What is the telemedicine protocol for managing nausea and vomiting in a pregnant patient?

Telemedicine Protocol for Nausea and Vomiting in Pregnancy

Initial Assessment via Telemedicine

Use the PUQE-24 (Pregnancy-Unique Quantification of Emesis) score to objectively quantify symptom severity over the past 24 hours, which assesses number of vomiting episodes, retching episodes, and hours of nausea, with scores ranging from 3 (no symptoms) to 15 (most severe). 1, 2, 3

• Mild symptoms: PUQE score ≤6 1, 2
• Moderate symptoms: PUQE score 7-12 1, 2
• Severe symptoms: PUQE score ≥13 1, 2

Ask specifically about:

• Weight loss (calculate percentage from prepregnancy weight) 2, 4
• Ability to keep down liquids for the past 24 hours 1
• Urination frequency and urine color (dark urine suggests dehydration) 1
• Orthostatic symptoms (dizziness when standing) 1
• Fever, severe abdominal pain, or severe headache 1
• Current gestational age 1, 2

Red Flags Requiring Immediate In-Person Evaluation

Any patient meeting the following criteria cannot be managed via telemedicine and requires immediate in-person or emergency department evaluation:

• Unable to keep down any liquids for >24 hours despite treatment 1
• Weight loss ≥5% of prepregnancy weight 2, 4
• PUQE score ≥13 or worsening despite initial treatment 1, 2
• Orthostatic symptoms, decreased urination, or dark urine 1
• Fever, severe abdominal pain, or severe headache (rule out other diagnoses) 1
• Signs of dehydration or ketonuria 2, 4

Treatment Algorithm by Gestational Age and Severity

For All Gestational Ages with Mild Symptoms (PUQE ≤6)

Start with vitamin B6 (pyridoxine) 10-25 mg orally every 8 hours combined with dietary modifications. 1, 2, 5

Dietary recommendations to prescribe:

• Small, frequent meals (every 2-3 hours) 5
• BRAT diet (bananas, rice, applesauce, toast) 5
• High-protein, low-fat meals 5
• Avoid spicy, fatty, acidic, and fried foods 5

For Moderate Symptoms (PUQE 7-12) at Any Gestational Age

Prescribe doxylamine-pyridoxine combination (Diclegis/Diclectin) as first-line pharmacologic therapy, starting with 2 tablets at bedtime (each tablet contains doxylamine 10 mg + pyridoxine 10 mg). 1, 2, 6

Dosing escalation protocol based on FDA-approved regimen 6:

• Day 1: 2 tablets at bedtime
• Day 2-3: If symptoms persist into afternoon, continue 2 tablets at bedtime
• Day 3 onward: If symptoms persist, escalate to 1 tablet in morning + 2 tablets at bedtime (3 tablets total)
• Day 4 assessment: If symptoms still present, escalate to maximum dose of 1 tablet in morning + 1 tablet mid-afternoon + 2 tablets at bedtime (4 tablets total)

For Moderate Symptoms Not Responding to Doxylamine-Pyridoxine

Add metoclopramide 5-10 mg orally every 6-8 hours as the preferred second-line agent, as 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, 2, 7

Ondansetron Use Based on Gestational Age

Before 10 weeks gestation: Use ondansetron cautiously due to small absolute risk increases: cleft palate (0.03% increase from 11 to 14 per 10,000 births) and ventricular septal defects (0.3% increase). 2, 5

At or after 10 weeks gestation: Ondansetron 4-8 mg every 8 hours can be used more liberally, though metoclopramide remains preferred. 1, 2

Critical Thiamine Supplementation

Start thiamine 100 mg daily immediately if vomiting has been persistent for more than 1-2 weeks, as thiamine stores can be exhausted after only 20 days of persistent vomiting, and depletion can lead to Wernicke encephalopathy. 1, 2, 8

Follow-Up Schedule via Telemedicine

Reassess PUQE score every 1-2 weeks during the acute phase to track treatment response. 2

• Monitor weight at each virtual visit—stabilization or gain (not continued loss) indicates clinical improvement 2
• If symptoms worsen or red flags develop, immediately refer for in-person evaluation 1, 2
• Most cases resolve by week 16-20 (80% of patients), though 10% experience symptoms throughout pregnancy 2

When to Escalate Beyond Telemedicine

Admit for intravenous therapy if any of the following occur:

• Persistent vomiting despite oral antiemetics 2
• Weight loss ≥5% of prepregnancy weight 2, 4
• Ketonuria with dehydration 2, 4
• Electrolyte abnormalities 2, 4
• Inability to tolerate oral intake for >24 hours 2

Common Pitfalls to Avoid

Do not delay pharmacologic treatment waiting for dietary modifications alone, as this allows symptoms to worsen and increases risk of progression to hyperemesis gravidarum (which affects 0.3-10.8% of pregnancies and can lead to severe complications including Wernicke encephalopathy). 5, 7, 8

Do not withhold doxylamine-pyridoxine due to teratogenicity concerns—it is FDA-approved for pregnancy and has extensive safety data. 2, 6, 4

Do not forget thiamine supplementation in patients with prolonged vomiting (>1-2 weeks), as Wernicke encephalopathy can develop rapidly and is potentially fatal. 1, 2, 8