Hyperemesis gravidarum

Background

• Simple nausea and vomiting affects 60-80% of patients 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

Nausea and vomiting in pregnancy

• Hyperemesis gravidarum
• Gastroenteritis
• Biliary disease
• Ectopic pregnancy
• Gastroenteritis
• Pancreatitis
• Appendicitis
• Hepatitis
• Peptic ulcer disease
• Pyelonephritis
• Acute fatty liver of pregnancy
• HELLP syndrome
• Gestational trophoblastic disease (may present with intractable vomiting)
  • Molar pregnancy
• Thyrotoxicosis (may present with intractable vomiting)

Evaluation

• H&P
• CBC
• Chemistry
• Urinalysis
• Consider TSH

Management

Antiemetics

ACOG recommends a stepwise approach to nausea and vomiting in pregnancy

• 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

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

Rehydration

• IVF
• Consider fluid with D5 in the setting of ketonuria

Disposition

• Discharge if ketonuria reversed and patient able to tolerate PO
• Admit if:
  • Uncertain diagnosis
  • Intractable vomiting
  • Persistent ketone or electrolyte abnormalities after volume repletion
  • Weight loss >10% of prepregnancy weight