What is the initial telemedicine protocol for a pregnant patient at approximately 10 weeks gestation experiencing nausea and vomiting?

Initial Telemedicine Protocol for Nausea and Vomiting at 10 Weeks Gestation

For a pregnant patient at 10 weeks gestation reporting nausea and vomiting via telemedicine, immediately assess symptom severity using the PUQE-24 score (asking about vomiting episodes, hours of nausea, and retching episodes over 24 hours), then initiate pharmacologic treatment with doxylamine-pyridoxine combination (Diclectin) as first-line therapy, or if unavailable, start vitamin B6 10-25 mg every 8 hours, escalating to metoclopramide 5-10 mg every 6-8 hours if symptoms are moderate-to-severe. 1

Immediate Telemedicine Assessment

Severity Scoring via Phone/Message

• Ask three specific questions to calculate the PUQE-24 score over the past 24 hours: 1, 2, 3
  • How many times have you vomited?
  • How many hours have you felt nauseated?
  • How many times have you had dry heaves/retching?
• Interpret the score: Mild (≤6), Moderate (7-12), Severe (≥13) 1, 4
• Ask about red flags requiring urgent in-person evaluation: 1
  • Signs of dehydration (dizziness when standing, decreased urination, dry mouth)
  • Inability to keep down any liquids for >24 hours
  • Weight loss >5% of pre-pregnancy weight
  • Severe abdominal pain or fever (to rule out other diagnoses)

Critical Caveat at 10 Weeks Gestation

• At exactly 10 weeks, you are at a critical decision point for ondansetron use - ACOG recommends case-by-case decision-making for ondansetron before 10 weeks due to small absolute risk increases in cleft palate (0.03% increase) and ventricular septal defects (0.3% increase), but after 10 weeks these concerns diminish significantly 1

Treatment Algorithm Based on PUQE-24 Score

Mild Symptoms (PUQE ≤6)

• Start with vitamin B6 (pyridoxine) 10-25 mg orally every 8 hours 1
• Provide dietary counseling: Small frequent meals, avoid triggers, ginger supplementation 1, 4
• Important safety limit: Keep total daily B6 dose ≤100 mg/day to avoid peripheral neuropathy 1
• Follow-up telemedicine check in 48-72 hours to reassess PUQE score 1

Moderate Symptoms (PUQE 7-12)

• Prescribe doxylamine-pyridoxine combination (Diclectin) as delayed-release tablets: doxylamine 10 mg + pyridoxine 10 mg 1
• If Diclectin unavailable or inadequate after 2-3 days, add metoclopramide 5-10 mg orally every 6-8 hours (3-4 times daily, not once daily) 1
• Metoclopramide is preferred over ondansetron at 10 weeks gestation because meta-analysis of 33,000 first-trimester exposures showed no significant increase in major congenital defects (OR 1.14,99% CI 0.93-1.38) 1
• Alternative if metoclopramide causes side effects: Promethazine as H1-receptor antagonist, safe throughout pregnancy 1

Severe Symptoms (PUQE ≥13) or Hyperemesis Gravidarum

• This requires urgent in-person or emergency evaluation - cannot be fully managed via telemedicine alone 1
• While arranging urgent visit, you can prescribe metoclopramide 10 mg every 6-8 hours and emphasize need for immediate evaluation 1
• Consider thiamine 100 mg daily supplementation immediately to prevent Wernicke encephalopathy with prolonged vomiting 1
• Patient needs assessment for: IV hydration, electrolyte replacement, ketonuria testing, and possible hospitalization 1, 5

Specific Medication Guidance for Telemedicine Prescribing

First-Line: Doxylamine-Pyridoxine

• Dose: Start with 2 tablets at bedtime, can increase to 4 tablets daily (1 morning, 1 afternoon, 2 bedtime) based on response 1
• This is ACOG's preferred first-line pharmacologic therapy 1

Second-Line: Metoclopramide

• Dose: 5-10 mg orally every 6-8 hours (give 3-4 times daily on schedule, not once daily or PRN only) 1
• Safety at 10 weeks: Excellent safety profile with no increased malformation risk 1
• Warn patient: Discontinue immediately if extrapyramidal symptoms develop (muscle spasms, restlessness, tremor) 1

Ondansetron Considerations at 10 Weeks

• Use ondansetron as second-line only if metoclopramide fails or is not tolerated 1
• At 10 weeks, the risk-benefit calculation shifts - you can use ondansetron more liberally than at 8 weeks, but metoclopramide remains preferred 1
• Dose if prescribed: 4-8 mg every 8 hours orally 1

Follow-Up Telemedicine Protocol

Reassessment Timing

• Mild symptoms: Repeat PUQE-24 score via telemedicine in 48-72 hours 1, 4
• Moderate symptoms on treatment: Check-in at 24-48 hours to assess response and adjust medications 1
• If no improvement or worsening: Arrange urgent in-person evaluation 1

Monitoring Questions for Follow-Up

• Repeat PUQE-24 score - looking for reduction of ≥3 points as clinically meaningful improvement 2, 3
• Ask about oral intake: Can she keep down liquids? Solids? 5
• Ask about medication side effects: Drowsiness with antihistamines, restlessness with metoclopramide 1
• Ask about urination frequency as proxy for hydration status 1

Red Flags Requiring Immediate In-Person Evaluation

• Cannot keep down any liquids for >24 hours despite treatment 1
• Orthostatic symptoms (dizziness, lightheadedness when standing) 1
• Decreased urination or dark urine 1
• PUQE score ≥13 or worsening despite initial treatment 1
• Fever, severe abdominal pain, or headache (rule out other diagnoses like thyroid storm, given that biochemical hyperthyroidism is common with hyperemesis) 6, 1

Documentation for Telemedicine Visit

• Record the specific PUQE-24 score (not just "moderate nausea") for objective tracking 2, 3
• Document gestational age precisely (10 weeks matters for ondansetron risk counseling) 1
• Note any prior treatments tried and their response 1
• Document red flag screening was performed 1