When should I consider referring a patient with hyperemesis gravidarum to a specialist?

Consider referring a patient with hyperemesis gravidarum to a specialist or for hospital admission if any of the following apply:

• The patient has persistent moderate-to-severe nausea and vomiting despite oral antiemetic treatment.
• There is suspected hyperemesis gravidarum that is not controlled with primary care management.
• The patient is unable to tolerate oral antiemetics or oral fluids.
• The patient cannot take other necessary oral medications, such as antibiotics or treatments for comorbidities.
• There is any co-morbidity combined with an inability to take medications.
• Clinical signs of dehydration are present.
• There is weight loss greater than 5% of body weight.
• There are concerns regarding the patient’s mental health.
• The Pregnancy-Unique Quantification of Emesis (PUQE) score is greater than 13.

Referral may involve multidisciplinary input including midwives, dietitians, pharmacists, endocrinologists, gastroenterologists, and mental health specialists, especially for severe or refractory cases.

Inpatient care may be necessary for severe symptoms not responding to outpatient or primary care, requiring interventions such as intravenous fluids, electrolyte replacement, antiemetics via non-oral routes, thiamine supplementation, anticoagulants, and possibly enteral or parenteral feeding.

Serial ultrasound scans should be offered if symptoms persist into late second or third trimester to monitor fetal growth.

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.