ESSENTIALS OF DIAGNOSIS
Morning or evening nausea and vomiting.
Persistent vomiting severe enough to result in weight loss, dehydration, starvation ketosis, hypochloremic alkalosis, hypokalemia.
May have transient elevation of liver enzymes.
Appears related to high or rising serum hCG.
More common with multi-fetal pregnancies or hydatidiform mole.
Nausea and vomiting begin soon after the first missed period and cease by the fifth month of gestation. Up to three-fourths of women complain of nausea and vomiting during early pregnancy, with the vast majority noting nausea throughout the day. This problem exerts no adverse effects on the pregnancy and does not presage other complications.
Persistent, severe vomiting during pregnancy—hyperemesis gravidarum—can be disabling and require hospitalization. Hyperthyroidism can be associated with hyperemesis gravidarum, so it is advisable to determine thyroid-stimulating hormone (TSH) and free thyroxine (FT4) values in these patients. Of note, these patients will not have a goiter.
A. Mild Nausea and Vomiting of Pregnancy
In most instances, only reassurance and dietary advice are required. Because of possible teratogenicity, drugs used during the first half of pregnancy should be restricted to those of major importance to life and health. Vitamin B6 (pyridoxine), 50–100 mg/day orally, is nontoxic and may be helpful in some patients. Pyridoxine alone or in combination with doxylamine (10 mg doxylamine succinate and 10 mg pyridoxine hydrochloride, two tablets at bedtime) is first-line pharmacotherapy. Antiemetics, antihistamines, and antispasmodics are generally unnecessary to treat nausea of pregnancy.
B. Hyperemesis Gravidarum
With more severe nausea and vomiting, it may become necessary to hospitalize the patient. In this case, a private room with limited activity is preferred. It is recommended to give nothing by mouth until the patient is improving, and maintain hydration and electrolyte balance by giving appropriate parenteral fluids and vitamin supplements as indicated. Antiemetics such as promethazine (12.5–25 mg orally, rectally, or intravenously every 4–6 hours), metoclopramide (5–10 mg orally or intravenously every 6 hours), or ondansetron (4–8 mg orally or intravenously every 8 hours) should be started. Ondansetron has been associated in some studies with congenital anomalies. Data are limited, but the risks and benefits of treatment should be addressed with the patient. Antiemetics will likely need to be given intravenously initially. Rarely, total parenteral nutrition may become necessary but only if enteral feedings cannot be done. As soon as possible, the patient should be placed on a dry diet consisting of six small feedings daily. Antiemetics may be continued orally as needed. After in-patient stabilization, the patient can be maintained at home even if she requires intravenous fluids in addition to her oral intake. There are conflicting studies regarding the use of corticosteroids for the control of hyperemesis gravidarum, and it has also been associated with fetal anomalies. Therefore, this treatment should be withheld before 10 weeks’ gestation and until ...