SDMS ID: P2010/0324-001 WACSClinProc1.

13 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Nausea and Vomiting in Pregnancy New guideline Management of women with nausea and vomiting in pregnancy Midwives, nursing and medical staff, LGH Nausea, vomiting, hyperemesis gravidarum Parenteral Nutrition Protocol (P2010/0461-001)

Purpose: 80 85% of pregnant women experience nausea during pregnancy. 52% of these women vomit. Severity varies greatly. For the majority of women these symptoms resolve by 12 to 14 weeks. The emotional, social and psychological impact can be marked. Hyperemesis gravidarum is described as persistent vomiting accompanied by weight loss, ketonuria and dehydration. The exact pathogenesis of hyperemesis remains unknown. 1% of women with nausea and vomiting will develop the pathological condition of hyperemesis gravidarum. Mild to Moderate Nausea and Vomiting Dietary advice Maintain hydration Folate supplement 0.5mg once daily Nausea: Pyridoxine (vitamin B6) 10 to 25 mg o o Ginger 250mg 6/24 orally o Acupuncture or acupressure Nausea and Vomiting: o Promethazine 12.5-25 mg orally eight hourly o Metoclopramide 10 mg orally eight hourly o Prochlorperazine 5 mg orally eight hourly or 25mg suppository per rectum twelve hourly Hyperemesis Gravidarum Maternal observations Urinalysis SG and ketones Weight Investigations: o Bloods for electrolytes, urea and creatinine and liver function tests. o Consider serum free T4 concentration. o Consider ultrasound scan to exclude gestational trophoblastic disease and multiple pregnancy Rehydration with IV Hartmanns solution or Normal Saline avoiding dextrose until thiamine (vitamin B1) replacement therapy provided. Continue intravenous fluids until urinalysis negative for ketones Electrolyte replacement as required
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First line anti-emetics such as: o Promethazine IV or IMI four hourly o Metoclopramide 10 mg IV TDS o Prochlorperazine 25mg PR BD or 12.5mg IMI six hourly Ranitidine 150mg orally BD or 50mg IVI TDS Thiamine 100mg orally daily If no response to first line anti-emetics: Ondanestron 2-4 mg IV or IM 8hourly if no response to first line anti-emetics. Ondanestron 4mg Wafer orally 12 hourly or daily For severe hyperemesis: Hydrocortisone 100mg 12/24 IV or prednisolone 50mg once daily orally reducing over 10-14 days. Advice for women with nausea and vomiting in pregnancy Eat a diet high in complex carbohydrates (such as bread, rice, potatoes) and protein, low in fat. Drink plenty of fluids Eat five to six small meals a day, including a late-evening snack. Low blood sugar can cause nausea and shakiness. Sucking on hard sweets maybe helpful. Try eating a small snack before getting up. Eat many small meals each day but avoid lying down immediately after eating Get plenty of rest. Being overly tired can set off nausea. Consider taking a ginger supplement Limit stressful events. Avoid noxious odours that trigger vomiting, cigarette smoke and tastes that trigger nausea, such as coffee. Consider acupuncture or acupressure to assist in relieving nausea.

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Attachments Attachment 1 Attachment 2

Pathology Results References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years via Policy and Procedure working group coordinated by the Clinical and Quality improvement midwife. November 2009 Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _1 August 2007___

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ATTACHMENT 1 Pathology Results abnormalities may or may not be present Electrolyte imbalance hypokalemia and metabolic alkalosis An increase in hematocrit, including hemoconcentration due to plasma volume depletion. The degree of hemoconcentration may be underestimated unless the physiologic decline in hematocrit seen in normal pregnancies is considered Abnormal liver enzyme values occur in approximately 50% of women who are hospitalised with hyperemesis. The most striking abnormalities is an increase in serum aminotransferase. Alanine aminotransferase (ALT) is typically elevated to a greater degree than aspartate aminotransferase (AST). Values for both are typically only mildly elevated. Serum amylase and lipase may increase as much as five-fold and are of salivary rather than pancreatic origin. The degree of abnormality in liver tests correlates with the vomiting; the highest elevations are seen in women with the most severe or protracted vomiting. Abnormal liver biochemical tests resolve promptly upon resolution of the vomiting. Mild hyperthyroidism, possibly due to high serum concentration of HCG which has thyroid stimulating activity. Some women have elevated serum free t4 concentrations and therefore met the definition of hyperthyroidism.

ATTACHMENT 2 REFERENCES Funai, E 2006, Hyperemesis gravidarum, UpToDate, Online: http://uptodateonline.com/utd/content/topic.do?topicKey=pregcomp/27432&selectedTitle=1 ~23&source=search_result Jewell, D & Young, G 2003, Intervention for nausea and vomiting in early pregnancy, Cochrane Review, Online: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD000145/frame.html Pairman S, Pincombe J, Thorogood C, Tracy S, Midwifery preparation for practice 2006 Elsevier Australia

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