Hyperemesis gravidarum: Difference between revisions
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*Simple [[nausea and vomiting]] affects 60-80% of patients during first 12wk of pregnancy | *Simple [[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 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 [[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== | ||
* | *Defined as intractable [[vomiting]] with at least 1 of following: | ||
* | **Weight loss | ||
*Note: [[Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis | **[[Hypovolemia|Volume depletion]] | ||
**[[Hypokalemia]] | |||
**[[Ketonemia]] | |||
''Note: [[Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis'' | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 13: | Line 18: | ||
==Evaluation== | ==Evaluation== | ||
===Workup=== | ===Workup=== | ||
*[[Urinalysis]] | *[[Urinalysis]] for ketones | ||
*Chemistry | |||
**May show signs of dehydration, hypokalemia | |||
*CBC | *CBC | ||
=== | ==Management== | ||
===Rehydration=== | |||
* | *PO fluids if able to tolerate | ||
* | *IV fluid repletion (use D5NS in the setting of ketonuria) | ||
===Antiemetics=== | ===Antiemetics=== | ||
''ACOG recommends a stepwise approach to [[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>'' | ''ACOG recommends a stepwise approach to [[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>'' | ||
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*ADD [[Doxylamine]] 12.5mg q6-8hrs | *ADD [[Doxylamine]] 12.5mg q6-8hrs | ||
*ADD [[Promethazine]] 12.5-25mg q4hrs PO or PR | *ADD [[Promethazine]] 12.5-25mg q4hrs PO or PR | ||
*ADD [[Dimenhydrinate]] 50mg q4-6hrs IV '''OR''' [[ | *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 | *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 | **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.<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" | {| class="wikitable" | ||
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| [[Promethazine]]||C | | [[Promethazine]]||C | ||
|} | |} | ||
==Disposition== | ==Disposition== | ||
*Discharge if able to tolerate PO and ketonuria resolved | *Discharge if able to tolerate PO and ketonuria resolved | ||
*Admit | |||
**Uncertain diagnosis | |||
*Uncertain diagnosis | **Intractable [[vomiting]] | ||
*Intractable [[vomiting]] | **Persistent [[ketonemia]] or [[electrolyte abnormalities]] after [[volume repletion]] | ||
*Persistent ketonemia or [[electrolyte abnormalities]] after [[volume repletion]] | **Weight loss >10% of pre-pregnancy weight | ||
*Weight loss >10% of pre-pregnancy weight | |||
==References== | ==References== | ||
Revision as of 16:58, 25 August 2019
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
- 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
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
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 | 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.