Nausea Vomiting and Hyperemesis Gravidarum

Nausea and vomiting of pregnancy are generally seen in the first 12 weeks. Both are extremely common, with nausea seen in 70 percent of patients and vomiting in 50 percent, and symptoms are mild in most. Hyperemesis gravidarum is intractable vomiting with weight loss and laboratory values that show hypokalemia or ketonemia. The cause is not known. Women who lose more than 5 percent of prepregnancy body weight have an increased risk of intrauterine growth restriction and low-birth-weight infants. Patients with GTD may also present with intractable vomiting.

The presence of abdominal pain in nausea and vomiting of pregnancy or hyperemesis gravidarum is highly unusual and should suggest another diagnosis. Occasionally, women with ruptured ectopic pregnancies present with nausea and vomiting as well as diarrhea and abdominal pain. After the first trimester, the volume of the gallbladder increases during fasting and postcontraction after a meal. Also, biliary sludge seems to increase in pregnancy in 30 percent, predisposing to stone formation.7 Cholelithiasis and cholecystitis are more common in pregnant women than in women of comparable age and health status who are not pregnant. Differential diagnosis of vomiting or vomiting with abdominal pain should include cholecystitis, cholelithiasis, gastroenteritis, pancreatitis, hepatitis, peptic ulcer, pyelonephritis, ectopic pregnancy, and fatty liver of pregnancy.

Findings upon physical examination are usually normal except for signs of volume depletion. Rectal examination should be performed to rule out fecal impaction and occult blood. A pelvic examination should be performed if there is pelvic pain, vaginal bleeding, or discharge.

If the examination reveals only loss of volume, laboratory tests to consider include CBC, serum electrolyte determinations, blood urea nitrogen (BUN) and creatinine determinations, and urinalysis. The finding of ketonuria is important, since it is an early sign of starvation. Serial measurement of urinary ketones can be used to determine success of therapy.

Treatment consists of intravenous fluids containing 5% glucose in either lactated Ringer's or normal saline solution to reverse dehydration and ketonuria. A number of antiemetic drugs can be used (T§ble..,..101-.1) for patients who remain nauseated or continue to vomit after fluid hydration. Initially, the patient should be given nothing by mouth. Oral fluids should be started after the nausea and vomiting are controlled and prior to discharge.

TABLE 101-1 Antiemetics

The patient may be discharged after reversal of ketonuria, correction of electrolyte imbalance, and a successful trial of oral fluids. Discharge with antiemetic medication is usually necessary. Admission guidelines include uncertain diagnosis, intractable vomiting, persistent ketone or electrolyte abnormalities after volume repletion, and weight loss over 10 percent of prepregnancy weight.

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