Clinical Case 021: Pregnant and puking

Had an interesting case this week.  25 yo G3P2 presented after about 6 weeks amenorrhea with typical sxs of early pregnancy – breast tenderness, nausea and vomiting.  She had done a home urine HCG which was positive 3 days earlier.

Tonight she has come in with persistent vomiting, poor oral intake and feeling like crap.  Urinalysis showed 4+ ketones and SG = 1.030, no glucose.  But – here it the but – on questioning, she never really got any morning sickness with her 2 previous pregnancies.  So what is going on?  Is this “normal emesis gravidarum” or is there another cause?

I think we sometimes get a bit casual with this scenario – we all know how to manage the early pregnancy chucking, but we still need to consider the possible differentials before going down the well trodden treatment pathways.

Emesis / hyperemesis gravidarum – idiopathic

Urinary tract infection / pyelo

Gastroenteritis / peptic ulcer disease / Helicobacter

Surgical causes – think gallbladder, appendix

Endocrine – Thyrotoxic state, DKA,

Multiple gestation

Molar pregnancy

Medications – Fe supps are common

Transabdo Us = twin yolk sacs in the same GS

Dehydration is the big one – often requiring admsission for IV rehydration.

Rare complications include – Wernicke’s encephalopathy, other neurological lesions (myelinolytic), ketoacidosis

Mental health problem are common – depression and anxiety.

Well, a 2010 Cochrane review of the subject basically came up dry! They looked at acupressure, ginger, pyridoxine, antiemetics etc and saw no consistent benefit from any study or intervention.

So what do we do?

IV rehydration seems to help – usually when you have ketosis and objective evidence of dehydration

Antiemetics – metocloramide, promethazine

Steroids have been used

I like 5HT drugs – ondansetron – comes in a wafer, so women can use it at home and attempt to stay away from the hospital

Ginger can help, unlikely to harm.

Consider using thiamine supplemenation / multiB vitamins and watch out for low calcium – risk of later osteoporosis.

Nice review here on the topic. Surprisingly the babies of these poor women do well, there is an increased incidence of small-for-age, low birth weight and premature delivery. The miracle is that the outcomes are not worse given the sometimes severe and prolonged nutritional problems!

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