Hyperemesis gravidarum

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

  • 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 B6A
DimenhydrinateB
DoxylamineA
OndansetronB
MetoclopramideB
PromethazineC

Disposition

  • Discharge if able to tolerate PO and ketonuria resolved
  • Admit

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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