New Green-top Guidelines Address Effective Management of Pregnancy-Related Nausea and Vomiting
UK: The management of nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) has been addressed in the latest Green-top Guideline No. 69, which offers comprehensive, evidence-based recommendations for healthcare providers. These guidelines, published in BJOG: An International Journal of Obstetrics & Gynaecology, aim to improve the diagnosis and management of NVP and HG across various settings, including community care, ambulatory day care, and inpatient care, and emphasize the importance of supporting women before, during, and after their pregnancies.
NVP is a common condition that affects up to 90% of pregnant women. Typically, the symptoms occur before 16 weeks of gestation and are characterized by nausea and/or vomiting without any other underlying causes. Although the condition is often referred to as "morning sickness," it can occur at any time of day and significantly impacts the quality of life. In severe cases, HG can develop, affecting between 0.3% and 3.6% of pregnant women. HG is a much more serious condition that interferes with a woman’s ability to eat and drink and can cause severe distress.
The new guidelines provide clinical advice for managing these conditions and emphasize the need for a multidisciplinary approach to care. Key recommendations include using validated tools like the Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) to classify the severity of NVP and HG. These tools help healthcare providers determine the appropriate level of intervention.
The guidelines highlight that ketonuria should not be used as a measure of dehydration, as it does not accurately assess the severity of the conditions. For first-line treatment, the guidelines recommend antiemetics such as H1 antihistamines, phenothiazines, and doxylamine/pyridoxine (Xonvea). These medications are considered safe and effective for managing NVP and HG. If first-line treatments fail, ondansetron is recommended as a second-line therapy, though healthcare providers should reassure women of its safety, noting a very small increase in the risk of orofacial clefts when used in the first trimester.
Metoclopramide, another effective antiemetic, is also recommended but should be used cautiously due to its potential for extrapyramidal side effects. When using metoclopramide intravenously, it should be administered slowly to minimize these effects. In severe cases, intravenous hydration with normal saline (0.9% NaCl) and potassium chloride is recommended, alongside daily monitoring of electrolytes.
The guidelines also stress the importance of thiamine supplementation in women with severe vomiting or poor dietary intake. Additionally, healthcare providers are urged to exhaust all therapeutic options before considering termination of pregnancy as a last resort.
This updated guideline aims to improve the care of pregnant women experiencing nausea, vomiting, or hyperemesis and acknowledges the profound impact these conditions can have on women's physical and mental health. By providing clear, evidence-based recommendations, the guideline ensures that women receive the best care possible while minimizing risks to their health and their babies.
Reference:
Nelson-Piercy C, Dean C, Shehmar M, Gadsby R, O’Hara M, Hodson K, et al; on behalf of the Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69). BJOG. 2024;00:1–30. https://doi.org/10.1111/1471-0528.17739
