Nausea/Vomiting in Pregnancy
Assess severity and hydration status
All Pathways
Obstetrics & GynecologyManagement
Hyperemesis Gravidarum Management (ACOG 2018)
Hyperemesis Gravidarum Management (ACOG 2018): Nausea/Vomiting in Pregnancy → Initial Assessment → Severity Assessment → Mild NVP - Outpatient → Antieme...
Pathway Overview
13 steps
Algorithm Steps
13 total
01Start 02Action 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?)
03Decision 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
04Action 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)
05Action 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
06Decision Clinical Improvement?
Tolerating PO, weight stable
07Outcome 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
08Outcome 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)
09Action 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
- Path rejoins step 08Shared downstream outcome
10Action 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
- Path rejoins step 05Shared downstream outcome
11Action 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
12Warning ⚠️ 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
- Path rejoins step 05Shared downstream outcome
13Decision Consider Alternative Diagnoses
If atypical presentation
- Onset after 10 weeks - consider other causes
- Hyperthyroidism
- Molar pregnancy
- GI disorders (gastroparesis, cholecystitis)
- UTI
- Appendicitis
Guideline Source
ACOG Practice Bulletin No. 189: Nausea and Vomiting of Pregnancy
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Diagnosis of exclusion - rule out other causes
- Thiamine deficiency can cause Wernicke encephalopathy
- Some patients require prolonged hospitalization or TPN
Applicable Regions
USEUGlobal
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Hyperemesis Gravidarum Management (ACOG 2018)?
The Hyperemesis Gravidarum Management (ACOG 2018) is a management clinical algorithm for Obstetrics & Gynecology. It provides a structured decision tree to guide clinical decision-making, based on ACOG Practice Bulletin No. 189: Nausea and Vomiting of Pregnancy.
What guideline is the Hyperemesis Gravidarum Management (ACOG 2018) based on?
This algorithm is based on ACOG Practice Bulletin No. 189: Nausea and Vomiting of Pregnancy (DOI: 10.1097/AOG.0000000000002456).
What are the limitations of the Hyperemesis Gravidarum Management (ACOG 2018)?
Known limitations include: Diagnosis of exclusion - rule out other causes; Thiamine deficiency can cause Wernicke encephalopathy; Some patients require prolonged hospitalization or TPN. Individual patient factors may require deviation from these recommendations.
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