Shifting Perspectives on Hyperemesis Gravidarum

The new RCOG guidelines (Royal College of Obstetricians and Gynaecologists) are rewriting the narrative surrounding Hyperemesis Gravidarum (HG). It's not just a "9-month ordeal" anymore — it's a condition with lasting effects.

Recognising the mental health toll, the guidelines highlight increased risks of Post Natal Depression (PND) and Post Traumatic Stress Disorder (PTSD). It's not just physical symptoms; it's about long-term mental well-being.

Moreover, the guidelines shed light on the high risk of HG recurrence in subsequent pregnancies. This awareness is crucial for better preparation and support for women planning future pregnancies.

"There is variation in the care of women who have nausea and vomiting of pregnancy (NVP) or hyperemesis gravidarum (HG) with the potential for lack of understanding of its severity and options for treatment and support.

The aim of this guideline is to provide updated evidence-based or best clinical practice information regarding the diagnosis and subsequent management of NVP and HG across community, ambulatory day care and inpatient settings. A summary for general practitioners is given in Appendix Vai and Vaii. It gives advice for multidisciplinary professionals involved in the care of women with these conditions, including how to counsel and support women before, during and after their pregnancies.

Within this document we use the terms woman and women's health. However, it is important to acknowledge that it is not only women for whom it is necessary to access women's health and reproductive services in order to maintain their gynaecological health and reproductive wellbeing. Gynaecological and obstetric services and delivery of care must therefore be appropriate, inclusive and sensitive to the needs of those individuals whose gender identity does not align with the sex they were assigned at birth."

For pregnant individuals battling Hyperemesis Gravidarum (HG), effective management is paramount for their well-being and that of their baby. With evolving research and clinical insights, here are some key updates and recommendations to consider:

Objective Assessment Tools
Utilising objective indices like the Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can aid in classifying the severity of Nausea and Vomiting of Pregnancy (NVP) and HG. These validated tools provide a standardised approach for healthcare professionals to assess and monitor symptoms.

Hyperemesis Australia have a printable PUQE-24 test here. 

Rethinking Dehydration Indicators
Traditionally, ketonuria (high levels of ketones in your urine) has been used as an indicator of dehydration in HG. However, recent evidence suggests otherwise. Ketonuria should no longer be relied upon as a sole marker for dehydration assessment.

If you are in the early stages of pregnancy dehydration, we recommend Morning Relief, which has electrolytes to address maternal depletion. If your dehydration is severe, IV fluids are extremely beneficial.

First-Line Antiemetics
First-line antiemetics such as anti (H1) histamines, phenothiazines, and doxylamine/pyridoxine (Xonvea®) have demonstrated both safety and efficacy. These medications should be prescribed initially when required for managing NVP and HG.

Second-Line Options
Ondansetron, despite previous concerns, has been deemed safe and effective as a second-line antiemetic. It can be considered if first-line treatments prove ineffective. While there's a slight increase in the risk of orofacial clefting with first-trimester use, this risk must be balanced with the potential consequences of poorly managed HG.

Metoclopramide, also safe and effective, can be used alone or in combination with other antiemetics. However, due to the risk of extrapyramidal effects, it's recommended as second-line therapy.

Hydration and Electrolyte Management
Intravenous hydration plays a crucial role in managing HG. Normal saline with additional potassium chloride is the preferred intravenous hydration solution. Electrolyte levels should be monitored daily to guide administration.

Combination Therapy
For individuals not responding to single antiemetic therapy, combinations of different drugs may be necessary. Healthcare providers can refer to suggested antiemetics for UK use for guidance.

Thiamine Supplementation
Thiamine supplementation should be administered to all women admitted with vomiting or severely reduced dietary intake. This can be given orally or intravenously as part of a vitamin B complex (Pabrinex®) before dextrose or parenteral nutrition.

This blog post aims to provide updated information on managing HG, incorporating the latest recommendations to support pregnant individuals effectively. Always consult with healthcare professionals for personalized advice and treatment.