Hyperemesis Gravidarum

Definition/ Etiology:

Hyperemesis gravidarum is pregnancy-related severe nausea and vomiting that is persistent and results in >5% loss of pre-pregnancy weight.

• Interferes with work performance
• Interferes with daily functioning
• Causes anxiety / depression
• Can lead to termination of pregnancy and avoidance of future pregnancy

Risk factors:

• History of migraines
• History of nausea with estrogen medications
• History of motion sickness
• History of prior hyperemesis gravidarum
• Hydatidiform molar pregnancy

Pathophysiology:

Cause is not clearly understood, but may be related to:

• Hormonal changes (hCG, estrogen, progesterone)
• Abnormal gastric motility
• H. pylori
• Genetic predisposition

Clinical Presentation:

Generally:

• Starts in week 5-6
• Peaks in week 9
• Subsides in week 16-20 for most, but can continue throughout in a few patients

Scoring scales rate:

• Number of hours/day with nausea
• Episodes of vomiting/day
• Episodes of dry heaves/day

Collaborative Management:

Testing:

• Patient weight
• Confirm fetal heart tones
• Fetal ultrasound to rule out molar pregnancy and confirm number of fetuses
• CMP / amylase / lipase / Mag / Phos / TSH
• Urinalysis/ketones
• Orthostatic BP/pulse

Medications:

• Diphenhydramine or Meclazine
• Promethazine
• Ondansetron
• Gabapentin
• Antacids
• Crystalloids / banana bag

Evaluation | Patient Monitoring | Education:

• Cardiac monitoring due to potential for electrolyte disturbances
• PO challenge after treatment
• Use extra caution if patient is diabetic. Frequent glucose checks.
• Although rare, a Mallory-Weiss tear could occur from frequent vomiting.  Remain alert for coffee ground emesis or frank blood.
• Wernicke’s encephalopathy can occur from vitamin deficiency from hyperemesis.  Ataxia, eye movement disorder, and confusion are signs of this.

Mitigating:

• Encourage small, frequent snacks
• BRAT diet (bananas, rice, applesauce, toast)
• Discourage large meals
• Peppermint or ginger
• Vitamin B6
• Acupressure

Linchpins: (Key Points)

• Watch for electrolyte abnormalities.
• Monitor very carefully if diabetic.
• Small frequent meals, and small volume frequent fluids. 
• Mallory-Weiss tear can occur. Prenatal vitamins to avoid complications.