•  A 23 year old primigravida is pregnant with twins at 11 weeks gestation. She is experiencing nausea and vomiting of moderate intensity that is worse in the morning. She has tried nonpharmacologic therapies with limited success. She has also tried drinking and eating small amounts at a time, and staying away from odors that make her feel nausea. Labs reveal a hypochloremic alkalosis.
  • Excessive vomiting during pregnancy is a serious form of normal early morning sickness (affects 50% of pregnant women)
    • persists past 16 weeks
  • Hyperemesis gravidum probably develops because of
    • oversensitivity of the vomiting center in the brain to the hormones produced during pregnancy including hCG, thyroid and GI hormones
    • but it may also be of psychological origin
  • More common in primigravida
  • Usually a first trimester phenomenon
  • Can be caused by a molar pregnancy
  • Symptoms
    • weight loss
    • dehydration
  • Labs
    • ketonemia
    • hypokalemia
    • classically metabolic hypochloremic alkalosis
  • Fluids
  • Electrolyte repletion
  • First line medication is Vitamin B6 (pyrodixine)
    • works well in conjunction with doxylamine
  • Second line medications are antihistamines (if refractory to lifestyle interventions)
    • diphenhydramine
    • meclizine
    • dimenhydrinate
  • Third line medications are additional antiemetics
    • metoclopramide
    • promethazine
    • ondansetron
  • In severe cases TPN may be necessary

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