Hyperemesis Gravidarum

Question 1

23-year-old primigravida presents at 20 weeks with continued vomiting. How would you assess and manage?

Answer 1

Impression
N/V is a common presentation in pregnancy, occurs in 90% o pregnancies. The peak is at 9-11/50 weeks, most are resolved by 20 weeks gestation. I would consider HG as a potential diagnosis in this case, particularly if developed before 10/40 and persistent.

Hyperemesis gravidarum represents the severe end of the spectrum(<1% of patients). Main differentiating feature is >5% weight loss from pre-pregnancy weight.

HG is a diagnosis of exclusion so I would be concerned about other potential causes;

• Drugs
• CNS infections
• thyroid disease
• Intracranial: SOL,
• complications of vomiting: electrolyte derangements

Question 2

HG - Initial assessment

Answer 2

Initial assessment:
would keep in mind the potential for electrolyte derangements and hypovolaemia from fluid loss in the setting of non-remitting vomiting, and thus would start with A to E approach to ensure HD stability, and initiate any stabilising measures
A
B
C - BP monitoring, ECG, IVC, VBG, FBC, UEC, LFT, administer fluids, address any electrolyte derangements
E
F - fetus: CTG, antenatal assessment

Question 3

HG - History

Answer 3

History

• sx: Pattern of nausea, fluid intake and diet, weight loss, any current management
• RISK: history of hyperemesis, multiple pregnancies, molar pregnancy, pre-eclampsia
• REDFLAGS: fever, weight loss, abdominal pain, PV bleeding/discharge, CNS derangements, seizures
• O&G Hx: GTPAL, Yellow book, Scans to date and results, vaccinations, other obstetric complications
• PMHx, FamHx, PSHx
• Medications, allergies
• SNAP, psychosocial

Question 4

HG - Examination

Answer 4

Examination

• General appearance + vitals + anthropometric measurements
• Fluid balance assessment: HR, skin turgor, MM, BP, output, input, serial weights, etc
• antenatal assessment (FHR, etc)
• other: Pregnancy Unique Quantification of Emesis score

Question 5

HG - Investigations

Answer 5

Investigations

• Bedside: UA, VBG @POC
• Bloods: FBC, LFT, lipase, TSH,
• Imaging: abdo US for fetal development (or as per normal screening regimen)

Question 6

HG - Management

Answer 6

Management
Consider admission if any signs of significant hypovolaemia/HD instability, or unable to tolerate POs.

Supportive:

• correct any electrolyte derangements
• IV fluids (1L stat)
• manage hypokalaemia
• manage any nutritional
• specific hyperemesis diet: small regular meals, increased protein, reduced carbs and fats

Definitive:

• anti-emetic (Doxylamine - Metoclopramide - Ondansetron)
• MDT
• Admit if orals are not tolerated