UK Drs protocols

[Natasha]

I have been trying to find out where it is the doctors get there information from!

I have found a site which has quite a bit of information on regarding HG and the protocols on treatment. Its long and you probably won't learn anything you didn't already know but it might help to give you an insight as to why the doctors are so bloddy useless!!

http://www.cks.library.nhs.uk/nausea_vo ... e_guidance

[Natalie]

Natasha,

Thanks for finding that. It's interesting to read this kind of thing. What site did you find it on?

I found this a while ago on the Blooming Awful website. It's got to be out of date now - well, I assume it must be because it's from 2001. It also has some interesting insight into HG management in the UK.

Nausea and Vomitting of Pregnancy and Hyperemesis Gravidarum

K A Abidogun, T Luckett. N C Wathen January 2001. HOMERTON HOSPITAL LONDON

PROTOCOL FOR MANAGEMENT AND RECOMMENDATIONS

(Recommendations are graded from ‘A’ to ‘C’ on the strength on clinical evidence on which each is based according to
scheme adopted by the RCOG and the NHS Executive. This is reproduced in appendix I)

INTRODUCTION

Nausea and vomiting of pregnancy (NVP) is a common experience affecting about 50% to 90%
of all pregnant women(1,2). Typically NVP occurs very early in pregnancy and may be seen as part
of the usual spectrum of symptoms in the first trimester however the symptoms usually resolve by 12
weeks in 60% and by 16 weeks in 90% of women. Persistent nausea and vomiting beyond 20 weeks
is seen in about 1% - 3% of women (1,3). NVP is more common in primigravidae, younger women,
women with fewer that 12 years education, non-smokers and women weighing more than 170
pounds and multiple gestation. It appears that the main risk for NVP is pregnancy itself.

Hyperemesis gravidarum (HG) is an extreme form of this symptom of pregnancy. It has been
defined as persistent vomiting in pregnancy associated with weight loss greater than 5% of pre-
pregnancy weight and large ketonuria . This has a reported incidence of between 3 and 20 per 1000
pregnancies with 5 per 1000 being the most commonly accepted figure(3). It is characterised by
intractable nausea and vomiting, so severe as to cause dehydration, weight loss and muscle
wasting, electrolyte and metabolic disturbances and nutritional deficiency necessitating
hospitalisation. Signs of dehydration with postural hypotension are common at presentation and there
is ketosis. In addition to nausea and vomiting there may be ptyalism and spitting. Risk factors
include, increased body weight, multiple gestation, trophoblastic disease, hyperemesis gravidarum in
a prior pregnancy and nulliparity.

It is important that these two groups of women are identified and correctly. The majority of women
with NVP are able to manage themselves by learning which particular foods to avoid to minimise
symptoms and to eat at the time of the day when symptoms are less severe. These women are
unlikely to present for medical attention and in any event may be managed my simple measures
without hospitalisation (Grade B).

The following Table of Grades of Evidence is used to evaluate the evidence
which underpins the guideline recommendations.

Grade
A Requires at least one randomised control trial as part of the body of literature of overall
good quality and consistency addressing the specific recommendation)
B Requires availability of well-conducted clinical studies but no randomised clinical trials on
the topic of recommendation
C Requires evidence from expert committee reports or opinions and/ or clinical experience of
respected authorities. Indicates absence of directly applicable studies of good quality

DIAGNOSIS AND CLINICAL MANAGEMENT

Initial assessment

The aim of the initial assessment is to identify one of the following groups of women

1. Nausea and vomiting of pregnancy in the first trimester.
2. Hyperemesis gravidarum.
3. Nausea and vomiting beyond the 20th week of pregnancy


Vomiting either persisting or onset beyond 20 weeks is uncommon and should prompt a search for
other causes(Grade B). The differential diagnosis include

Gastrointestinal Endocrine
Gastroenteritis Diabetic ketoacidosis
Peptic ulcer disease Porphyria
Appendicitis Addison's disease
Intestinal obstruction Thyrotoxicosis
Cholecystitis Hypercalcaemia
Cholelithiasis Central nervous disease
Hepatitis Pseudomotor cerebri
Pancreatitis Vestibular lesions
Genitourinary Migraine headaches
Urinary tract infection Tumours
Uraemia Pregnancy related conditions
Kidney stones Acute fatty Liver
Torsion of an ovarian cyst Preeclampsia
Miscellaneous Degenerating uterine leiomyoma
Drug induced vomiting (especially iron)

INVESTIGATIONS

This should include a detailed history and clinical examination. The time of onset and the duration of
symptoms should be noted.

