Updated: 1/28/2020

Hyperemesis Gravidum

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  • Snapshot
    • A 25-year-old primigravida is pregnant with twins at 11 weeks of gestation. She is experiencing daily 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 nauseous. Labs reveal a hypochloremic metabolic alkalosis.
  • Introduction
    • Overview
      • a severe form of morning sickness
      • excessive nausea/vomiting during pregnancy
      • typically during first 2-3 months of pregnancy but may persist throughout pregnancy
  • Epidemiology
    • Incidence
      • 0.3-6% of pregnancies
    • Demographics
      • higher rates in younger, primigravid women
      • increased prevalence in Western countries and urban areas
      • less common in Africa and Asia
    • Risk factors
      • history of motion sickness
      • history of migraines
      • history of nausea/vomiting from estrogen-based medications
      • women with heightened sense of smell or taste
      • multiple gestation
      • hydatidiform molar pregnancy
      • prior history of hyperemesis gravidarum
      • gastrointestinal disorders
        • acid reflux
  • ETIOLOGY
    • Pathogenesis
      • unclear etiology
      • potentially related to hormones such as hCG, estrogen, progesterone
      • possible genetic component
        • increased rate of hyperemesis gravidarum in women whose mothers and/or sisters also suffered from hyperemesis gravidarum
  • Presentation
    • Symptoms
      • daily nausea and vomiting
      • weight loss
      • dehydration
        • dizziness
        • reduced urination
      • symptoms may occur at any time of day despite name “morning sickness”
    • Physical exam
      • weight loss
        • >5% of pre-pregnancy weight
      • signs of dehydration
        • orthostatic hypotension
        • tachycardia
        • delayed capillary refill time
        • dry mucous membranes
        • decreased skin turgor
  • Studies
    • Comprehensive metabolic panel
      • hypokalemia
      • hypochloremic metabolic alkalosis
        • elevated serum bicarb
      • elevated serum blood urea nitrogen (BUN)
        • sign of hypovolemia and dehydration
      • abnormal liver enzymes
        • in 50% of hospitalized women with hyperemesis
    • Ketones
      • present in urine or serum
      • due to reduced nutritional intake and frequent emesis
    • Urine specific gravity
      • elevated due to dehydration
    • Hemoglobin/hematocrit
      • increased due to hemoconcentration from dehydration
  • Differential
    • Hydatidiform molar pregnancy
      • key distinguishing factors
        • “snowstorm” appearance on ultrasound
        • abnormally elevated β-hCG
    • Preeclampsia
      • key distinguishing factors
        • hypertension
        • proteinuria
    • HELLP syndrome
      • key distinguishing factors
        • hemolysis
        • low platelets
  • Treatment
    • Behavioral
      • lifestyle modifications
        • eat small meals/snacks often
          • eat as soon as hungry or even before feeling hungry
          • aim for high protein/carbohydrate foods that are low in fat
        • avoid spicy, greasy, or acidic foods
        • drink cold, clear beverages and drink between meals rather than during meals
        • avoid lying down right after eating
    • Medical
      • intravenous fluids
        • indications
          • hypovolemia/dehydration
        • modalities
          • bolus
            • up to 2L lactated ringers over 3-5 hours
            • can use normal saline if only mild symptoms of dehydration
          • maintenance fluids
            • D5 ½ normal saline with potassium
          • must also replace any low-level vitamins
            • thiamine, calcium, magnesium
      • anthistamine (H1 antagonists)
        • indications
          • first-line treatment for vomiting during pregnancy
        • modalities
          • doxylamine-pyridoxine
            • first-line
          • dimenhydrinate, meclizine, diphenhydramine
            • if doxylamine-pyridoxine ineffective
      • dopamine antagonists
        • indications
          • if continued vomiting after use of antihistamine
        • modalities
          • metoclopramide, promethazine, prochlorperazine
      • seratonin antagonists
        • indications
          • if continued vomiting after use of other first and second-line medications
          • small risk of fetal cardiovascular anomalies
        • modalities
          • ondansetron
      • acid-reducing agents
        • indications
          • used as adjuvant therapy with anti-emetics
        • modalities
          • antacids containing aluminum of calcium
          • H2-receptor antagonists
            • ranitidine, cimetidine
  • Complications
    • Dehydration
  • Prognosis
    • no harm to fetus
    • excellent prognosis if dehydration addressed

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