Diagnosis + Assessment

All women should be asked about NVP at each visit between 4 and 16 weeks and if present, severity should be assessed by PUQE-24 score, measurement of weight and hydration status. For more information on what further investigations should be conducted please consult the full SOMANZ Guidelines available here. NVP is so common in early pregnancy that all maternity focussed care providers should be equipped to care for any woman with mild-moderate symptoms (a PUQE-24 score of 12 or less).

Given that many women expect to be unwell in the first trimester, they may turn to their local pharmacist for advice rather than speaking to their doctor or midwife about it. For this reason, pharmacists and their staff are a vital source of support of information for women.

When it comes to treating women with severe NVP or HG (a PUQE-24 score of 13 or above) assessment and care should be undertaken by clinicians with experience with these conditions. If a specialist of this nature is not available consideration should be given to referring the woman on to someone else, or seeking help via telemedicine. Please get in touch with us if you would like information about specialists available for consultation.

Regardless of who is treating the woman and in what setting, the lead clinician needs to have a clearly communicated and well-documented plan for ongoing management. This allows both the patient and other care providers to understand the nature of the condition, the options available to them for increasing treatment as required and the nature of arrangements for ongoing care.

For more information on providing care for women with NVP or HG please consult the full SOMANZ Guidelines available here.

Symptoms

As with most chronic illnesses, there is a spectrum of symptoms that may or may not be present in someone suffering from NVP or HG. Symptoms usually begin in the first trimester at about 6-8 weeks gestation, typically peaking at about 9-weeks and settling about 14-weeks for NVP; HG commonly persists until 21-weeks and for some, it will continue throughout the pregnancy until delivery. Most commonly sufferers will be experiencing one or more of these as a result of the nausea and/or vomiting.

Loss of 5% (or more) of pre-pregnancy weight

Dehydration
Constipation
Nutritional disorders, such as vitamin B1 (thiamine) deficiency, vitamin B6 (pyridoxine) deficiency or vitamin B12 (cobalamin) deficiency
Metabolic imbalances such as metabolic ketoacidosis or thyrotoxicosis
Headaches or migraines
Aversions to food (including the sight or smell)
Excessive salivation
Exhaustion
Low blood pressure
Disorientation
Dizziness
Raised pulse

Diagnosis

There are two diagnostic tests that can determine the severity of these conditions in sufferers. The Society of Obstetric Medicine of Australia and New Zealand’s Guideline for the Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum recommends using the Pregnancy-Unique Quantification of Emesis and Nausea (PUQE-24) test over a 24-hour period. The resulting score will determine whether her condition is mild, moderate or severe and will inform the course of treatment that is appropriate. You can download a printable version of the PUQE-24 questionnaire below.

1. In the last 24 hours, for how long have you felt nauseated or sick to your stomach_ Not at all (1) 1 hour or less (2) 2-3 hours (3) 4 to 6 hours (4) More than 6 hours (5) 2. In the last 24 hours, have you vomited (1).png

PUQE-24 scoring system (scores in brackets)
MILD: 4-6
MODERATE: 7 to 12
SEVERE: ≥13

Download

The HER Foundation have developed The HyperEmesis Level Prediction (HELP) Score Assessment to quantify HG symptoms into a score that can be trended over time to monitor progress and response to treatment. Download a printable copy of the HELP Score here.

Ketone analysis has historically been used as a diagnostic criteria and threshold for treatment for HG. Recent systematic reviews have shown the presence of ketones has no correlation to severity of symptoms and is not an indicator of dehydration. Additionally, some pregnant women will have ketones present in their urine throughout pregnancy even when their carbohydrate intake is sufficient. Therefore, in addition to a lack of ketones being a barrier to treatment, ketosis has sometimes been a barrier to discharge in women who have been well enough to go home from the hospital. Based on the best available evidence we do not recommend the use of keto analysis in assessing women with pregnancy sickness or hyperemesis gravidarum.

For more information on why we stand behind the Ditch the Ketones campaign run by Pregnancy Sickness Support, read chairperson Caitlin Dean’s outline here. We also recommend reading the American Journal of Obstetrics and Gynaecology review of ketone use here.

SOMANZ Proposed Definitions

Nausea and vomiting of pregnancy: Nausea, vomiting and/or dry retching caused by pregnancy, with symptoms commencing in the first trimester without an alternate diagnosis.

Hyperemesis Gravidarum: Nausea and/or vomiting caused by pregnancy leading to a significant reduction of oral intake and weight loss of at least 5% compared with pre-pregnancy, with or without dehydration and/or electrolyte abnormalities. By definition, this condition is considered severe.