🤰 NAUSEA & VOMITING OF PREGNANCY ALGORITHM

Source: HER Foundation | Presented by: Swaraj Hospital and Research Institute

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🟢 STEP 1: INITIAL MANAGEMENT (HELP Score <20)

Start here for baseline symptoms.

• B6/Pyridoxine: 10–25 mg PO (w/ or w/o Doxylamine 10-25 mg) q 6-8 h.

• Thiamin/Benfotiamine: 100 mg PO 1-3x/day (Min 250 mg daily PO after 20 weeks).

• Prenatal Vitamin: Continue if tolerated, OR change to single vitamins (B1, B9, D with K, Ca, Mg).

• Gastric Protection: Add at bedtime with onset of vomiting/poor intake.

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⚖️ DECISION POINT: Is the patient dehydrated?

🔴 NO DEHYDRATION (HELP Score <32)

Follow this progression if symptoms persist.

1. Add up to 1 from each class:

• Antihistamine (discontinue doxylamine)

  • Dimenhydrinate: 25-50 mg q 4–6 h PO/PR

  • Diphenhydramine: 25–50 mg PO q 4–6 h

  • Meclizine or Cyclizine: 25 mg PO q 6-8 h

• Dopamine Antagonist (Use 1 at a time or alternate)

  • Metoclopramide: 2.5-10 mg q 6-8 h PO or ODT

  • Promethazine: 25 mg q 4-6 h PO or PR

  • Prochlorperazine: 5-10 mg q 6-8 h PO or 25 mg PR q 12 h

  • Domperidone: 10-20 mg PO q 6-8 h

2. Add DAILY Bowel Care + Serotonin Antagonists (5-HT3)

• Bowel Care: Daily stool softener, magnesium, PEG + stimulant laxative/enema.

• Ondansetron: 4-8 mg q 3-6 h PO, ODT, or vaginally (max 32 mg/day) OR

• Granisetron: 1 mg q 12 h PO or 3 mg TD patch.

3. Consider Nutrition + Fluids + 1 of the following:

• Mirtazapine (15 mg), Methylprednisolone (16 mg, if 9+ weeks), Chlorpromazine (25–50 mg), Olanzapine (5 mg), OR Gabapentin (300-800 mg).

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🚨 YES: DEHYDRATION (HELP Score ≥32)

Requires immediate IV intervention.

1. IV Fluids and Dilute Vitamins (Infuse Slowly)

• NS or LR + MVI + B1 + B6 + B Complex.

• Always give 200 mg B1 IV w/dextrose to prevent WE.

• Slowly replace low/marginal electrolytes to prevent ODS.

• Always include Thiamin/B1 100-500 mg IV q 8 h daily.

2. If Oral Meds Ineffective/Not Tolerated: Change to 1 of the following with Daily Bowel Care:

• Ondansetron: IV (4-8 mg over 15 mins) or SubQ continuous infusion.

• Granisetron: 1 mg q 12 h IV or continuous infusion/TD.

3. If Symptoms Continue, add one or both:

• Dimenhydrinate or Diphenhydramine: 25-50 mg q 4–6 h IV.

• Metoclopramide: IV (2.5–10 mg q 8 h SLOW) or SubQ continuous.

⚠️ Wean IV/SubQ to PO very slowly when stable. Monitor 24 hrs before discharge. Consider enoxaparin for DVT prophylaxis.

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🛡️ SUPPLEMENTAL PROTOCOLS

💊 GERD / Gastric Protection	🥗 NUTRITION PROTOCOL (Weight loss ≥7% or persistent HG)
1. Calcium Antacid: Avoid Aluminum, Bismuth, Bicarbonate.	1. Consult: GI & Nutrition & IV access team.
2. H2 Antagonist BID: Famotidine 20-40 mg PO/IV.	2. Prevent Refeeding Syndrome: Restart slowly, monitor weight, rhythm, and electrolytes for 1+ week.
3. PPI (q 24 h at bedtime): Esomeprazole/Pantoprazole 40 mg OR Lansoprazole 15-30 mg.	3. Consider EN/PN: Enteral (NJ/GJ preferred) or Parenteral nutrition until gaining weight on PO intake.

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📌 IMPORTANT CLINICAL NOTES

1. Follow arrows to next level of care if symptoms persist. Always wean slowly.

2. Most medications can cause QT prolongation; consider EKG for high-risk patients.

3. IM injections are NOT recommended due to muscle atrophy/pain.

4. Dehydration and nutrient deficiencies decrease treatment response.

5. Start prophylactic anticoagulation for DVT if immobilized/hospitalized >72 hours.

6. HELP = HyperEmesis Level Prediction Score.