Hyperemesis gravidarum: Difference between revisions

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==Background==
==Background==
*Simple [[nausea and vomiting]] affects 60-80% of pts during first 12wk of pregnancy
*Simple [[nausea and vomiting]] affects 60-80% of patients during first 12wk of pregnancy
*Hyperemesis gravidarum defined as intractable vomiting with at least 1 of following:
*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>
**Wt loss
*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>
**Volume depletion
 
==Clinical Features==
*Defined as intractable [[vomiting]] with at least 1 of following:
**Weight loss
**[[Hypovolemia|Volume depletion]]
**[[Hypokalemia]]
**[[Hypokalemia]]
**Ketonemia
**[[Ketonemia]]


==Clinical Features==
''Note: [[Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis''
*Signs of volume depletion
*[[Abdominal pain]] is highly unusual and if present suggests a different diagnosis


==Differential Diagnosis==
==Differential Diagnosis==
*Gestational trophoblastic disease (may present with intractable vomiting)
{{NV in pregnancy DDX}}
*[[Thyrotoxicosis]] (may present with intractable vomiting)
*[[Biliary disease]]
*[[Ectopic pregnancy]]
*[[Gastroenteritis]]
*[[Pancreatitis]]
*[[Appendicitis]]
*[[Hepatitis]]
*[[Peptic ulcer disease]]
*[[Pyelonephritis]]
*Fatty liver of pregnancy
*[[HELLP syndrome]]


==Diagnosis==
==Evaluation==
*H&P
===Workup===
*[[Urinalysis]] for ketones
*Chemistry
**May show signs of dehydration, hypokalemia
*CBC
*CBC
*Chemistry
*UA


==Management==
==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 [[Metoclopramide]] 5-10mg q8hrs IV OR [[Promethazine]] 12.5-25mg q4hrs IV
*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]], have a discussion about claimed risks of birth defects, and document this due to arising class action lawsuits
**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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| [[Dimenhydrinate]]||B
| [[Dimenhydrinate]]||B
|-
|-
| [[Doxylamine]]||B
| [[Doxylamine]]||A
|-
|-
| [[Ondansetron]]||B
| [[Ondansetron]]||C
|-
|-
| [[Metoclopramide]]||C
| [[Metoclopramide]]||B
|-
|-
| [[Promethazine]]||C
| [[Promethazine]]||C
|}
|}
===Rehydration===
*IVF
*Consider fluid with D5 in the setting of ketonuria


==Disposition==
==Disposition==
*Discharge if ketonuria reversed and pt able to tolerate PO
*Discharge if able to tolerate PO and ketonuria resolved
*Admit if:
*Admit
**Uncertain diagnosis
**Uncertain diagnosis
**Intractable [[vomiting]]
**Intractable [[vomiting]]
**Persistent ketone or [[electrolyte abnormalities]] after [[volume repletion]]
**Persistent [[ketonemia]] or [[electrolyte abnormalities]] after [[volume repletion]]
**Wt loss >10% of prepregnancy weight
**Weight loss >10% of pre-pregnancy weight


==References==
==References==
<references/>
<references/>


[[Category:OB/GYN]]
[[Category:OBGYN]]
[[Category:GI]]
[[Category:GI]]

Revision as of 16:58, 25 August 2019

Background

Clinical Features

Note: Abdominal pain is highly unusual and should prompt consideration of a different diagnosis

Differential Diagnosis

Nausea and vomiting in pregnancy

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]

Medication Pregnancy Drug Class
Vitamin B6 A
Dimenhydrinate B
Doxylamine A
Ondansetron C
Metoclopramide B
Promethazine C

Disposition

References

  1. Goodwin, TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am. 2008 Sep;35(3):401-17
  2. 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
  3. 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
  4. Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 153. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2015; 126(3):e12-24
  5. Fejzo MS, et al. Ondansetron in pregnancy and risk of adverse fetal outcomes in the United States. Reprod Toxicol. 2016 Jul;62:87-91.