How should I manage a patient presenting with hyperemesis gravidarum in early pregnancy?

Management of hyperemesis gravidarum in early pregnancy involves a stepwise approach starting with supportive care and progressing to pharmacological and possibly inpatient treatment if needed.

• Offer reassurance and advice on sources of information and support, such as NHS leaflets, RCOG materials, and pregnancy sickness support charities.
• Advise self-care measures including rest, avoiding sensory triggers (odours, heat, noise), eating small frequent protein-rich meals low in carbohydrate and fat, and drinking fluids little and often.
• Consider acupressure as an adjunct treatment.
• If symptoms are mild to moderate and the woman is not dehydrated, manage in the community with support, reassurance, antiemetics, oral rehydration, and dietetic advice.
• If symptoms persist or are severe (e.g., inability to tolerate oral intake, dehydration, weight loss >5%, or mental health concerns), consider outpatient or inpatient care.
• Inpatient management may include intravenous fluids, electrolyte replacement, thiamine supplementation, antiemetics via various routes (IV, rectal, subcutaneous, intramuscular), anticoagulant treatment, and enteral or parenteral feeding if necessary.
• Pharmacological treatment should start with oral antiemetics such as cyclizine, promethazine, prochlorperazine, chlorpromazine, or doxylamine/pyridoxine (Xonvea®), reassessing 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.
• Consider combination antiemetic therapy if single agents are insufficient.
• Women with severe symptoms may require multidisciplinary team input including midwives, dietitians, pharmacists, and mental health specialists.

Monitor fetal growth with serial ultrasounds if symptoms persist into late second or third trimester.

Advise urgent medical review if complications or alternative diagnoses are suspected.

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

Note: Avoid recommending ginger for hyperemesis gravidarum as it may worsen symptoms and delay effective treatment.

All management steps should be tailored to the woman's preferences and clinical response.

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