see also:

• gynaecology;
• Obstetrics;
• pregnancy;
• anti-emetics
• WH Patient information Sheet (docx) - WH intranet only

• nausea and vomiting effect up to 85% of pregnant women
  • usually mild and self-limiting, frequently resolving before 14wks gestation
  • it is thought to be an evolutionary function to avoid eating foods which may be high risk to either the foetus (teratogenic or abortifacient such as plant toxins, alcohol, caffeine) or to the immunosuppressed mother who is at risk of food-borne pathogens which are more likely in meats, fish and eggs, while safer foods such as fruit, grains and sweets are craved ¹⁾
  • it tends to be associated with a positive pregnancy outcome (50-75% lower miscarriage rates)²⁾
• more severe cases with significant dehydration and ketonuria are a frequent presentation to ED
  • ~13% of these patients have symptoms beyond 20wks gestation ³⁾

• hyperemesis gravidarum
  • transient hyperthyroidism of first trimester pregnancy
• gastroenteritis - in particular, suspect this if diarrhoea is present as well
• urinary tract infections (UTIs) / cystitis - UTI and persistent bacteriuria is a common problem in pregnancy due to ureteric stasis
• multiple pregnancy

• molar pregnancy - hydatidiform mole - Dx on USS
• hyperthyroidism

• surgical abdominal causes including biliary disease, pancreatitis and appendicitis
• adrenocortical insufficiency
• diabetic ketoacidosis (DKA)
• incarcerated diaphragmatic hernia ⁴⁾

• these patients usually do well with iv rehydration Rx + anti-emetics such as metoclopramide or if that fails, ondansetron
• often these patients can be directly admitted from triage to a ED short stay observation unit using a care plan pathway
• send bloods for FBE, U&E, and, TSH if thyroid testing has not been done
• check urinalysis and send MSU m/c/s if suspicious of UTI
• ensure an USS has be done or will be done within a week or so to exclude multiple pregnancies and molar pregnancy.
• repeated vomiting usually causes some oesophagitis and may even cause Mallory-Weiss tear resulting in small amounts of blood in vomit.
  • this does not usually need Ix but Mx with antacids or ranitidine may be useful.

• these patients can usually be managed as an outpatient
• check urine, USS as above
• oral agents to consider (as per RWH guideline 2009):
  • first line:
    • pyridoxine (vitamin B6) 50mg o qid or 200mg o nocte
  • second line:
    • add doxylamine (Restavit, a H1 antagonist) 12.5mg o nocte, increase to 25mg nocte, then add 12.5mg mane and afternoon if needed
  • third line - add another sedating antihistamine:
    • promethazine (Phenergan) 10-25mg o tds/qid, or, Ddimenhydrinate (Dramamine) 50mg o tds/qid
  • fourth line, add either ONE of the following:
    • metoclopramide (Maxolon) (Maxolon, Pramin) 10mg o tds/qid, or,
    • prochlorperazine (Stemetil) (Stemetil) 5-10mg o bd/tds, or 25mg PR once or twice daily
  • fifth line if severe, persistent or resistant vomiting:
    • ondansetron (Zofran) 4mg o (tablet or wafer) bd/tds - needs approval by Head of Unit
  • sixth line - consider parenteral administration of ONE of the following:
    • metoclopramide (Maxolon) 10mg iv/im 8hrly
    • prochlorperazine (Stemetil) 12.5mg im 8hrly
    • promethazine 12.5-25mg im 4-6hrly
    • ondansetron 4mg iv/im 8-12hrly
  • seventh line:
    • prednisolone 50mg o daily for 3 days, then 25mg o daily for 3 days, then reduce by 5mg as tolerated
      • monitor glucose levels and consider prophylactic ranitidine 300mg o nocte to prevent gastritis

• don't forget to remind patient to take folate supplements as well to reduce probability of neural tube defects