Hyperemesis Gravidarum

Nausea and vomiting in pregnancy is common and at best an unpleasant experience for the patient, and at worst can be life threatening. It normal starts @ 4-7/40, peaks @ 9/40, and finishes @ 20/40.

We need to conduct a thorough history and examination looking for causes other than a high βHCG. these include:

  • Abdominal pathology
  • Urinary pathology
  • Infections
  • Drug History
  • Chronic H.Pylori


  • Ketones (RCOG state – ketones should not be relied upon over and above clinical symptoms)
  • FBC
  • U&E
  • Glucose
  • MSU/Urine dip
  • PUQE-24 score

PUQE-24 score

RCOG Algorithm

We don’t have an ambulatory pathway at our trust! However, our Gynae, colleagues suggest following:

In ED hydration and symptom control if the patients clinic picture improves & urine ketones <2+ discharge from ED could be considered. Otherwise ref to Gynae team for 4c.


Inpatient management should be considered if there is ≥1 of the following:

  • Continued nausea and vomiting and inability to keep down oral antiemetics
  • Continued nausea and vomiting associated with ketonuria and/or weight loss (greater than 5% of body weight), despite oral antiemetics
  • Confirmed or suspected comorbidity (such as urinary tract infection and inability to tolerate oral antibiotics)

Recommended Antiemetics

Ginger has been shown to reduce nausea and vomiting, and may be a n alternative if patients with mild symptoms who don’t wish to take medication.

Ondansetron WARNING: MHRA (Medicines & Healthcare products Regulatory Agency)  has recently published a warning regarding the use of ondasetron in early pregnancy.leading to a small but significant risk of cleft lip

RCOG – The Management of Nausea andVomiting of Pregnancy and Hyperemesis Gravidarum

RCOG – Patient Advice

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