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Hyperemesis gravidarum
From WikEM
Contents
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]
Clinical Features
- Persistent nausea and vomiting
- Signs of 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
- Fatty liver of pregnancy
- HELLP syndrome
- Gestational trophoblastic disease (may present with intractable vomiting)
- Thyrotoxicosis (may present with intractable vomiting)
- Molar pregnancy
Evaluation
Workup
- Urinalysis
- CBC
- Chemistry
Diagnosis
Defined as intractable vomiting with at least 1 of following:
- Weight loss
- Volume depletion
- Hypokalemia
- Ketonemia
Management
Antiemetics
ACOG recommends a stepwise approach to nausea and vomiting in pregnancy[2]
- 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
- Newer data indicates that ondansetron is not the cause of birth defects[3]
| Medication | Pregnancy Drug Class |
| Vitamin B6 | A |
| Dimenhydrinate | B |
| Doxylamine | B |
| Ondansetron | B |
| Metoclopramide | C |
| Promethazine | C |
Rehydration
- PO fluids if able to tolerate
- IV fluids (use fluid containing D5 in the setting of ketonuria)
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
- ↑ 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.
