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]]
 
''Note: [[Abdominal pain]] is highly unusual and should prompt consideration of a different diagnosis''
 
==Differential Diagnosis==
{{NV in pregnancy DDX}}


==Clinical Features==
==Evaluation==
*Signs of volume depletion
===Workup===
*Abdominal pain is highly unusual and if present suggests a different diagnosis:
*[[Urinalysis]] for ketones
*Chemistry
**May show signs of [[dehydration]], [[hypokalemia]]
*CBC


==Work-Up==
==Management==
#CBC
===Rehydration===
#Chemistry
*[[oral rehydration therapy|PO fluids]] if able to tolerate
#UA
*[[IVF|IV fluid repletion]] (use D5NS in the setting of ketonuria)


==DDx==
===Antiemetics===
*Gestational trophoblastic disease (may present with intractable vomiting)
''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>''
*[[Thryotoxicosis]] (may present with intractable vomiting)
*[[Vitamin B6]] 10-25mg q6-8hrs
*[[Biliary disease]]
*ADD [[Doxylamine]] 12.5mg q6-8hrs
*[[Ectopic pregnancy]]
*ADD [[Promethazine]] 12.5-25mg q4hrs PO or PR
*[[Gastroenteritis]]
*ADD [[Dimenhydrinate]] 50mg q4-6hrs IV '''OR''' [[metoclopramide]] 5-10mg q8hrs IV '''OR''' [[promethazine]] 12.5-25mg q4hrs IV
*[[Pancreatitis]]
*ADD [[Methylprednisolone]] 16mg q8hrs PO or IV for 3 days and taper to effective dose '''OR''' [[ondansteron]] 8mg (or 4mg) q12hrs IV
*[[Appendicitis]]
**If using [[ondansetron]], reasonable to have a discussion about claimed risks of birth defects.
*[[Hepatitis]]
**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>
*[[Peptic ulcer disease]]
*[[Pyelonephritis]]
*Fatty liver of pregnancy
*[[HELLP syndrome]]


==Treatment==
{| class="wikitable"
#IVF (use fluid containing 5% glucose to reverse ketonuria)
| align="center" style="background:#f0f0f0;"|'''Medication'''
#Antiemetics
| align="center" style="background:#f0f0f0;"|'''[[Drug ratings in pregnancy|Pregnancy Drug Class]]'''
##[[Ondansetron]] 8mg IV or 4mg PO TID<ref>“Ondansetron Compared With Metoclopramide for Hyperemesis Gravidarum
|-
A Randomized Controlled Trial”
| [[Vitamin B6]]||A
http://www.ncbi.nlm.nih.gov/pubmed/24807340</ref>
|-
##[[Promethazine]] 25-50mg IV q4hr
| [[Dimenhydrinate]]||B
#Alternative Medications
|-
##Ginger 1-1.5g PO divided BID-QID
| [[Doxylamine]]||A
##Diclegis
|-
##[[Antihistamines]] (1st line tx Diphenhydramine, Meclizine, Dimenhydrinate)
| [[Ondansetron]]||C
|-
| [[Metoclopramide]]||B
|-
| [[Promethazine]]||C
|}


==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


==Source==
==References==
Tintinalli
<references/>
<references/>
[[Category:OB/GYN]]
 
[[Category:OBGYN]]
[[Category:GI]]

Revision as of 21:26, 29 September 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

Management

Rehydration

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.
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