Hyperemesis gravidarum
Background
- Simple nausea and vomiting affects 60-80% of pts during first 12wk of pregnancy
- Hyperemesis gravidarum defined as intractable vomiting with at least 1 of following:
- Wt loss
- Volume depletion
- Hypokalemia
- Ketonemia
Clinical Features
- Signs of volume depletion
- Abdominal pain is highly unusual and if present suggests a different diagnosis
Differential Diagnosis
- Gestational trophoblastic disease (may present with intractable vomiting)
- Thyrotoxicosis (may present with intractable vomiting)
- Biliary disease
- Ectopic pregnancy
- Gastroenteritis
- Pancreatitis
- Appendicitis
- Hepatitis
- Peptic ulcer disease
- Pyelonephritis
- Fatty liver of pregnancy
- HELLP syndrome
Diagnosis
- H&P
- CBC
- Chemistry
- UA
Management
Antiemetics
- ACOG recommends a stepwise approach to N/V in pregnancy[1]
- Vitamin B6 10-25mg q6-8hrs
- ADD Doxylamine 12.5mg q6-8hrs
- ADD Promethazine 12.5-25mg q4hrs PO or PR
- ADD Dimenhydrinate 50mg q4-6hrs IV OR Metoclopramide 5-10mg q8hrs IV OR Promethazine 12.5-25mg q4hrs IV
- ADD Methylprednisolone 16mg q8hrs PO or IV for 3 days and taper to effective dose OR ondansteron 8mg (or 4mg) q12hrs IV
- If using ondansetron, have a discussion about claimed risks of birth defects, and document this due to arising class action lawsuits
- Ondansetron is still class B (no proven risk to humans)
- Promethazine, class C
- Metoclopramide, class C
- Doxylamine, class B
- Vitamin B6, class A
- Dimenhydrinate, class B
Rehydration
- IVF
- Consider fluid with D5 in the setting of ketonuria
Disposition
- Discharge if ketonuria reversed and pt able to tolerate PO
- Admit if:
- Uncertain diagnosis
- Intractable vomiting
- Persistent ketone or electrolyte abnormalities after volume repletion
- Wt loss >10% of prepregnancy weight
References
- ↑ Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 52. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2004; 103:803-815