

Significantly abnormal urea and electrolytes (U & Es) (Sodium <120mmol/l)

Loss of 10% body weight
Haematemesis
Severe abdominal pain or symptoms suggestive of another cause for vomiting
Persistent vomiting after day case rehydration
Persistent large ketosis on urinalysis after day case rehydration
3 previous attendances for day case rehydration

Initial Assessment and Investigation by SHO and Midwife / Nurse

Assess for clinical dehydration dry mucus membranes, tachycardia, weight loss,
concentrated urine
History other causes of vomiting to be excluded
Infection: UTI, Hepatitis
Drug Induced: Iron supplementation, Antibiotics
Metabolic: Thyrotoxicosis (inc pre existing disease), DKA, Addisons disease,
Hyperparathyroidism, / hypercalaemia, Uraemia
Gastrointestinal - Appendicitis, Cholecystitis, small bowel obstruction, Pancreatitis
Weigh patient
Record pulse and BP
Urine analysis. MSU to exclude UTI. NB if glycosuria as well as ketones consider
diabetes
Full blood count (FBC) haematocrit is usually raised
U & Es usually reveals hyponatremia, hypokalaemia and high serum urea.
Check magnesium if hyperemesis severe, or if potassium <3.0mmol/l
Liver function tests (LFTs) usual mild elevations in serum transminases and total bilirubin
Thyroid function tests not required unless history suggests thyrotoxicosis
- Abnormal in two-thirds of patients raised free thyroxin and/ or suppressed TSH
- Patients clinically euthyroid and abnormalities resolve as hyperemesis improves
Ultrasound scan if not already scanned in this pregnancy
- To confirm gestation and exclude multiple or molar pregnancy.

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Management
Avoid dextrose containing fluids carbohydrate rich IV fluids may precipitate Wernicke`s
encephalopathy.
1. Fluid and Electrolyte Replacement
2000ml Hartmans Solution given over 4 hours
Additional fluid and electrolyte requirements should be adapted based on urinalysis and
U & E levels.
Potassium usually required with subsequent IV fluids
2. Anti-emetic Therapy
Withhold non-essential medications associated with nausea & vomiting e.g. oral iron.
First dose IM / IV on admission.
Continued regular prescription is essential. These should be given IM or IV until the
patient is eating without vomiting
A combination of medications may be required
First line 2 of these drugs used together may be more effective than a single drug.
1. Phenothiazines Prochlorperazine (Stemetil) 12.5 mg deep IM or 25mg
rectal suppository followed after 6 hours by oral or rectal maintenance dose 510mg 2-3 times daily
2. Antihistamines Cyclizine (valoid) by IM or IV injection. Cyclizine lactate 50
mg x 3 per day or by mouth cyclizine hydrochloride 50 mg up to 3 times daily.
3. Metoclopramide (Maxalon). By mouth or IM injection over 1-2 minutes 10mg
x 3 daily. Reduce dose to 5mg in patients <60 kg.
N.B: Oculogyric crisis may occur with phenothiazines and also metoclopramide.
Emergency treatment is with procyclidine 5mg IM or IV.
Second line in addition to a first line drug
Ondansetron 4-8mg IV 12 hourly for 2 doses then 8mg 12 hourly orally or
16mg PR daily
Third line
Steriods .Hydrocortisone 100mg bd initially followed by Prednisolone 20mg bd
for 7 days, reducing the dose thereafter.
2.

Nutrition
Nil by mouth until dehydration is corrected followed by small frequent feeding advancing
from liquids to solids as tolerated
Encourage women to drink clear fluids initially
Early involvement of dieticians
MUST tool
N.B: In some women total parenteral nutrition (TPN) may be life saving. TPN has been
shown to produce a rapid therapeutic effect. However, due to significant risks associated
with TPN it should only be considered as a last resort and after discussion with the
patients consultant

3. Thiamine
Oral thiamine supplementation is required for all women. 50mg x 3 daily.
If unable to tolerate oral thiamine consider Pabrinex IV diluted in 100ml Sodium Chloride
0.9% infused over 30-60 minutes, once discharged, once weekly dose to be discussed with
consultant.
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4. Thromboprophylaxis
A VTE assessment proforma must be completed on admission and anti embolic stockings
and fragmin should be given to all clinically dehydrated patients

Midwifery Care

Nurse in a side room if possible

Urinalysis on every urine specimen
Accurate fluid balance chart kept on MEOWS chart
Weigh on each admission or weekly if woman remains an inpatient
Emotional and psychological support

On Discharge:
TTO thiamine and oral / PR anti-emetic even if well on discharge
Dietary advice :
- Eat some dry bread, biscuits or cereal before getting up in the morning. Get out of
bed slowly, avoiding sudden movements
- Drink liquids between, rather than with, meals to reduce the volume entering your
stomach at any one time
- Slowly sip a fizzy drink when feeling nauseated
- Avoid large meals and greasy highly spiced foods
- Suck something sour e.g. a slice of lemon
- Relax rest and take fresh air as much as possible. Keep rooms well ventilated and
odour free
- Try food and drinks containing ginger as they can relieve nausea.

