Hyperemesis Gravidarum Management (ACOG 2018)

Algorithm Steps

1. ▶

   Start

   Nausea/Vomiting in Pregnancy

   Assess severity and hydration status

   1. ●

      Action

      Initial Assessment

      Evaluate severity and exclude other causes

      • Vital signs - orthostatic hypotension?
      • Weight loss (>5% of prepregnancy weight = HG)
      • Ketonuria on urinalysis
      • Electrolytes, BMP
      • TSH (hyperthyroidism can cause vomiting)
      • Consider ultrasound (multiple gestation, molar?)
      1. ◆

         Decision

         Severity Assessment

         NVP vs Hyperemesis Gravidarum

         • MILD NVP: Occasional vomiting, tolerating some PO
         • MODERATE: Daily vomiting, poor intake, mild dehydration
         • HYPEREMESIS: Weight loss >5%, ketonuria, severe dehydration
         1. ●

            Action

            Mild NVP - Outpatient

            First-line therapy

            • Dietary modifications:
            • - Small, frequent meals
            • - Avoid triggers (smells, spicy foods)
            • - Ginger 250mg QID or ginger tea
            • FIRST LINE: Vitamin B6 (pyridoxine) 10-25mg TID-QID
            • Add doxylamine 12.5mg TID-QID if needed (Diclegis/Bonjesta)
            1. ●

               Action

               Antiemetic Escalation

               Step-wise approach

               • STEP 1: B6 + doxylamine
               • STEP 2: Add ondansetron 4-8mg q8h
               • STEP 3: Add metoclopramide or promethazine
               • STEP 4: Methylprednisolone 16mg TID x 3 days, then taper
               • Avoid metoclopramide >12 weeks (tardive dyskinesia)
               • Ondansetron: theoretical cleft palate risk - discuss
               1. ◆

                  Decision

                  Clinical Improvement?

                  Tolerating PO, weight stable

                  1. ✓

                     Outcome

                     Discharge Criteria

                     Transition to outpatient

                     • Tolerating PO intake
                     • No orthostatic hypotension
                     • No ketonuria
                     • Antiemetic regimen established
                     • Follow-up in 1-2 weeks
                     • Home IV if needed
                     1. ✓

                        Outcome

                        Prognosis

                        Most cases resolve by 20 weeks

                        • Symptoms typically improve 14-20 weeks
                        • 10-20% have symptoms throughout pregnancy
                        • Reassure: HG does NOT harm fetus if treated
                        • Counsel on recurrence risk (15-20% next pregnancy)
                  2. ●

                     Action

                     Refractory Cases

                     When standard therapy fails

                     • Enteral nutrition (NG/NJ tube)
                     • TPN if enteral not tolerated (last resort)
                     • PICC line for long-term IV access
                     • Consider psychiatry consultation
                     • Social work/support services
                     • May require prolonged hospitalization
         2. ●

            Action

            Moderate - Consider IV Hydration

            Escalate therapy

            • IV fluids (NS or LR) - outpatient infusion or ED
            • Thiamine 100mg IV BEFORE dextrose
            • Add antiemetics if B6/doxylamine inadequate:
            • - Ondansetron 4-8mg PO/IV q8h
            • - Metoclopramide 5-10mg PO/IV q6-8h
            • - Promethazine 12.5-25mg PO/PR/IV q4-6h
         3. ●

            Action

            Hyperemesis Gravidarum - Admit

            Inpatient management

            • NPO initially
            • IV fluids with electrolyte repletion
            • THIAMINE 100mg IV BEFORE any dextrose (prevent Wernicke)
            • IV antiemetics scheduled (not PRN)
            • Correct electrolyte abnormalities
            • Daily weights, I/O monitoring
            1. ⚠

               Warning

               ⚠️ THIAMINE Before Dextrose

               Prevent Wernicke encephalopathy

               • Give thiamine 100mg IV BEFORE any glucose/dextrose
               • Dextrose can precipitate Wernicke in thiamine-depleted patients
               • Signs: confusion, ataxia, ophthalmoplegia
      2. ◆

         Decision

         Consider Alternative Diagnoses

         If atypical presentation

         • Onset after 10 weeks - consider other causes
         • Hyperthyroidism
         • Molar pregnancy
         • GI disorders (gastroparesis, cholecystitis)
         • UTI
         • Appendicitis