Nausea and vomiting of pregnancy is generally seen in the first trimester. EM Mindset always starts with the "ruling out the life threats first", therefore we need to think of other life-threatening pathologies as well before labelling someone as "Simple Nausea and Vomiting of Pregnancy".
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Severe nausea and vomiting of pregnancy is
known as hyperemesis gravidarum and is defined as intractable vomiting
with weight loss >5%, volume depletion, and laboratory values showing
hypokalemia or ketonemia. Findings on physical examination in nausea and vomiting of pregnancy
are usually normal except for signs of volume depletion.
Physical exam is often normal in Nausea and Vomiting of pregnancy
The presence of abdominal pain in nausea and vomiting of pregnancy or hyperemesis gravidarum is very atypical and should prompt further work up.
Etiology
The exact mechanism remains unknown. One theory is that nausea and vomiting are protective in pregnancy as it reduces exposures to teratogenic materials while others believe that elevated human chorionic gonadotropin (hCG) or estradiol levels could be the cause.
Potential mimics
- Ectopic Pregnancy, Molar Pregnancy
- Appendicitis
- Cholecystitis/Hepatitis
- UTI (Pyelonephritis)
- DKA
- Pancreatitis
- Ovarian Torsion
- Pre-eclampsia
- Gastroenteritis
- Bowel Obstruction
- HELLP Syndrome
Management
- IV fluids containing 5% dextrose to replete volume and reverse ketonuria
- Antiemetic drugs
- Thiamine 100 mg (to avoid Wernicke’s encephalopathy)
- Oral fluids as and when possible
Serial measurements of urinary ketones can be used to determine success of therapy. With resolving ketonuria, correction
of dyselectrolytemia and able to keep up with oral fluids, patients can usually be discharged with oral anti-emetics.There is no clear drug
of choice. Options include Diphenhydramine, Ondansetron, Prochlorperazine, Phenothiazines, Doxylamine and
pyridoxine, Metocloperamide.
Steroids are used as last resort in patients who require parenteral nutrition due to weight loss. However, corticosteroids should be used with caution or possibly avoided before 10 weeks gestation as recent studies have linked oral clefts with methylprednisolone use in the first trimester.
Complications
- Wernicke’s encephalopathy
- Acute Renal Failure
- Central pontine myelinolysis
- Mallory-Weiss tear
- Pneumomediastinum
Admission Criteria
- Uncertain Diagnosis
- Any complications
- Unable to tolerate orally
- Persistent ketonuria or dyselectrolytemia
- Weight loss >10% prepregnancy weight.
References:
- Current Diagnosis and Treatment Emergency Medicine 7e, Chapter 38. Obstetric and Gynecological Emergencies and Rape. Ryan Tucker, MD; Melissa Platt, MD
- Goodwin TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am 2008;35(3):401–417 [PubMed: 18760227].
Posted by:
Lakshay Chanana
Speciality Doctor
Northwick Park Hospital
Department of Emergency Medicine
England
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