How should I manage a patient presenting with severe nausea and vomiting in early pregnancy?

Management of severe nausea and vomiting in early pregnancy:

• Assess the severity of symptoms and consider the possibility of hyperemesis gravidarum if vomiting is prolonged, severe, or associated with dehydration or weight loss greater than 5% of body weight.
• Offer outpatient management if the patient can tolerate oral antiemetics and the PUQE score is less than 13; otherwise, consider inpatient care.
• Inpatient care includes intravenous fluids and electrolyte replacement, antiemetics via IV, rectal, subcutaneous, or intramuscular routes, thiamine supplementation, and possibly anticoagulant treatment.
• Consider enteral or parenteral feeding if symptoms are severe and refractory to treatment.
• Prescribe oral antiemetics starting with first-line options such as cyclizine, promethazine, prochlorperazine, chlorpromazine, or doxylamine/pyridoxine (Xonvea®), and reassess after 24-72 hours.
• If first-line treatment is ineffective, switch to second-line antiemetics like metoclopramide, domperidone, or ondansetron, with caution regarding duration and potential adverse effects.
• Provide advice on self-care measures including rest, avoiding sensory triggers, eating small frequent protein-rich meals, and drinking fluids little and often.
• Advise against the use of ginger for severe symptoms as it may worsen symptoms and delay effective treatment.
• Consider acupressure as an adjunct treatment.
• Monitor for complications and provide multidisciplinary support as needed, including dietitians, pharmacists, and mental health specialists.
• Reassure that mild-to-moderate symptoms are common and usually resolve by 16–20 weeks gestation, but severe cases require active management.

Urgent medical review is needed if there are signs of complications or alternative diagnoses.

For subsequent pregnancies, early use of lifestyle measures and antiemetic treatment at symptom onset may reduce severity.

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