Hyperemesis Gravidarum
Clinical detail
Additional detail checked 2026-10-17 against the linked sources. This check covers the section below; the rest of the module retains its displayed verification status.
Severe pregnancy vomiting affects hydration, nutrition, daily function and mental health. Assess the ability to drink and retain medicines as well as the number of vomiting episodes.
Assessment & interpretation
- Review fluid intake, urine output, weight change, observations and relevant blood tests. Consider alternative causes when the timing or associated symptoms are atypical.
- Ask about the impact on work, family life and wellbeing; symptoms should not be dismissed as an inevitable part of pregnancy.
Decisions that change management
- Outpatient treatment may be suitable for some patients; dehydration, inability to retain fluids or medicines, or concerning blood tests can require admission.
- In hospital, fluid replacement, antiemetic treatment and nutritional assessment should include attention to thiamine replacement.
- Assess thrombosis risk because pregnancy, dehydration and reduced mobility can combine to increase it.
Follow-up & safety-netting
- Before discharge, confirm an achievable plan for drinking, eating, taking prescribed medicines and returning if symptoms recur.
- Ongoing severe symptoms after 20 weeks need reassessment. Persistent poor intake or inadequate weight gain may alter fetal-growth follow-up.
Clinical pitfalls
- Different antiemetics or routes may be needed when oral tablets cannot be retained; repeated failed oral treatment is not a complete care plan.
Admission & discharge
Admission/discharge guidance checked 2026-10-18 against the linked sources. This is a clinical checklist for an individual decision, not an automatic discharge order.
When admission or continued hospital care is needed
- Admit dehydration, inability to retain fluids/oral medicines, abnormal blood tests, significant ongoing weight/nutritional loss or comorbidity made unsafe by vomiting.
When clinic, day care or home care may be suitable
- Some patients improve after ambulatory IV rehydration and antiemetics and can go home with a functioning oral plan.
Before going home
- Hydration and electrolyte problems are corrected or safely improving, oral fluids/medicines are tolerated and a nutrition/antiemetic plan is feasible.
- Review weight, ongoing needs and the risk of thiamine deficiency; ketonuria alone is not a reliable severity or discharge measure.
Discharge medicines and treatment changes
- Supply the selected oral antiemetic(s), with dose/frequency and how to reduce as symptoms improve; do not list all alternatives as simultaneous prescriptions.
- Provide indicated oral thiamine; review whether iron worsens vomiting and assess VTE prevention for ongoing risk rather than automatically continuing inpatient prophylaxis.
Medicine doses — use only when indicated
Use the medicines selected for this patient. Listed alternatives are not instructions to prescribe all of them together. Confirm the actual remaining course, pregnancy/postnatal context and monitoring plan.
One selected formulation-specific option.
- Indication: Nausea and vomiting of pregnancy: the cited product contains 10 mg/10 mg PER tablet
- Sedation, symptom control, ability to eat/drink; avoid driving if drowsy
Only if selected after risk/benefit review; heed hepatic/QT cautions.
- Indication: Second-line nausea/vomiting or hyperemesis after assessment and discussion of benefits and small absolute fetal-risk signals
- This obstetric guideline differs from the more restrictive MSF general ondansetron monograph; the app uses the RCOG HG pathway after counselling.
- Response, constipation, QT/ECG risk, potassium/magnesium and interacting QT-prolonging drugs
When prolonged poor intake makes supplementation indicated.
- Indication: Prolonged vomiting or markedly reduced dietary intake; protect against thiamine deficiency
- Dietary intake, weight, hydration; confusion, ataxia or eye-movement abnormalities require urgent assessment
Tests, pending results and their reviewer
- Record electrolyte/renal results and any repeat testing needed. Persistent severe symptoms later in pregnancy may require growth assessment.
Home care and counselling
- Discuss small tolerated intake, hydration, prescription supply before tablets run out and when to re-contact the maternity team.
Follow-up: when and what to review
| When | Action / responsible service |
|---|---|
At the booked early treatment review | Review intake, weight, medicines and any repeat electrolytes; bring forward review if oral treatment fails. |
If severe symptoms persist beyond 20 weeks | Arrange maternity review and consider fetal-growth surveillance. |
Return urgently
- Inability to keep fluids/medicines down, reduced urine, faintness, confusion, haematemesis or worsening illness requires reassessment.
Open the complete discharge checklist →
Treatment
① Immediate stabilization — first minutes
Give thiamine before carbohydrate in prolonged vomiting when possible; never delay lifesaving glucose for severe hypoglycaemia while searching for thiamine. Assess dehydration, electrolytes and nutrition immediately.