Clinical features to look for are, tachycardia, postural hypotension, dehydration weight loss and
muscle wasting.

The following investigations should be carried out.

1. FBC. The haematocrit is usually raised in HG
2. U/E, LFT
3. Urine: Check for ketonuria, and urine specific gravity and MCS
4. TFT
5. Ultrasound Scan of the uterus
In HG investigations usually reveals hyponatraemia, hypokalemia, a low serum urea and ketonuria. A
metabolic hypochloraemic alkalosis is seen unless the condition is severe in which case acidaemia
may be encountered. There may be evidence of dehydration with increased urine specific gravity,
ketonuria, and raised serum creatinine.

There may be abnormalities of the liver function test in 25-40% of patients with HG. The most usual
are mild elevations in serum aminotransferases and total bilirubin. However jaundice is uncommon.
Mild elevations in serum amylase may also occur. These abnormalities resolve as HG spontaneously
improve. Significant elevations of transaminases especially in the presence of jaundice should
prompt a search for viral hepatitis(1) (Grade B).

Abnormal thyroid function tests occur in two-thirds of patients with HG. There is biochemical
thyrotoxicosis with a raised free thyroxin level and or a suppressed thyroid stimulating hormone TSH
level. These patients are clinically euthyroid and these abnormalities usually resolve as the HG
improves. Treatment with anti-thyroid drugs are usually inappropriate and unnecessary(1) (Grade A).

An Ultrasound scan of the uterus should be performed to confirm gestational age, diagnose multiple
pregnancy and exclude hydatidiform mole (Grade B).

Clinical management of NV of pregnancy and Hyperemesis Gravidarum

The management of NVP depends on the severity and ranges from conservative dietary
modifications in the mildly symptomatic woman to drug therapy and total parenteral nutrition for those
with severe intractable symptoms (1) (Grade B).

a) Simple (uncomplicated) Nausea and Vomiting of Pregnancy

The outcome of uncomplicated NVP is usually favourable. It is considered by some to be a
favourable prognostic sign of pregnancy with a decreased risk of miscarriage, stillbirth, fetal
mortality, preterm delivery, low birth weight, perinatal mortality or growth retardation. The
management strategy for these group of patients should include then following (Grade B),

1. Outpatient management with supervision by the General Practitioner.
2. Reassurance as to the physiological nature of the symptoms, its transient nature and the overall
good prognosis.
3. Dietary modifications which include, Avoidance of known emetogenic foods, Try frequent small,
dry, bland, high carbohydrate meals with avoidance of fatty fried high protein and spicy food.
Eating at times of the day when nausea is less severe and eating before getting out of bed in the
morning have been found to be helpful. Avoidance of the smell of food and minimising time spent
in the kitchen may reduce symptoms. It is essential to stress the importance of drinking small
amounts of fluid regularly between meals. Iron supplements should be temporarily discontinued
especially in the first trimester as these may cause nausea and vomiting in some women(1)
(Grade B).
4. Outpatient trial of anti-emetic medications. This should be considered in women who have
persistent nausea and vomiting despite conservative measures. This may prevent some
admissions and reduce morbidity (Grade B). (see following section on anti-emetics)
5. Alternative therapies (see later)
b) Hyperemesis Gravidarum

1. Admission to hospital. Any woman who has severe nausea and vomiting accompanied by
dehydration, ketosis, or metabolic or electrolyte disturbance needs to be admitted to hospital
(Grade B).
2. Fluid and electrolyte replacement. The mainstay of therapy is adequate fluid and electrolyte
replacement.. Infusion of dextrose containing fluids is too dangerous and is to be avoided. This is
because Wernicke’s encephalopathy may be precipitated by carbohydrate rich intravenous
fluids. The hyponatraemia demands infusion of sodium containing fluids, so Normal saline (NaCl
0.9% ; 150mmol/L sodium) or Hartmann’s solution (NaCl 0.6%; 131mmol/L sodium) are
appropriate solutions. Potassium chloride is added to the infusion bags as required. Fluid and
electrolyte requirements should be adapted daily based on daily measurements of serum sodium
and potassium levels and the fluid balance charts.
3. Nutrition: Nothing should be given by mouth in the first 24 hours until the dehydration is
corrected. Afterwards small frequent feeding gradually advancing from liquids to solids can be
attempted as tolerated (Grade B).
4. Thiamine: This should be given routinely to all women admitted to hospital with prolonged
vomiting. If the woman is able to tolerate tablets she should have thiamine hydrochloride 25 to
50mg three time daily. Intravenous infusions are often required and this is given in the form of
100mg of thiamine diluted in 100ml of normal saline and infused over 30 minutes to 1hour once
weekly(2) (Grade B).
5. Anti-emetics: As in outpatient management the use of anti-emetic drugs should be considered
only in those women whose nausea and vomiting persist despite conservative management of
fluids and electrolyte imbalance. Extensive data exists to show lack of teratogenicity in humans
with dopamine antagonists (metoclopramide and domperidone), phenothiazines (chlorpromazine and prochlorperazine), and histamine H1 Receptor blockers (promethazine and cyclizine) (1,2).
Some studies have even found a better pregnancy out come in women with hyperemesis gravidarum treated with antihistamines, however it is best to withhold the use of anti-emetic drugs until after the first ten weeks of pregnancy. The following anti-emetics may be used (please refer to the BNF for full details)

