Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum are particularly challenging conditions for healthcare professionals to manage, particularly in community settings and when mothers already have young children to care for. Here we hope to give you some suggestions for how to help women with NVP and HG, in particular the information is aimed at General Practitioners in a community setting. If you are a midwife please see our Information for Midwives as well.
Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum can be particularly isolating for women experiencing them; in first pregnancies it is usually a complete shock to find themselves feeling so ill and it is important that Healthcare professionals take them seriously so that they can feel understood and that the condition is a valid one.
Most women expect a certain amount of pregnancy sickness, particularly in planned pregnancies and many women will put up with surprisingly severe symptoms before seeking help and treatment. If a women's ability to conduct her normal acts of daily living is affected by the severity of symptoms it could indicate that she requires treatment.
Early treatment could reduce admission rates to hospital and significant associated costs as well as further morbidity for the women.
Assessment of the symptom severity using our check-list for GPs and Midwives
Because morning sickness is considered a normal and healthy part of pregnancy most women expect to get it and some even report to us that they looked forward to it as a "life experience". So by the time many women present to their GP with NVP symptoms they are likely to have put up with a significant amount before seeking help. It is important that Healthcare professionals take them seriously so that they can feel understood and that the condition is a valid one.
The following assessment check-list was produced by Dr Roger Gadsby FRCGP MBE & Dr Tony Barnie-Adshead FRCGP trustees of Pregnancy Sickness Support Trust.
Background information from notes:
- How many weeks pregnant is she?
- How many previous pregnancies?
- History of NVP Symptoms in previous pregnancy?
NB: Symptoms usually begin in the first trimester at about 6-8 weeks gestation, typically peaking at about 9 weeks and settling about 12 weeks for NVP; HG commonly persists until 20 weeks and for some women will continue throughout the pregnancy. Gestation means from LMP.
- How many weeks from LMP did symptoms start?
- How many episodes of nausea occur each day? NB. A large majority of pregnant
have episodes of nausea before & after midday. Therefore the term morning
sickness is a misleading name. A more appropriate name is episodic nausea &
vomiting of pregnancy
- For how many hours a day are you feeling nauseated?
- Have you vomited?
- How many times a day?
- Have you lost weight compared to your weight before you became pregnant?
Tip: Download this daily symptom diary for women to fill in, this will assist your assessment and help them find a pattern of nausea free moments in which to eat and drink.
Assess the effect of the symptoms:
- Can you eat and drink properly?
- How many times vomiting a day? NB. No. of vomits and quantity of fluids lost are
- Have you lost weight more than 5% of weight before you became pregnant?
- Is nausea affecting your normal lifestyle?
- Is your ability to shop, cook or do housework affected?
- Are your symptoms affecting your ability to do paid work?
- Are you feeling depressed because of your symptoms of NVP?
- Offer anti-emetics to women in primary care in whom nausea & vomiting interferes
with normal function.
Prescribe Oral Anti-emetic Therapy if required
- Following recommendations within RCOG Greentop Guidelines for nausea and vomiting in pregnancy and hyperemesis gravidarum.
Tip: Refer women to our support network of emotional support too.
Assess for signs of Hyperemesis Gravidarum (HG):
- is there any evidence of dehydration? NB. Symptoms & signs may include scanty
dark infrequent urine, thirst,dry mouth,difficulty in swallowing ,red swollen tongue ,loss
of skin elasticity ,loss of weight , low B.P., raised pulse rate ,lethargy or later
- is there weight loss >5% of pre-pregnancy weight despite oral anti-emetics?
Criteria for referral to secondary care
- Continued nausea and vomiting associated with weight loss (greater
than 5% of pre-pregnancy body weight) despite oral anti-emetics
- Continued nausea and vomiting and inability to keep down oral anti-emetics
- Confirmed or suspected co-morbidity (such as confirmed urinary tract infection and unable to tolerate oral antibiotics)
Tip: to find out which consultant to refer women in your area to or to contact one of our GP's for further information please get in touch.
IV at Home Service
For rural areas an IV at Home service can be absolutely incredible for women with hyperemesis gravidarum who are facing long journeys for multiple admissions to hospital for rehydration. In America, where healthcare is insurance led, IV at home by community based nursing teams is a standard procedure because it is cost effective for the companies paying.
The charity gets many phone calls every year asking if this is something they can access in the UK but sadly it is not yet a well established service. That is however changing rapidly. In the South West of England Virgin Care, who provide the community services for the NHS have a team of acute care at home nurses who have expanded their roles to include providing IV hydration for hyperemesis patients in their area. Their service won the Nursing Times 2014 Award for Nursing in the Community.
You can watch the video below about their service and see their treatment pathway here. We will have further information about how to develop a similar service in your area.
The following film was made about the Virgin Care (previously Sirona Care and Health) IV at home service. Thanks go to Lizzie for sharing her journey and to Sirona Care and Health for allowing us to share this film.
Most women with pregnancy sickness present first to their GP and care at this point can vary greatly. Many women receive excellent care and pro-active treatment from their GPs, however there are still many doctors who are so concerned about treating pregnancy sickness that women are left without treatment until they require hospital admission.
Early treatment for symptoms which are causing a significant impact on a woman's quality of life and affecting her ability to eat and/or drink can reduce the overall severity of the condition and potentially prevent hyperemesis gravidarum, in some cases.
To help GP's gain confidence in treating women presenting to them with NVP symptoms we have collaborated with GP colleagues in Nottingham to produce a sample guideline which can be adapted for use in your own area.
Please not this guideline is for moderate to severe NVP symptoms rather than diagnosed hyperemesis gravidarum, which might require further treatment to control symptoms in conjunction with a consultant. Additionally, while assessing for signs of a urinary tract infection is supported, checking for ketones and basing clinical decision on the results is no longer considered best practice as ketone level does not correspond with severity of HG symptoms and is not a sign of dehydration.
Did you know?
Early access to treatments is likely to be more effective and may prevent symptoms developing into HG
HG Training for Healthcare Professionals
The risk of a baby being born with a congenital abnormality - the difference between relative and absolute risk
Please note this guideline is for moderate to severe NVP symptoms rather than HG
RCOG Green-top Guideline No. 69
The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum
BMJ Clinical Update 2018
Management of severe pregnancy sickness and hyperemesis gravidarum
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