Hyperemesis gravidarum: Difference between revisions
| Line 12: | Line 12: | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
===[[Nausea and vomiting in pregnancy]]=== | |||
*Gestational trophoblastic disease (may present with intractable vomiting) | *Gestational trophoblastic disease (may present with intractable vomiting) | ||
*[[Thyrotoxicosis]] (may present with intractable vomiting) | *[[Thyrotoxicosis]] (may present with intractable vomiting) | ||
| Line 24: | Line 25: | ||
*Fatty liver of pregnancy | *Fatty liver of pregnancy | ||
*[[HELLP syndrome]] | *[[HELLP syndrome]] | ||
**[[Biliary disease]], hepatic disease (e.g. fatty liver of pregnancy, [[HELLP syndrome]]) | |||
**[[Pancreatitis]] | |||
**[[Appendicitis]] | |||
**[[Hepatitis]] | |||
**[[Gastroenteritis]] | |||
**[[Pyelonephritis]] | |||
**[[Thyrotoxicosis]] | |||
==Evaluation== | ==Evaluation== | ||
Revision as of 14:28, 10 November 2016
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
- 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
- Biliary disease, hepatic disease (e.g. fatty liver of pregnancy, HELLP syndrome)
- Pancreatitis
- Appendicitis
- Hepatitis
- Gastroenteritis
- Pyelonephritis
- Thyrotoxicosis
Evaluation
- H&P
- CBC
- Chemistry
- Urinalysis
- Consider TSH
Management
Antiemetics
ACOG recommends a stepwise approach to nausea and vomiting 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
| 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
References
- ↑ Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 153. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 126(3):e12-24