5.1 Phenothiazines
Prochlorperazine (stemetil) [1st line drug]

In the acute phase give 12.5mg deep i.m. or 25mg rectal suppository when required followed
if necessary after 6 hours by an oral or rectal maintenance dose. Where appropriate in the
out patient setting patients may be given an oral loading dose in the form of 20mg initially
then 10mg after 2 hours.
Oral or rectal maintenance dose: 5-10mg 2-3 times daily

Comments: Phenothiazines have been found to give substantial improvement of
symptoms in 83% of patients with NVP and 63% of HE after 1 to 2 days of treatment(5).
However they cross the placenta and are eliminated from fetal and neonatal tissues more
slowly than in adults; therefore potential toxicity can occur. Neonatal extrapyramidal effects
have been occasionally reported from third trimester exposure (BNF).

5.2 Antihistamines
a) Promethazine teoclate (Avomine)
Dose: 25mg at bed time increased to a maximum of 100mg daily.


b) Cyclizine (Valoid) [2nd line drug]
Dose: By intramuscular or intravenous injection, cyclizine lactate 50 mg 3 times daily.
My mouth, cyclizine hydrochloride 50 mg up to 3 times daily.


Comments: These are widely prescribed in pregnancy and have been associated with
complete relief of symptoms in 82 to 98% of patients (5,6). There has been no evidence of
teratogenicity (BNF)

5.3 Metoclopramide (maxolon) [2nd line drug]
Dose: By mouth or intramuscular or intravenous injection over 1 to 2 minutes, 10 mg (5mg in
young adults 15-19 years under 60kg) 3 times daily.
Comments: This is highly efficacious with a good-to-fair response in 79% of patients. It is
not known to be harmful (BNF)

6. Vitamin B6 (Pyridoxine).
The American Medical Association Council on drugs in 1979 found no convincing evidence
that Vitamin B6 was effective for nausea and vomiting of pregnancy however recent controlled studies support the efficacy of pyridoxine in relieving nausea and vomiting of pregnancy (9, 10) (Grade A).
Dose: Recommended dose is 10 - 50 mg every 8 hours(3)

OTHER DRUGS
Corticosteroids: Case reports support the use of corticosteroids in hyperemesis gravidarum
unresponsive to adequate intravenous fluid replacement with thiamine supplementation and
regular anti-emetic medication(2,3) (Grade B). The doses have ranged from 40 to 60 mg/day
of prednisolone or intravenous hydrocortisone 50 to 100 mg twice daily. The response has
been dramatic but not all studies support its efficacy (2). In patients who do respond the
dosage must be reduced slowly and usually continued until the stage of gestation at which
the hyperemesis would have resolved naturally. Screening for the complications of
corticosteroid use in pregnancy, particularly an increased risk of urinary tract infection,
gestational diabetes mellitus is recommended in those patients on long term use. Their use
is however not recommended routinely until the results of randomised control studies are
available (2). The use of corticosteroids where indicated as above should be discussed with
the consultants.

5. Nutritional support: In some cases of severe HG total parenteral nutrition becomes necessary.
This has been shown to have a rapid therapeutic effect however metabolic and infective
complications are a risk.

6. Psychotherapy: All patients with severe NVP of HG require emotional and psychological support
from nursing and medical staff. This should aim to develop common-sense, practical approaches
to the problem through encouragement, explanation, reassurance and the opportunity to vent
emotions. When patients do not respond to the medical and supportive care of the medical team
psychiatric referral is indicated (Grade B).
Potentially serious complications of HG

Rare complications of HG include Wernicke’s encephalopathy, pancreatitis and renal failure.

