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

Work-Up

1. CBC
2. Chemistry
3. UA

DDx

• 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

Treatment

• IVF (use fluid containing 5% glucose to reverse ketonuria)
• Antiemetics
  • Ondansetron 8mg IV or 4mg PO TID
    • 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 25-50mg IV q4hr
• Alternative Medications
  • Ginger 1-1.5g PO divided BID-QID
  • Doxylamine succinate + pyridoxine hydrochloride (Diclegis)
  • B6 10-25 mg PO q6 hrs if B6 alone
  • 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