Assessing and managing NVP

NICE clinical guidance

NICE suggests non-pharmacological rehydration and conservative management as first line treatment of NVP1,2, for example:

  • Rest
  • Avoid any foods or smells that trigger symptoms (for example spicy or fatty foods)
  • Eat plain biscuits or crackers in the morning before getting up
  • Eat bland, small, frequent meals low in carbohydrate and fat but high in protein. Cold meals may be more easily tolerated if nausea is smell-related
  • Drinking little and often rather than large amounts, as this may help to prevent vomiting
  • Ginger
  • P6 (wrist) acupressure
  • Consider advising avoidance of iron-containing preparations if they make symptoms worse

Information on all self-help and non-pharmacological treatment options should be made available to women with NVP.

If symptoms persist pharmacological intervention with an anti-emetic should be considered2,3 and the 2016 RCOG Guidelines state that anti-emetics should be considered in all women with NVP, and recommends antihistamines as the first-line pharmacotherapy treatment option (please note that nearly all anti-emetics and antihistamines are not approved for use in NVP).2 

NICE suggests that if an anti-emetic is required for NVP, prescribe an antihistamine, or a phenothiazine* (oral prochlorperazine), and reassess after 24 hours. If treatment response is good, continue treatment and review again after one week. If the response is inadequate, the woman is not dehydrated and there is no ketonuria, switch to another anti-emetic from a different class and reassess after 24 hours. If the response after the second anti-emetic is still inadequate, seek specialist advice and review the woman once a week thereafter.2

*Not licensed for NVP

Pregnancy Unique Quantification of Emesis (PUQE) Score4,5

The PUQE Score can help track your patient’s NVP symptoms and consists of the PUQE symptom score and the Global assessment of well-being (GAWB).

The PUQE symptom score

The questions below can help determine the severity of their NVP symptoms. The PUQE symptom score measures hours of nausea, number of times vomiting, and number of times retching for a total overall score of symptoms on a scale rated from 3 (no symptoms) to 15 (most severe).

Ask the patient Point value for responses Total
  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) 4-6 hours (4) More than 6 hours (5) Score out of 5 (1-5)?
  1. In the last 24 hours have you vomited or thrown up?
 I did not throw up (1) 1-2 times (2) 3-4 times (3) 5-6 times (4) 7 or more times (5) Score out of 5 (1-5)?
  1. In the last 24 hours how many times have you had retching or dry heaves without bringing anything up?
 No times (1) 1-2 times (2) 3-4 times (3) 5-6 times (4) 7 or more times (5) Score out of 5 (1-5)?
Sum of point values for the three questions to find the PUQE score: Total score out of 15?

The total score will give an indication of the severity of the patient’s nausea and vomiting of pregnancy:

PUQE score ≤6 7-12 13-15
Severity of nausea and vomiting of pregnancy Mild Moderate Severe

Global assessment of well-being (GAWB)

How many hours have you slept out of 24h?
If this is not your normal sleep hours, why?
On a scale of 0-10, how would you rate your well-being in the last week? (Reference scale 0 (worst possible) to 10 (the best you felt before pregnancy)
Can you tell me what causes you to feel this way?

References:

  1. NICE (March 2008; updated Jan. 2017). Antenatal care for uncomplicated pregnancies (Clinical Guideline (CG) 62). National Institute for Health and Care Excellence. https://www.nice.org.uk.
  2. NICE Clinical Knowledge Summaries. Nausea/vomiting in pregnancy. Last revised in June 2017.
  3. Royal College of Obstetricians and Gynaecologists. The management of nausea and vomiting of pregnancy and hyperemesis gravidarum (Green-top Guideline No. 69). 22 June 2016. Royal College of Obstetricians and Gynaecologists: London. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg69/.
  4. Koren G, Piwko C, Ahn E, et al. Validation studies of the Pregnancy Unique-Quantificationof Emesis (PUQE) scores. J Obstet Gynaecol. 2005;25(3):241-244.
  5. Ebrahimi N et al. Nausea and vomiting of pregnancy: using the 24-hour Pregnancy-Unique Quantification of Emesis (PUQE-24) scale. J Obstet Gynaecol Can. 2009;31(9):803–807.