③ First-line treatment & drug regimens
Rehydrate with sodium chloride 0.9%; add potassium only from the measured level and prescribed replacement plan. Review pulse/BP, urine output, weight and electrolytes daily, more often if unstable. Adjust volume/rate to deficit, ongoing losses and cardiac/renal status; a fixed multi-litre schedule is not appropriate for every patient. Give thiamine before carbohydrate when possible and prescribe antiemetics by the complete cards below.
- Acupressure/ginger adjunct evidence modest
- Steroids (methylprednisolone) LAST resort refractory cases - taper quickly, avoid T1 prolonged use
④ Drug treatment detail (7 agents)
- Indication: Nausea and vomiting of pregnancy: the cited product contains 10 mg/10 mg PER tablet
- Sedation, symptom control, ability to eat/drink; avoid driving if drowsy
- Indication: First-line antihistamine option in RCOG HG guidance
- This row is ORAL. Injectable promethazine is not interchangeable and has separate tissue-injury/administration precautions.
- Sedation, anticholinergic effects, oral intake and interactions with other sedatives/QT-prolonging drugs
- Indication: RCOG second-line antiemetic after assessing hydration and prior treatments
- Renal / hepatic: CrCl 15–60: reduce daily dose by 50%; ≤15: reduce by 75%; severe hepatic impairment: reduce by 50%.
- RCOG places this after first-line options because of extrapyramidal reactions.
- Acute dystonia/akathisia, drowsiness, response, hydration and renal function; stop if neurological adverse effects occur
- Indication: Second-line nausea/vomiting or hyperemesis after assessment and discussion of benefits and small absolute fetal-risk signals
- This obstetric guideline differs from the more restrictive MSF general ondansetron monograph; the app uses the RCOG HG pathway after counselling.
- Response, constipation, QT/ECG risk, potassium/magnesium and interacting QT-prolonging drugs
- Indication: Second-line HG when oral treatment cannot be retained
- ECG/QT risk, potassium/magnesium, symptom control and constipation
- Indication: Prolonged vomiting or markedly reduced dietary intake; protect against thiamine deficiency
- Dietary intake, weight, hydration; confusion, ataxia or eye-movement abnormalities require urgent assessment
- Indication: Prolonged HG with inability to retain oral thiamine; before IV carbohydrate/nutrition
- RCOG HG guidance describes oral thiamine or parenteral vitamin-B preparations; product composition and the ongoing course must be explicitly prescribed.
- Hypersensitivity, mental state, eye signs, gait, electrolytes and nutrition
Definitive treatment
Symptoms typically improve substantially by 16-20 wks; nutritional rehabilitation is the endpoint.
Monitoring
| Domain | Schedule |
|---|---|
Weights | Each visit/admission |
Electrolytes | Daily during IV phase |
Nutritional intake diary | Daily |
VTE risk | Assess at each immobile admission |
Response assessment
- Vomiting episodes falling; oral tolerance rising; ketones clearing; weight stabilising
Treatment failure
- Multiagent failure -> enteral feeding (NG) consideration, parenteral nutrition rarely; TPN-line sepsis risks discussed
Second-line treatment
- Gastroenterology/dietitian co-management refractory
Rescue treatment
Wernicke suspected: IMMEDIATE thiamine + neurology; termination counselling offered only in extreme life-threatened refractory cases (documented multidisciplinary).
Procedure / surgery
NG feeding technique per nutrition team.
Escalation
- Admission criteria: dehydration needing IV, ketonuria+, electrolyte derangement, weight loss, social unsafety
⑮ Complications & their management
Wernicke encephalopathy
Thiamine urgently; avoid glucose-first errors
Mallory-Weiss tears
Usually self-limited; PPI; assess bleeding
VTE
LMWH prophylaxis for immobile admissions (risk assessment)
Post-treatment care
- Discharge with antiemetic plan + early-return rules
- Psychological support (HG distress is real)
- Recurrence anticipation next pregnancy (~15-20%)
Diagnosis & assessment
- Wernicke signs (confusion/ataxia/nystagmus) - thiamine deficiency
- Severe electrolyte derangement
- Intractable despite multi-agent
- Weight loss >10%
- Venous thrombosis signs
Definition: Persistent vomiting >3x/day + >5% weight loss/ketonuria beyond simple NVP causing metabolic disturbance.
