Hyperemesis gravidarum: Difference between revisions
(Add MedicationDose SMW entries for pyridoxine, doxylamine, promethazine, metoclopramide, ondansetron; doses verified against ACOG guidelines) |
|||
| (47 intermediate revisions by 9 users not shown) | |||
| Line 1: | Line 1: | ||
<languages/> | |||
<translate> | |||
==Background== | ==Background== | ||
*Simple [[nausea and vomiting]] affects 60-80% of | |||
*Hyperemesis gravidarum | *Simple [[Special:MyLanguage/nausea and vomiting|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 has (rarely) been known to cause [[Special:MyLanguage/Wernicke's encephalopathy|Wernicke's encephalopathy]]<ref>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</ref><ref>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</ref> | |||
==Clinical Features== | ==Clinical Features== | ||
== | [[Special:MyLanguage/Pregnancy|Pregnancy]] with: | ||
*Nausea and vomiting | |||
*Weight loss | |||
*[[Special:MyLanguage/Hypovolemia|Volume depletion]] | |||
Note: [[Special:MyLanguage/Abdominal pain|Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis'' | |||
==Differential Diagnosis== | |||
</translate> | |||
{{NV in pregnancy DDX}} | |||
<translate> | |||
== | |||
*IVF (use | ==Evaluation== | ||
===Workup=== | |||
***If using ondansetron, have a discussion about claimed risks of birth defects, and | *[[Special:MyLanguage/Urinalysis|Urinalysis]] for ketones | ||
*Chemistry | |||
**May show signs of [[Special:MyLanguage/dehydration|dehydration]], [[Special:MyLanguage/hypokalemia|hypokalemia]] | |||
*CBC | |||
* | |||
* | |||
* | ==Diagnosis== | ||
** | |||
*Defined as intractable [[Special:MyLanguage/vomiting|vomiting]] with at least 1 of following: | |||
**Weight loss | |||
**[[Special:MyLanguage/Hypovolemia|Volume depletion]] | |||
**[[Special:MyLanguage/Hypokalemia|Hypokalemia]] | |||
**[[Special:MyLanguage/Ketonemia|Ketonemia]] | |||
''Note: [[Special:MyLanguage/Abdominal pain|Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis'' | |||
==Management== | |||
===Rehydration=== | |||
*[[Special:MyLanguage/oral rehydration therapy|PO fluids]] if able to tolerate | |||
*[[Special:MyLanguage/IVF|IV fluid repletion]] (use D5NS in the setting of ketonuria) | |||
===Antiemetics=== | |||
''ACOG recommends a stepwise approach to [[Special:MyLanguage/nausea and vomiting|nausea and vomiting]] in pregnancy<ref>Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 153. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 126(3):e12-24</ref>'' | |||
*[[Special:MyLanguage/Vitamin B6|Vitamin B6]] 10-25mg q6-8hrs | |||
*ADD [[Special:MyLanguage/Doxylamine|Doxylamine]] 12.5mg q6-8hrs | |||
*ADD [[Special:MyLanguage/Promethazine|Promethazine]] 12.5-25mg q4hrs PO or PR | |||
*ADD [[Special:MyLanguage/Dimenhydrinate|Dimenhydrinate]] 50mg q4-6hrs IV '''OR''' [[Special:MyLanguage/metoclopramide|metoclopramide]] 5-10mg q8hrs IV '''OR''' [[Special:MyLanguage/promethazine|promethazine]] 12.5-25mg q4hrs IV | |||
*ADD [[Special:MyLanguage/Methylprednisolone|Methylprednisolone]] 16mg q8hrs PO or IV for 3 days and taper to effective dose '''OR''' [[Special:MyLanguage/ondansteron|ondansteron]] 8mg (or 4mg) q12hrs IV | |||
**If using [[Special:MyLanguage/ondansetron|ondansetron]], reasonable to have a discussion about claimed risks of birth defects. | |||
**First-trimester exposure to [[Special:MyLanguage/ondansetron|ondansetron]] was not associated with cardiac or congenital malformations but was associated with a small increased risk of oral clefts.<ref>Fejzo MS, et al. Ondansetron in pregnancy and risk of adverse fetal outcomes in the United States. Reprod Toxicol. 2016 Jul;62:87-91.</ref> | |||
{| class="wikitable" | |||
