Guidelines for Treatment of Hyperemesis Gravidarum and Implementation in Clinical Practice in Norway: A Descriptive Study

Abstract

Background. The severe pregnancy complication hyperemesis gravidarum (HG) requires intravenous fluids, antiemetics, and nutrition to prevent maternal and fetal complications. Several guidelines exist for the treatment of HG within and across countries. The aim of this study was to investigate whether the guideline issued by the Norwegian Society for Obstetrics and Gynecology (NGF) was implemented in clinical practice by comparing department treatment protocols and assessing provided treatment. Methods. Department protocols for the treatment of HG were requested from all Norwegian gynecology departments and compared to the NGF guideline regarding the use of Pregnancy Unique Quantification of Emesis (PUQE-24) score, antiemetics, thiamine, and fluid and nutritional therapy. Additionally, we performed a retrospective chart review of provided treatment during 2017–2019 at four hospitals. Results. In all, 28 of 39 (72%) departments replied, of which 11 reported using the NGF guidelines unaltered. Of the 17 local department protocols in use, 16 closely resembled the NGF guidelines regarding the use of PUQE score, fluid therapy, nutritional treatment, and thiamine. Eight department protocols differed slightly from the NGF guidelines regarding the antiemetic medication treatment pathway, and two recommended antiemetic medication not supported by national or international guidelines. The retrospective chart review of 343 patients at four hospitals showed that the provided care aligned with the guidelines regarding intravenous fluids and the use of PUQE score, and the use of antiemetics mostly aligned with the treatment pathway provided in the NGF guideline. However, the proportion of patients receiving ondansetron varied between 32% and 79% and thiamine from 38 to 86% between hospitals. Overall, few patients were provided with nutritional treatment by partial peripheral nutrition (14%), enteral tube feeding (8%), or total parenteral nutrition (1.5%). Conclusion. The NGF guideline was used unaltered or largely integrated in department protocols. Treatment data suggest that the guideline was implemented in clinical practice, but differences in the provision of ondansetron and thiamine suggest geographical inequality of care. Infrequent use of nutritional treatment by parenteral nutrition or enteral feeding tube could suggest improvements in pharmacological symptom management or undertreatment of malnutrition.