Hyperemesis Gravidarum

Question 1

Define hyperemesis gravidarum

Answer 1

Persistent and severe vomiting during pregnancy, which leads to

TRIAD = >5% weight loss, dehydration and electrolyte imbalances

Question 2

Outline the pathophysiology of hyperemesis gravidarum

Answer 2

It is thought to be due rapidly increasing levels of beta human chorionic gonadotrophin (hCG) hormone, which is released by the placenta.

High hCG stimulates the chemoreceptor trigger zone in the brainstem, which feeds into the vomiting centre of the brain.

Question 3

How is nausea and vomiting in pregnancy assessed?

Answer 3

Classify the severity =

Pregnancy-Unique Quantification of Emesis (PUQE) score =

• 6 correlates to mild NVP
• 7-12 moderate
• 13-15 severe

Question 4

Outline a Hx for hyperemesis gravidarum

Answer 4

Age, parity and gestation

HPC

• Duration N+V
• Frequency of vomiting
• Oral intake
• Weight loss
• Urinary symptoms
• Bowel habit

PMH

• History of HG: current and previous pregnancies
• Previous admissions for HG
• Thyroid disease

DH
- Anti-emetics used

Question 5

Outline an examination for hyperemesis gravidarum

Answer 5

Observations

• Temperature
• Pulse
• Blood pressure
• Respiratory rate
• Oxygen saturations

Clinical examination

• Signs of dehydration: dry mucous membranes, increased skin turgor
• Signs of muscle wasting
• Abdo examination
• Other examination guided by history

Question 6

Give a DDx for N+V

Answer 6

• Gastroenteritis
• Cholecystitis
• Hepatitis
• Pancreatitis
• Chronic H. Pylori infection
• Peptic ulcers
• UTI or pyelonephritis
• Metabolic conditions
• Neurological conditions
• Drug-induced

Question 7

How should hyperemesis gravidarum be investigated?

Answer 7

Bedside =

• weight
• dipstick (marked ketonuria, UTI)
• PT

Lab

• MSU
• FBC, U+E, glucose, LFT, amylase, TFT, ABG

USS - exclude multiple preg/GTD

Question 8

How should hyperemesis gravidarum be managed correctly?

Answer 8

Mild = community, oral anti-emetics CYCLIZINE (1st line in preg), oral hydration
- Metoclopramide and ondansetron 2nd line, shouldn’t be used for >5d

Moderate = ambulatory daycare, IV fluids (no glucose), parenteral antiemetics, thiamine (replace folic acid)

Severe = inpatient, IV fluids (no glucose), ranitidine (H2RA), thiamine, thromboprophylaxis

Question 9

Outline the prescription of antiemetics

Answer 9

First line:

• Cyclizine
• Prochlorperazine
• Promethazine
• Chlorpromazine

Second line:

• Metoclopramide (max 5 days due to risk of extrapyramidal side effects)
• Domperidone
• Ondansetron

Third line:
- Hydrocortisone IV