| align="center" style="background:#f0f0f0;"|'''Medication''' | |||
| align="center" style="background:#f0f0f0;"|'''[[Special:MyLanguage/Drug ratings in pregnancy|Pregnancy Drug Class]]''' | |||
|- | |||
| [[Special:MyLanguage/Vitamin B6|Vitamin B6]]||A | |||
|- | |||
| [[Special:MyLanguage/Dimenhydrinate|Dimenhydrinate]]||B | |||
|- | |||
| [[Special:MyLanguage/Doxylamine|Doxylamine]]||A | |||
|- | |||
| [[Special:MyLanguage/Ondansetron|Ondansetron]]||B | |||
|- | |||
| [[Special:MyLanguage/Metoclopramide|Metoclopramide]]||B | |||
|- | |||
| [[Special:MyLanguage/Promethazine|Promethazine]]||C | |||
|} | |||
==Medication Dosing== | |||
===1st Line (ACOG Stepwise)=== | |||
*{{MedicationDose|drug=Pyridoxine|dose=10-25 mg q6-8hr|route=PO|context=1st line antiemetic (Vitamin B6)|indication=Hyperemesis gravidarum|population=Adult}} | |||
*{{MedicationDose|drug=Doxylamine|dose=12.5 mg q6-8hr|route=PO|context=1st line antiemetic (add to B6)|indication=Hyperemesis gravidarum|population=Adult}} | |||
===2nd Line=== | |||
*{{MedicationDose|drug=Promethazine|dose=12.5-25 mg q4hr|route=PO/PR/IV|context=2nd line antiemetic|indication=Hyperemesis gravidarum|population=Adult}} | |||
*{{MedicationDose|drug=Metoclopramide|dose=5-10 mg q8hr|route=IV|context=2nd line antiemetic|indication=Hyperemesis gravidarum|population=Adult}} | |||
===3rd Line=== | |||
*{{MedicationDose|drug=Ondansetron|dose=4-8 mg q12hr|route=IV|context=3rd line antiemetic|indication=Hyperemesis gravidarum|population=Adult|notes=Small increased risk of oral clefts in 1st trimester}} | |||
==Disposition== | ==Disposition== | ||
== | *Discharge if clear diagnosis and able to tolerate POs | ||
*Admit | |||
**Uncertain diagnosis | |||
**Intractable [[Special:MyLanguage/vomiting|vomiting]] | |||
**Persistent [[Special:MyLanguage/ketonemia|ketonemia]] or [[Special:MyLanguage/electrolyte abnormalities|electrolyte abnormalities]] after [[Special:MyLanguage/volume repletion|volume repletion]] | |||
**Weight loss >10% of pre-pregnancy weight | |||
==See Also== | |||
*[[Special:MyLanguage/Nausea and vomiting|Nausea and vomiting]] | |||
==External Links== | |||
==References== | |||
<references/> | <references/> | ||
[[Category: | |||
[[Category:OBGYN]] | |||
[[Category:GI]] | |||
</translate> | |||
Latest revision as of 17:56, 20 March 2026
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 (rarely) been known to cause Wernicke's encephalopathy[2][3]
Clinical Features
Pregnancy with:
- Nausea and vomiting
- Weight loss
- 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 for ketones
- Chemistry
- May show signs of dehydration, hypokalemia
- CBC
Diagnosis
- Defined as intractable vomiting with at least 1 of following:
- Weight loss
- Volume depletion
- Hypokalemia
- Ketonemia
Note: Abdominal pain is highly unusual and should prompt consideration of a different diagnosis
Management
Rehydration
- PO fluids if able to tolerate
- IV fluid repletion (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 | B |
| Metoclopramide | B |
| Promethazine | C |
Medication Dosing
1st Line (ACOG Stepwise)
- Pyridoxine 10-25 mg q6-8hr PO
- Doxylamine 12.5 mg q6-8hr PO
2nd Line
- Promethazine 12.5-25 mg q4hr PO/PR/IV
- Metoclopramide 5-10 mg q8hr IV
3rd Line
- Ondansetron 4-8 mg q12hr IV — Small increased risk of oral clefts in 1st trimester
Disposition
- Discharge if clear diagnosis and able to tolerate POs
- Admit
- Uncertain diagnosis
- Intractable vomiting
- Persistent ketonemia or electrolyte abnormalities after volume repletion
- Weight loss >10% of pre-pregnancy weight
See Also
External Links
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.