References
1. Neill A, Nelson-Piercy C. Hyperemesis gravidarum. The Obstetrician & Gynaecologist.
2003;204-7
2. NHS Forth Valley Trust. Hyperemesis Gravidarum- Inpatient Guideline. December 2009.
3. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy:
randomised double masked placebo controlled trial. Obstet Gynaecol 2001; 97:577-82.
4. Subramaniam R, Soh EB, Dhillin HK, Abindin HZ. TPN and steroid usage in the
management of hyperemesis gravidarum. Aust N Z J Obstet Gynaecol 1998;38:339-41

3. Monitoring compliance and effectiveness

Element to be
monitored

The number of women managed as an inpatient compared to

number of women managed as a day case prior to the change in
practice

Lead

Ward manager

Tool

Data collection of all women treated as inpatients

Number of times a woman returns for treatment

Frequency
Reporting

Data to be reviewed 1 year after the introduction of the guideline

Data to be presented at perinatal audit meeting

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arrangements
Acting on
recommendations
and Lead(s)
Change in
practice and
lessons to be
shared

Ward manager

Any recommendations will result in a change to the guideline,

which will be communicated through the guidelines communication
pathway

3. Equality and Diversity

3.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement.

3.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information

Document Title

In-patient Guideline for Hyperemesis

Gravidarum in pregnancy

Date Issued/Approved:

1st March 2012

Date Valid From:

1st March 2012

Date for Review:

1st March 2015

Directorate / Department responsible

(author/owner):

Karen Stoyles
Obs and gynae directorate

Contact details:

01872 252149
To inform midwives and obstetricians about
the inpatient management of pregnant
women with hyperemesis gravidarum

Brief summary of contents

Hyperemesis, hyperemesis in pregnancy,

inpatient management of hyperemesis
RCHT
PCT
CFT

Executive Director of Nursing, Midwifery

and AHPs

Suggested Keywords:
Target Audience
Executive Director responsible for
Policy:
Date revised:
This document replaces (exact title of
previous version):

New document

Approval route (names of

committees)/consultation:

Maternity guidelines group

Obs and gynae directorate meeting

Divisional Manager confirming

approval processes

{Original Copy Signed}

Name and Post Title of additional

signatories
Signature of Executive Director giving
approval
Publication Location (refer to Policy
on Policies Approvals and
Ratification):
Document Library Folder/Sub Folder

{Original Copy Signed}

Internet & Intranet

Intranet Only

Midwifery and obstetrics

Links to key external standards

Related Documents:

Day case rehydration for women with

moderate hyperemesis gravidarum in

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pregnancy
No

Training Need Identified?

Version Control Table
Date

Versio
n No

10
February
2012

V1.0

Summary of Changes
Initial Issue

Changes Made by
(Name and Job Title)
Karen Stoyles
Ante natal and day
assessment unit

All or part of this document can be released under the Freedom of Information
Act 2000
This document is to be retained for 10 years from the date of expiry.
This document is only valid on the day of printing
Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust
Policy on Document Production. It should not be altered in any way without the
express permission of the author or their Line Manager.

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Appendix 2.Initial Equality Impact Assessment Screening Form

Name of service, strategy, policy or project (hereafter referred to as policy) to be
assessed: In-patient Guideline for Hyperemesis Gravidarum in pregnancy
Directorate and service area:
Is this a new or existing Procedure?
Obs and gynae directorate
New
Name of individual completing
Telephone:
assessment: Jan Clarkson
01872 252270
1. Policy Aim*
To inform midwives and obstetricians about the inpatient
management of pregnant women with hyperemesis
gravidarum
2. Policy Objectives*

To ensure that pregnant women with hyperemesis

gravidarum receive the appropriate level of care

3. Policy intended
Outcomes*

To ensure appropriate inpatient admission for women with

severe hyperemesis gravidarum

4.
How will you
measure the outcome?

Via compliance monitoring

5. Who is intended to
benefit from the Policy?

Pregnant women with hyperemesis gravidarum

6a. Is consultation
required with the
workforce, equality
groups, local interest
groups etc. around this
policy?
b. If yes, have these
groups been consulted?
c. Please list any groups
who have been consulted
about this procedure.

*Please see Glossary

7. The Impact
Please complete the following table using ticks. You should refer to the EA guidance notes
for areas of possible impact and also the Glossary if needed.

Where you think that the policy could have a positive impact on any of the equality
group(s) like promoting equality and equal opportunities or improving relations
within equality groups, tick the Positive impact box.
Where you think that the policy could have a negative impact on any of the equality
group(s) i.e. it could disadvantage them, tick the Negative impact box.

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Where you think that the policy has no impact on any of the equality group(s) listed
below i.e. it has no effect currently on equality groups, tick the No impact box.

Equality
Group
Age

Positive
Impact

Negative
Impact

No
Impact

Reasons for decision

Disability
Religion or
belief
Gender
Transgender
Pregnancy/
Maternity
Race

Yes

Sexual
Orientation
Marriage / Civil
Partnership
You will need to continue to a full Equality Impact Assessment if the following have
been highlighted:
A negative impact and
No consultation (this excludes any policies which have been identified as not
requiring consultation).
8. If there is no evidence that the policy
promotes equality, equal opportunities
or improved relations - could it be
adapted so that it does? How?

Full statement of commitment to policy of

equal opportunities is included in the policy

Please sign and date this form.

Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean
House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ
A summary of the results will be published on the Trusts web site.
Signed Jan Clarkson

Date 10th February 2012

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