Wernicke’s encephalopathy (WE) caused by thiamine (Vitamin B1) deficiency is characterised by
diplopia, abnormal ocular movements, ataxia and confusion. It may develop in any condition causing
prolonged vomiting and inadequate nutrition. It may be precipitated by carbohydrate rich foods and
intravenous dextrose or glucose. Abnormal LFT are common in HG complicated By WE and may
participate in the production of WE by decreasing the conversion of thiamine to its active metabolite
thiamine pyrophosphate.

Hyponatraemia (plasma sodium levels < 120mmol/l) causes lethargy seizures and respiratory arrest

Other vitamin deficiencies which may occur in HG include cyanocobalamine (Vitamin B12) and
pyridoxine (Vitamin B6) causing anaemia and peripheral neuropathy

Prolonged vomiting may lead to Mallory-Wiess tears of the oesophagus and episodes of
haematemesis.

Nursing and Midwifery care of Hyperemesis Gravidarum on admission

This generally follows from the above protocol.
A full nursing history should be obtained
Baseline investigations should include urinalysis for ketonuria. This should then be repeated daily.
The patient should be weighed on admission and then twice weekly.
A fluid balance chart should be accurately maintained in HG.
The patient should be nil by mouth and have intravenous hydration for the first 24 hours in the
presence of dehydration.
Patients should be encouraged to be actively involved in their management as far as possible.
Dietary advice should be offered and a dietary leaflet given (available on Priestly ward)
On discharge from the ward, ensure TTA’s are made available and the patient encouraged to
continue with their medications while at home. Also ensure that follow-up arrangements with the
appropriate professional (GP, Midwife, Obstetrician, or EPAU) are made.


c) Outpatient management of troublesome NVP or HG with EPAU or FWU follow-up

Patients with persistent NVP or resolving HE may be suitable for outpatient management with daily
follow-up for anti-emetic therapy with fluid and electrolyte monitoring and intravenous hydration as
necessary without the need for admission.

This is presently not routinely available but may be possible in the future.


References

1. C N Broussard, J E Richter: Nausea and vomiting of pregnancy. Gastroenterology clinics of
North America. 1998 ;27:23-151
2. C Nelson-Piercy: Treatment of nausea and vomiting in pregnancy. Drug safety. 1998;19:155-164
3. T M Goodwin: Hyperemesis gravidarum. Clinical Obstetrics and Gynaecology. 1998;41:597-605
4. Seto A, Einarson T, Koren G: Pregnancy outcome following firs trimester exposure to
antihistamines – meta analysis. Am J Perinatol. 1997;14:119-24
5. Leatham A: safety and efficacy of antiemetics used to treat nausea and vomiting of pregnancy.
Clin Pharmacy. 1986;5:660
6. Diggory PL, Tomkinson JS: Nausea and vomiting in pregnancy. Lancet. 1962;2:370
7. Vickers AJ. Can acupuncture have specific effects on health? A systematic review of
acupuncture antiemesis trials. J R Soc Med 1996;89:303-311
8. British National Formulary. March 2000
9. Vityavanich T, Wongtra-Ngan S, Ruangsri R: Pyridoxine for nausea and vomiting of pregnancy; A
randomised, double blind, placebo controlled trial. Am J Obstet Gynecol 1995;173:881
10. Shakian V, Rouse D, Sipes S, et al: Vitamin B6 is effective therapy for nausea and vomiting of
pregnancy: A randomised, double blind, placebo controlled study. Obstet Gynecol 1991;78:33
Page 9 of 8
Nausea and Vomitting of Pregnancy and Hyperemesis Gravidarum
Draft version 0.1, July 2001.

The PDF document is stil on the Blooming Awful website www.hyperemesis.org.uk

Natalie, x

[Xphile_mo]

Well ...............!!

Can safely say my doctors didn't go to school on the day either of those articles were written!!! Cause none of them followed either one!!

Plus, there's a part missing in there about "when to give the pregnant woman the HAVE YOU NOT HEARD OF THALIDOMIDE!!! lecture" before continuing to report on how "if you are REALLY sick, you'd need fluids and all sorts ....!" Believe I was about 8 weeks pg when I got my lecture ... and had been out of hospital for about 4 days!!

Sigh, the NHS!! Don't you just love it!

[sarahkate]

I have yet to work in a hospital that actually has a protocol.

I think the main problem with that Natasha is that it confuses HG and NVP. And they are totally different things. I could say a lot more about it.... but won't.

Sarah x