Hyperemesis gravidarum: Difference between revisions

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*Simple [[nausea and vomiting]] affects 60-80% of patients during first 12wk of pregnancy
*Simple [[nausea and vomiting]] affects 60-80% of patients during first 12wk of pregnancy
*Hyperemesis gravidarum only affects 0.3-2% of pregnancies<ref>Goodwin, TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am. 2008 Sep;35(3):401-17</ref>
*Hyperemesis gravidarum only affects 0.3-2% of pregnancies<ref>Goodwin, TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am. 2008 Sep;35(3):401-17</ref>
*Hyperemesis gravidarum has been known to cause [[Wernicke's encephalopathy]]<ref>Kantor S, Prakash S, Chandwani J, Gokhale A, Sarma K, Albahrani MJ. Wernicke's encephalopathy following hyperemesis gravidarum. Indian J Crit Care Med. 2014;18(3):164–166. doi:10.4103/0972-5229.128706</ref><ref>Kotha VK, De Souza A. Wernicke's encephalopathy following Hyperemesis gravidarum. A report of three cases. Neuroradiol J. 2013;26(1):35–40. doi:10.1177/197140091302600106</ref>
*Hyperemesis gravidarum has (rarely) been known to cause [[Wernicke's encephalopathy]]<ref>Kantor S, Prakash S, Chandwani J, Gokhale A, Sarma K, Albahrani MJ. Wernicke's encephalopathy following hyperemesis gravidarum. Indian J Crit Care Med. 2014;18(3):164–166. doi:10.4103/0972-5229.128706</ref><ref>Kotha VK, De Souza A. Wernicke's encephalopathy following Hyperemesis gravidarum. A report of three cases. Neuroradiol J. 2013;26(1):35–40. doi:10.1177/197140091302600106</ref>


==Clinical Features==
==Clinical Features==
*Persistent nausea and vomiting
*Defined as intractable [[vomiting]] with at least 1 of following:
*Signs of volume depletion
**Weight loss
*''Note: [[Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis''
**[[Hypovolemia|Volume depletion]]
**[[Hypokalemia]]
**[[Ketonemia]]
 
''Note: [[Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis''


==Differential Diagnosis==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
===Workup===
===Workup===
*[[Urinalysis]]
*[[Urinalysis]] for ketones
*Chemistry
**May show signs of [[dehydration]], [[hypokalemia]]
*CBC
*CBC
*Chemistry
===Diagnosis===
*Defined as intractable vomiting with at least 1 of following:
**Weight loss
**Volume depletion
**[[Hypokalemia]]
**Ketonemia


==Management==
==Management==
===Rehydration===
===Rehydration===
*PO fluids if able to tolerate
*[[oral rehydration therapy|PO fluids]] if able to tolerate
*IV fluid repleation (use D5NS in the setting of ketonuria)
*[[IVF|IV fluid repletion]] (use D5NS in the setting of ketonuria)


===Antiemetics===
===Antiemetics===
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| [[Doxylamine]]||A
| [[Doxylamine]]||A
|-
|-
| [[Ondansetron]]||C
| [[Ondansetron]]||B
|-
|-
| [[Metoclopramide]]||B
| [[Metoclopramide]]||B
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**Uncertain diagnosis
**Uncertain diagnosis
**Intractable [[vomiting]]
**Intractable [[vomiting]]
**Persistent ketonemia or [[electrolyte abnormalities]] after [[volume repletion]]
**Persistent [[ketonemia]] or [[electrolyte abnormalities]] after [[volume repletion]]
**Weight loss >10% of pre-pregnancy weight
**Weight loss >10% of pre-pregnancy weight



Revision as of 21:53, 12 January 2021

Background

Clinical Features

Note: Abdominal pain is highly unusual and should prompt consideration of a different diagnosis

Differential Diagnosis

Nausea and vomiting in pregnancy

Evaluation

Workup

Management

Rehydration

Antiemetics

ACOG recommends a stepwise approach to nausea and vomiting in pregnancy[4]

Medication Pregnancy Drug Class
Vitamin B6 A
Dimenhydrinate B
Doxylamine A
Ondansetron B
Metoclopramide B
Promethazine C

Disposition

References

  1. Goodwin, TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am. 2008 Sep;35(3):401-17
  2. Kantor S, Prakash S, Chandwani J, Gokhale A, Sarma K, Albahrani MJ. Wernicke's encephalopathy following hyperemesis gravidarum. Indian J Crit Care Med. 2014;18(3):164–166. doi:10.4103/0972-5229.128706
  3. Kotha VK, De Souza A. Wernicke's encephalopathy following Hyperemesis gravidarum. A report of three cases. Neuroradiol J. 2013;26(1):35–40. doi:10.1177/197140091302600106
  4. Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 153. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 126(3):e12-24
  5. Fejzo MS, et al. Ondansetron in pregnancy and risk of adverse fetal outcomes in the United States. Reprod Toxicol. 2016 Jul;62:87-91.