Adult ECAT protocol

Nausea and vomiting in pregnancy

A7.5 Published: December 2023. Updated: January 2024. Printed on 24 Dec 2024.

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Any person, 16 years and over, less than 20 weeks gestation, presenting with nausea and vomiting only.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

  • Presenting complaint
  • Onset of symptoms
  • Frequency of vomiting
  • Last menstrual period
  • Expected due date
  • Known multiple pregnancies
  • Pain assessment – PQRST
  • Pre-hospital treatment
  • Past admissions
  • Medical and surgical history, including  thyroid disease, gynaecological and obstetric history
  • Previous nausea and/or vomiting in pregnancy, or hyperemesis gravidarum
  • Current medications
  • Known allergies
  • Psychosocial impact of symptoms

Signs and symptoms

  • Dry mucosa
  • Nausea
  • Dry retching
  • Inability to tolerate food or fluids
  • Postural dizziness
  • Headache
  • Fatigue
  • Weight loss of 5% and over of pre-pregnancy weight

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

  • Diabetes mellitus
  • First presentation with nausea and vomiting in pregnancy

Clinical

  • Altered level of consciousness
  • Seizure
  • Tachypnoea
  • Signs of severe dehydration, e.g. tachycardia or hypotension
  • Chest pain or arrhythmia
  • Abdominal or epigastric pain
  • Severe headache or visual abnormalities
  • Haematemesis
  • Decreased urine output less than 80 ml/hr over 4 consecutive hours
  • Signs of pre-eclampsia, e.g. proteinuria or peripheral oedema
  • Fever
  • Muscle weakness and/or cramps

Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

AssessmentIntervention

General appearance/first impressions

Position of comfort

Airway

AssessmentIntervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

AssessmentIntervention

Respiratory rate and effort

Consider auscultation of chest (breath sounds)

Oxygen saturation (SpO2)

Assist ventilation as clinically indicated

Consider oxygen if dyspnoeic, titrate oxygen to maintain SpO2 over 93%

Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Circulation

AssessmentIntervention

Perfusion (capillary refill, skin warmth and colour)

Pulse

Blood pressure

Cardiac rhythm

Assess circulation

Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern

Pregnancy-Unique Quantification of Emesis and Nausea (PUQE-24)

Complete PUQE-24 assessment – see specific treatment section

IVC and/or pathology

Insert IV cannula, if trained and clinically indicated

If unable to obtain IV access, consider intraosseous, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

AssessmentIntervention
ACVPU

If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength

GCS, pupillary response and limb strength

Obtain baseline and repeat assessment as clinically indicated

Pain

Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

AssessmentIntervention
Temperature

Measure temperature

Skin inspection, including posterior surfaces

Check and document any abnormalities

Weight

Record weight. Weight loss over 5% is an indicator of clinical severity

Fluids

AssessmentIntervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited Commence fluid balance chart, as required
Nausea and/or vomiting See nausea and/or vomiting section

Glucose

Assessment Intervention
BGL

Measure BGL

If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria):

  • give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal
  • reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L

If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake:

  • give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access
  • give 10% glucose 200 mL by IV infusion over 15 minutes, once only
  • if delay in IV access, give glucagon 1 mg IM, once only
  • reassess BGL in 15 minutes

If the patient is unconscious or peri-arrest:

  • give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis
  • if delay in IV access, give glucagon 1 mg IM, once only
  • reassess BGL in 15 minutes

Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Complete dehydration focused assessment.

Precautions and notes

  • Nausea and vomiting are common in pregnancy. Mild symptoms do not require investigation or IV treatment.
  • Hyperemesis gravidarum is the most severe form of nausea and vomiting in pregnancy. Incidence increases with multiple gestation, gestational trophoblastic disease and triploidy.
  • Consider early IV fluids in those with uncontrolled vomiting or dehydration.
  • Abdominal pain is unusual in hyperemesis and should prompt consideration of other causes.
  • Pre-eclampsia exhibits signs and symptoms of SBP over 140 mmHg and DBP less than 90 mmHg, including proteinuria, excessive oedema, headache, visual abnormalities, abdominal pain, epigastric pain, chest pain and dyspnoea.
  • Delay in treatment in hyperemesis can cause intrauterine growth restriction.
  • Liaise with patient’s obstetrician, GP and/or midwife where appropriate. If they have not received antenatal care, ensure this is arranged before discharge.
  • Psychosocial screening should be considered in all females presenting with nausea and/or vomiting in pregnancy.

Interventions and diagnostics

Specific treatment

Rehydrate based on PUQE-24 score:

Drag the table right to view more columns or turn your phone to landscape

PUQE-24 scoring system
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)

Over 6 hours (5)

2. In the last 24 hours, how many times have you vomited or thrown up?

I did not throw up (1)

1–2 (2)

3–4 (3)

5–6 (4)

7 or more (5)

3. In the last 24 hours, how many times have you had retching or dry heaves without throwing up?

I did not throw up (1)

1–2 (2)

3–4 (3)

5–6 (4)

7 or more (5)

PUQE-24 score Rehydration based on PUQE-24 score

Mild (6 and less)

Give 0.5 mL/kg of oral rehydration solution, e.g. Hydralyte, or patient choice of fluid every 5 minutes

Moderate and severe (7 and over)

Give sodium chloride 0.9% 1000 mL IV over one hour, once only

Give antacid for acid suppression, Gastrogel or equivalent, 20 mL, orally, once only

Analgesia

If pain score 1–6 (mild–moderate): give paracetamol 1000 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.


Nausea and/or vomiting

If nausea and/or vomiting is present, give:

  • metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
  • or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
  • or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.


Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.


Pathology

  • Urinalysis: mid-stream (preferred), clean catch or catheter urine. If positive for nitrites and/or leucocytes send for MC&S. Keep sample refrigerated if transport delayed
  • Severe nausea and vomiting (PUQE-24 score over 13 or suspected hyperemesis gravidarum based on patient history): FBC, UEC, LFT, Ca/Mg/PO4
  • Thyroid testing results not available within a 3-month range or nausea and vomiting unresponsive to treatment): TSH

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Drag the table right to view more columns or turn your phone to landscape

Drug Dose Route Frequency

Antacid suspension (Gastrogel or equivalent) H, R

20 mL

Oral

Once only

1 mg

IM

Once only

200 mL

IV infusion over 15 minutes

Once only

Glucose 40% gel
(0.4 g/mL)

15 g

Buccal

Repeat after 15 minutes if required

50 mL

Slow IV injection

Once only

Metoclopramide R

Over 20 years:
10 mg

Oral/IV/IM

Once only

Ondansetron

4 mg

Maximum dose 8 mg

Oral/IV/IM

Repeat once if required after 60 minutes

Oral rehydration solution (Hydralyte)

0.5 mL/kg

Oral

Every 5 minutes

Oxygen

2–15 L/min, device dependent

Inhalation

Continuous

Paracetamol H

1000 mg

Oral

Pain score 1–10

Once only

5 mg

Oral

Once only

OR

12.5 mg

IV/IM

Once only

1000 mL over 60 minutes

IV

PUQE-24 over 7

Once only

Sodium chloride 0.9%

250 mL

Maximum dose 1000 mL

IV/intraosseous

Bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Medications with contraindications or requiring dose adjustment are marked:

  • H for patients with known hepatic impairment
  • R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

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Evidence informed

Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.

Collaboration

This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.

Currency Due for review: Jan 2026. Based on a regular review cycle.
Feedback Email ACI-ECIs@health.nsw.gov.au

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/nausea-and-vomiting-in-pregnancy

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