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Nausea and Vomiting in Pregnancy
Sponsored by The Indian Health Service Clinical Support Center
7. Hyperemesis gravidarum: What is helpful
Case Scenario
Mrs P is a 19 y/o G1P0 at 11 weeks by her dates who presents to the emergency department complaining of severe nausea and vomiting. She is wretching, appears ill, and is only able to produce a small amount of concentrated urine that is strongly positive for ketones.
Your initial management should include?
Severe Nausea and Vomiting of Pregnancy (Hyperemesis gravidarum)
The diagnosis of hyperemesis gravidarum is applied to the most severely affected patients, approximately 0.5 to 2 percent of pregnancies.
Hyperemesis gravidarum is intractable vomiting, not responsive to the above outpatient treatments. It is associated with dehydration, 4+ ketonuria, and/or electrolyte derangements, such that hospitalization for intravenous hydration is required.
- Admit.
- NPO; advance to sips and chips as tolerated.
- IV hydration, with
electrolyte replacement as indicated.
- Rule out other causes (cholecystitis/pancreatitis, pyelonephritis, hepatitis, etc…..)
- Many patients with hyperemesis will demonstrate biochemical evidence of a hyperthyroid state, but this is usually secondary to their high HCG levels. Treatment with anti-thyroid medications is usually not indicated, does not relieve nausea and vomiting, and may cause the patient, and the fetus, to become hypothyroid if continued beyond 18 weeks gestation.
- IV multivitamin replacement (especially thiamine 100 mg per liter, to prevent a Wernicke’s encephalopathy-like picture) if symptoms very severe and protracted.
- Any of the following parenteral anti-emetics:
- dimenhydrinate 50 mg in 50 mL NS q4-6h IV over 20 minutes
- metoclopramide 5-10 mg q8h IV
- promethazine 12.5-25 mg q4h IV
- dolasetron 4-8 mg over 15 minutes q12h IV
When the patient tolerates adequate oral intake, she may be considered for outpatient management. She may be sent home on the pharmacologic interventions recommended above for “Moderate Nausea and Vomiting of Pregnancy”.
Algorithm
Here is another helpful approach from Levichek Z et al 2002
QUESTION One of my patients suffers from a moderate-to-severe form of morning sickness. She responded only partially to doxylamine and pyridoxine, and I wish to try adding another medication. What should my priority be?
ANSWER
An algorithm used
by Motherisk
to manage thousands of patients takes a hierarchical approach
to this condition. This approach is evidence based with regard to fetal safety
as well as efficacy. (Go to ‘algorithm
used by Motherisk’
and scroll down page to see algorithm)
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