Initial assessment
- Exclude causes: multiple pregnancy/molar (scan), UTI, thyroid (can coexist), GI obstruction
- PUQE score; weight; mucous membranes; ketones (urine/blood)
- Bloods: U&E (K!, Na), LFT, urate, CBC, TFTs if indicated
Investigations
| Test | Looking for |
|---|---|
U&E + magnesium/phosphate if severe | Hypokalaemia/hyponatraemia correction needs |
Urine ketones | Starvation marker |
TVS | Twins/mole |
Principles & follow-up
Management principles
Guideline conflict
MSF injectable ondansetron monograph
General postoperative-vomiting reference advises avoiding first-trimester use and does not recommend it for nausea/vomiting of pregnancy.
RCOG Green-top 69, 2024
Includes ondansetron as a second-line HG treatment with counselling about the small absolute fetal-risk signal and the harms of inadequately treated HG.
Population/setting difference: A general injectable/postoperative reference and a specialist pregnancy/HG pathway address different indications and prescribing decisions.
Practical India consideration: Review first-line response, gestation, electrolyte/QT risk and available routes with the patient and treating obstetric team.
Reason: The specialist pregnancy pathway directly addresses HG, its competing risks and route-specific dosing.
Sources (11)
2016; updates 2020–2025 (2nd ed maternal-health compendium 2025-03) · checked 2026-08-23 · verified-live
Open source ↗
WHO pages + NCBI compendium: daily IFA 30–60 mg elemental iron + 400 µg folic acid; intermittent IFA only where daily not acceptable & anaemia prevalence <20%; anaemia in ANC → 120 mg elemental iron daily until Hb normal; MMS recommended only within rigorous research contexts (supersedes 2016); ≥8 c…
· checked 2026-10-17 · verified-live
Open source ↗
Scope: additional clinical-detail explanation for hyperemesis-gravidarum. Checked the assessment, management-decision and follow-up statements in that section against this source. This does not certify all pre-existing regimens, calculations or recommendations in the module.
· checked 2026-10-17 · verified-live
Open source ↗
Postoperative indication/schedules and pregnancy caution (avoid first trimester; not recommended for NVP) checked. Displayed as a source/indication-specific conflict with RCOG GTG69, not silently combined with its HG doses.
· checked 2026-10-17 · verified-live
Open source ↗
Specific delayed-release product: day-by-day escalation from two bedtime tablets to four/day, swallowing/empty-stomach instructions, scheduled use and taper.
· checked 2026-10-17 · verified-live
Open source ↗
Primary 2024 RCOG/BJOG guideline (DOI 10.1111/1471-0528.17739) full PDF checked via an accessible copy because the publisher returned 403. Checked executive recommendations, section 7.1 and Appendix III: oral/IV ondansetron schedules, thiamine 100 mg three times daily or parenteral vitamin B, and th…
· checked 2026-10-17 · verified-live
Open source ↗
Adult 10 mg up to three times/day, daily limit 30 mg or 0.5 mg/kg, ≥6-hour interval including after vomiting, maximum five days, renal/hepatic reductions and extrapyramidal contraindications. RCOG Appendix III separately supplies pregnancy/HG 5–10 mg every eight hours.
· checked 2026-10-18 · verified-live
Open source ↗
Maternal/newborn transfer assessment, first void and effective feeding, handover, support/safeguarding, first midwife visit within 36 hours after transfer, postnatal danger symptoms. Full recommendations page read.
· checked 2026-10-18 · verified-live
Open source ↗
Normal-delivery discharge not less than 48 hours: full primary SOP PDF normal-delivery/discharge passages read. Corroborated by NHM CEmONC 2024 Part 1, chapter 8. This does not define a universal post-caesarean or complicated-case stay.
· checked 2026-10-18 · verified-live
Open source ↗
Official WHO summary read: at least 24-hour facility care after birth; additional contacts at 48–72 hours, 7–14 days and week 6; individual assessment/support. Summary facts only, not a claim that the full 242-page PDF was reviewed.
· checked 2026-10-18 · verified-live
Open source ↗
Full primary patient recovery page read: pain control, wounds, activity/VTE, urinary/bowel and infection warning signs, adult support and no driving/important decisions during the first 24 hours after general anaesthesia. Used as general recovery/handover principles, not operation-specific discharge…
· checked 2026-10-18 · verified-live
Open source ↗
Full primary recommendations read, focusing on critical-care-to-ward transfer: structured written handover, shared plan, monitoring, rehabilitation and receiving-team capability. Step-down is distinct from home discharge; no universal organ-support discharge cutoff is asserted.