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Hyperemesis GravidarumAka: Antiemetic in Pregnancy

See Also
1. Morning Sickness
Definition
1. Severe form of Vomiting in Pregnancy
Epidemiology
1. Incidence: 1 per 200 pregnancies
Pathophysiology
1. Helicobacter Pylori may be causal factor in some cases
History
1. Intractable Vomiting causing
  1. Ketonuria (Acetonuria)
  2. Weight loss
  3. Dehydration
  4. Electrolyte disturbance
2. Occurs in first trimester
3. Peak Incidence at 10-12 weeks
4. Often worse in morning
5. Quantify Vomiting
6. Establish inability to tolerate oral fluids
7. Urinary symptoms
  1. Decreased Urine Output
  2. Dysuria
  3. Flank pain
Signs
1. Weight loss, or no weight gain
2. Tachycardia
3. Dry mucus membranes
4. Poor skin turgor
5. Fever
6. Uterine Size
7. External Fetal heart tone monitoring
Differential Diagnosis
1. Gastrointestinal causes
  1. Peptic Ulcer Disease
  2. Cholecystitis
  3. Pancreatitis
  4. Bowel Obstruction
  5. Volvulus
  6. Appendicitis
2. Genitourinary causes
  1. Pyelonephritis
  2. Nephrolithiasis
  3. Ovarian torsion
3. Endocrine causes
  1. Diabetes Mellitus
  2. Hyperthyroidism
4. Neurologic causes
5. Miscellaneous conditions
Associated conditions
1. Molar Pregnancy
2. Multiple Gestation
3. Down Syndrome (affecting fetus)
4. Hydrops fetalis
Labs
1. Chemistry Panel (Chem7)
2. Complete Blood Count
3. Urinalysis
  1. Ketonuria (or Ketonemia)
4. Urine Culture
5. Thyroid Function Test
  1. Free T4
  2. Thyroid Stimulating Hormone (TSH)
6. Quantitative bhCG
7. Liver Function Test
Radiology
1. Ultrasound Pelvis
2. Ultrasound Right Upper Quadrant
  1. Gallbladder and Pancreas
Management: First Line
1. Dietitian consultation
2. See Morning Sickness
3. Phosphorated Carbohydrates (Emetrol)
  1. Dose prn: 15-30 ml PO q15 minutes prn
  2. Scheduled dosing: 15-30 ml PO qAM and q3h
4. Combination Regimen
  1. Contents
    1. Doxylamine (Unisom) 10 to 12.5 mg PO qd to bid
    2. Pyridoxine (B6) 25 mg PO q6-8 hours
  2. Preparations
    1. Diclectin (10 mg B6, 10 mg doxylamine): Canada
5. Doxylamine (Unisom)
  1. Dose: 50 mg PO qhs prn Sedation
  2. Also see combination regimen below
6. Other measures that may be helpful
  1. Pyridoxine (B6) 25 mg PO q6-8 hours
  2. Multivitamin (MVI-12)
    1. Dose: 1 IV or PO qd
  3. Metamucil
    1. Dose: 1 gram PO qid (1 tsp in fluid PO qd-tid)
  4. Thiamine
    1. Dose: 100 mg IM x 1 dose
Management: Antiemetics (Take 1/2 hour prior to meals)
1. Tigan
  1. Suppository: 200 mg PR tid
2. Prochlorperazine (Compazine)
  1. Parenteral and oral: 5-10 mg IM/IV/PO q4-6 hours
  2. Suppository: 25 mg PR q6-8 hours
3. Vistaril
  1. Dose: 25-50 mg IM/PO q4-6 hours
4. Phenergan
  1. Dose: 12.5-25 mg PO/PR q4-6 hours
  2. Maximum: 100 mg in 24 hours
5. Meclizine (Antivert)
  1. Oral: 25-50 mg PO q6 hours
  2. Consider using concurrently with Phenergan
6. Diphenhydramine (Benadryl)
  1. Dose: 25-50 mg IM/IV/PO q4-6 hours
  2. Maximum: 400 mg in 24 hours
7. Metoclopramide (Reglan)
  1. Dose: 10 mg PO qid or 1-2 mg IV
8. Corticosteroid regimen for refractory hyperemesis
  1. Methylprednisolone 16 mg PO tid, taper over 2 weeks
  2. Risk of Cleft Palate with first trimester use
  3. Safari (1998) Am J Obstet Gynecol 179:921
9. Antiemetics to avoid due to lack of safety data
  1. Avoid Ondansetron
  2. Avoid Droperidol
Admission Guidelines
1. Follow daily weights
2. Follow Input and Output
3. Follow Urine Ketones q8h
4. Intravenous fluid management
  1. First: Normal Saline 1-4 liters over 1-4 hours
  2. Next: D5LR with 20 KCl at 150-175 until no ketones
References

Obstetrics Book

Antepartum Disorders

http://www.fpnotebook.com/

Hyperemesis GravidarumAka: Antiemetic in Pregnancy

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