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
  2. ADD Doxylamine 12.5mg q6-8hrs
  3. ADD Promethazine 12.5-25mg q4hrs PO or PR
  4. ADD Dimenhydrinate 50mg q4-6hrs IV OR Metoclopramide 5-10mg q8hrs IV OR Promethazine 12.5-25mg q4hrs IV
  5. ADD Methylprednisolone 16mg q8hrs PO or IV for 3 days and taper to effective dose OR Ondansetron 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

1. Discharge if ketonuria reversed and pt able to tolerate PO
2. Admit if:
   1. Uncertain diagnosis
   2. Intractable vomiting
   3. Persistent ketone or electrolyte abnormalities after volume repletion
   4. Wt loss >10% of prepregnancy weight