Hyperemesis gravidarum
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 has been known to cause Wernicke's encephalopathy[2][3]
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
Workup
- Urinalysis
- CBC
- Chemistry
Diagnosis
- Defined as intractable vomiting with at least 1 of following:
- Weight loss
- Volume depletion
- Hypokalemia
- Ketonemia
Management
Rehydration
- PO fluids if able to tolerate
- IV fluid repleation (use D5NS in the setting of ketonuria)
Antiemetics
ACOG recommends a stepwise approach to nausea and vomiting in pregnancy[4]
- 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, reasonable to have a discussion about claimed risks of birth defects.
- First-trimester exposure to ondansetron was not associated with cardiac or congenital malformations but was associated with a small increased risk of oral clefts.[5]
| Medication | Pregnancy Drug Class |
| Vitamin B6 | A |
| Dimenhydrinate | B |
| Doxylamine | A |
| Ondansetron | C |
| Metoclopramide | B |
| Promethazine | C |
Disposition
- Discharge if able to tolerate PO and ketonuria resolved
- Admit
- Uncertain diagnosis
- Intractable vomiting
- Persistent ketonemia or electrolyte abnormalities after volume repletion
- Weight loss >10% of pre-pregnancy weight
References
- ↑ Goodwin, TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am. 2008 Sep;35(3):401-17
- ↑ Kantor S, Prakash S, Chandwani J, Gokhale A, Sarma K, Albahrani MJ. Wernicke's encephalopathy following hyperemesis gravidarum. Indian J Crit Care Med. 2014;18(3):164–166. doi:10.4103/0972-5229.128706
- ↑ Kotha VK, De Souza A. Wernicke's encephalopathy following Hyperemesis gravidarum. A report of three cases. Neuroradiol J. 2013;26(1):35–40. doi:10.1177/197140091302600106
- ↑ Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 153. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 126(3):e12-24
- ↑ Fejzo MS, et al. Ondansetron in pregnancy and risk of adverse fetal outcomes in the United States. Reprod Toxicol. 2016 Jul;62:87-91.