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.
Urinary tract infection / pyelo
Gastroenteritis / peptic ulcer disease / Helicobacter
Surgical causes – think gallbladder, appendix
Endocrine – Thyrotoxic state, DKA,
Medications – Fe supps are common
Rare complications include – Wernicke’s encephalopathy, other neurological lesions (myelinolytic), ketoacidosis
Mental health problem are common – depression and anxiety.
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.