What are the indications for referring a patient with hyperemesis gravidarum to a specialist or hospital?

Indications for referring a patient with hyperemesis gravidarum to a specialist or hospital include:

• Persistent moderate-to-severe nausea and vomiting despite oral antiemetic treatment in primary care.
• Suspected hyperemesis gravidarum not controlled with outpatient management.
• Inability to tolerate oral antiemetics or oral fluids.
• Inability to take other necessary oral medications, including antibiotics or treatments for comorbidities.
• Presence of any co-morbidity combined with inability to take medications.
• Evidence of clinical dehydration.
• Weight loss greater than 5% of body weight.
• Concerns regarding mental health.
• PUQE (Pregnancy-Unique Quantification of Emesis) score greater than 13.
• Severe or serious complications related to hyperemesis gravidarum.

Referral may be for inpatient care involving intravenous fluids, electrolyte replacement, antiemetics via non-oral routes, thiamine supplementation, anticoagulant treatment, and nutritional support if symptoms are severe or refractory.

Women with severe symptoms may also require multidisciplinary specialist input including midwives, dietitians, pharmacists, endocrinologists, gastroenterologists, and mental health specialists.

Reassessment after 24-72 hours of treatment is recommended to evaluate response and need for escalation.

These recommendations are based on NICE antenatal care guidelines, the RCOG Green-top guideline on nausea and vomiting in pregnancy, and expert opinion.