Hyperemesis gravidarum

Background

• Simple N/V 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
• Gestational trophoblastic disease also may present with intractable vomiting
• Thryotoxicosis also may present with intractable vomiting

Clinical Features

• Signs of volume depletion
• Abdominal pain is highly unusual and if present suggests a different diagnosis:

Work-Up

1. CBC
2. Chemistry
3. UA

DDx

1. Biliary disease
2. Ectopic pregnancy
3. Gastroenteritis
4. Pancreatitis
5. Appendicitis
6. Hepatitis
7. Peptic ulcer disease
8. Pyelonephritis
9. Fatty liver of pregnancy
10. HELLP syndrome

Treatment

1. IVF (use fluid containing 5% glucose to reverse ketonuria)
2. Antiemetics
   1. Zofran 8mg IV or 4mg PO TID
   2. Promethazine 25-50mg IV q4hr
3. Alternative Medications
   1. Ginger 1-1.5g PO BID-QID
   2. Diclegis
   3. Antihistamines (1st line tx Diphenhydramine, Meclizine, Dimenhydrinate)

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

Source

Tintinalli