Hyperemesis gravidarum: Difference between revisions
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==Background== | ==Background== | ||
*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 defined as intractable vomiting with at least 1 of following: | *Hyperemesis gravidarum defined as intractable vomiting with at least 1 of following: | ||
** | **Weight loss | ||
**Volume depletion | **Volume depletion | ||
**[[Hypokalemia]] | **[[Hypokalemia]] | ||
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==Clinical Features== | ==Clinical Features== | ||
*Persistent nausea and vomiting | |||
*Signs of volume depletion | *Signs of volume depletion | ||
*[[Abdominal pain]] is highly unusual and | *Note: [[Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Evaluation== | ==Evaluation== | ||
* | *[[Urinalysis]] | ||
*CBC | *CBC | ||
*Chemistry | *Chemistry | ||
==Management== | ==Management== | ||
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===Rehydration=== | ===Rehydration=== | ||
* | *PO fluids if able to tolerate | ||
* | *IV fluids (consider fluid containing D5 in the setting of ketonuria) | ||
==Disposition== | ==Disposition== | ||
*Discharge if | *Discharge if able to tolerate PO and ketonuria resolved | ||
*Admit if: | *Admit if: | ||
**Uncertain diagnosis | **Uncertain diagnosis | ||
**Intractable [[vomiting]] | **Intractable [[vomiting]] | ||
**Persistent | **Persistent ketonemia or [[electrolyte abnormalities]] after [[volume repletion]] | ||
**Weight loss >10% of prepregnancy weight | **Weight loss >10% of prepregnancy weight | ||
Revision as of 07:31, 24 December 2016
Background
- Simple nausea and vomiting affects 60-80% of patients during first 12wk of pregnancy
- Hyperemesis gravidarum only affects 0.3-2% of pregnancies[1]
- Hyperemesis gravidarum defined as intractable vomiting with at least 1 of following:
- Weight loss
- Volume depletion
- Hypokalemia
- Ketonemia
Clinical Features
- Persistent nausea and vomiting
- Signs of volume depletion
- Note: Abdominal pain is highly unusual and should prompt consideration of 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)
- Thyrotoxicosis (may present with intractable vomiting)
Evaluation
- Urinalysis
- CBC
- Chemistry
Management
Antiemetics
ACOG recommends a stepwise approach to nausea and vomiting in pregnancy[2]
- 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
- PO fluids if able to tolerate
- IV fluids (consider fluid containing D5 in the setting of ketonuria)
Disposition
- Discharge if able to tolerate PO and ketonuria resolved
- Admit if:
- Uncertain diagnosis
- Intractable vomiting
- Persistent ketonemia or electrolyte abnormalities after volume repletion
- Weight loss >10% of prepregnancy weight