Hyperemesis Gravidarum

Clinical:

Intractable vomiting of pregnancy with:

• Weight loss > 5%
• Ketonuria
• Hypokalemia
• Volume depletion

Work-up and Management:

Labs

• UA, Upreg → for ketonuria
• Chem7, Mg → for hypochloremic, hypokalemic metabolic alkalosis

Medical Management

• Lifestyle modifications → avoid triggers + small meals + ginger ale
• B6 + Doxylamine aka Diclegis
• D5NS with low threshold to add thiamine to avoid Wernicke’s
• Promethazine v. Reglan v. Zofran if refractory

Risk Management Strategies/ Pitfalls:

• Hyperemesis gravidarum and morning sickness should be a diagnosis of exclusion in the pregnant vomiting patient.
• Abdominal pain is highly unusual and should prompt a broad differential. Don’t forget about surgical etiologies like appendicitis and ovarian torsion
• Broaden the differential diagnosis when there is increase in vomiting at 9+ weeks

References:

Goodwin TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am 2008;35(3):401–417 [PubMed: 18760227].