Hyperemesis Gravidarum

Question 1

When does N&V typically occur in pregnancy?

Answer 1

first trimester

• N&V starts around 4 - 7 weeks gestation
• symptoms are worse around 10 - 12 weeks
• symptoms resolve by 16 - 20 weeks
• the symptoms can persist throughout pregnancy

the peak of N&V is typically around 8-12 weeks gestation

Question 2

What causes N&V in pregnancy?

Answer 2

• production of hCG by the placenta
• higher levels of hCG result in worse symptoms

Question 3

What type of pregnancies present with more severe N&V?

Answer 3

• molar pregnancies
• multiple pregnancies
• this is due to higher hCG levels
• it also tends to be worse in a first pregnancy + overweight women

Question 4

What must be present in order for N&V of pregnancy to be diagnosed?

Answer 4

• it is diagnosed based on a typical history
• the N&V must START in the first trimester
• other causes should be excluded

Question 5

What is hyperemesis gravidarum?

Answer 5

prolonged / severe N&V during pregnancy

Question 6

What criteria must be present for hyperemesis gravidarum to be diagnosed?

Answer 6

there must be “protracted” N&V and:

• > 5% weight loss compared to before pregnancy

AND

• dehydration

AND

• electrolyte imbalance

Question 7

How is the severity of hyperemesis gravidarum assessed?

Answer 7

pregnancy-unique quantification of emesis (PUQE) score

Question 8

How is the PUQE score used to determine severity of hyperemesis gravidarum?

Answer 8

mild N&V:

• a score < 7

moderate N&V:

• a score of 7 - 12

severe N&V:

• a score of 13 or higher

PUQE score is scored out of 15

Question 9

What is the management for N&V?

Answer 9

antiemetics can suppress nausea

Question 10

What are the preferred antiemetics for use in pregnancy?

Answer 10

1. prochlorperazine
2. cyclizine
3. ondansetron
4. metoclopramide

Question 11

What additional medications may be given alongside antiemetics?

Answer 11

ranitidine or omeprazole

• used if there is concurrent problems with acid reflux

Question 12

What is different in the management for mild / moderate-to-severe cases of N&V?

Answer 12

• mild cases can be managed at home with oral antiemetics
• mod-to-severe cases may require ambulatory care / admission

Question 13

When may admission be considered for N&V?

Answer 13

• unable to tolerate oral antiemetics / keep down fluids
• > 5% weight loss compared with pre-pregnancy
• ketones in the urine

high ketones in the urine (++) is a sign of acidosis