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Hyperemesis Gravidarum: Severe Nausea/Vomiting in Pregnancy

Hyperemesis Gravidarum (HG): Beyond Morning Sickness

HG affects 0.3–3% of pregnancies. It is not typical nausea/vomiting of pregnancy (NVP, 70–80%). HG involves persistent vomiting, weight loss >5% prepregnancy weight, ketonuria, electrolyte abnormalities, and functional impairment requiring medical intervention.

Pathophysiology

  • hCG / hCG variants: Peak correlates with symptom peak (8–12 wks); stimulates TSH receptor → thyrotoxicosis-like state.
  • Estrogen/Progesterone: Delay gastric emptying, relax LES.
  • Genetic: GDF15, IGFBP7, APP variants; familial recurrence.
  • Psychosocial: Not causal, but stress amplifies.

Risk Factors

  • Multiple gestation, molar pregnancy
  • Prior HG, family history
  • Female fetus (slight ↑)
  • History of motion sickness, migraine
  • High prepregnancy BMI
  • Young maternal age

Diagnostic Criteria (ACOG)

  • Persistent vomiting unrelated to other causes
  • Acute starvation signs: ketonuria, weight loss >5%
  • Electrolyte/acid-base disturbance (hypokalemia, metabolic alkalosis)
  • Volume depletion (tachycardia, hypotension, dry mucous membranes)

Management (Stepped)

  1. Outpatient: Dietary (small frequent, bland, cold, protein-rich), ginger (250 mg QID), B6 (pyridoxine 10–25 mg QID) + doxylamine 12.5 mg (Diclegis/Bonjesta), H1 blockers (meclizine, dimenhydrinate), metoclopramide, ondansetron (4–8 mg Q8H — discuss cardiac monitoring if prolonged QT).
  2. IV Hydration (Day Hospital/ED): NS/LR + KCl + MVI + thiamine 100 mg (prevent Wernicke's). Correct K⁺ <3.0 before dextrose.
  3. Inpatient (Refractory): Continuous IV fluids, antiemetic rotation (ondansetron, metoclopramide, prochlorperazine, promethazine), consider mirtazapine 15–30 mg HS, olanzapine 2.5–5 mg, steroid taper (methylprednisolone 16 mg → taper 2 wks — 2nd line).
  4. Enteral/Parenteral Nutrition: If >10% weight loss, persistent ketonuria, failed IV therapy.

Complications of Untreated HG

  • Wernicke's encephalopathy (thiamine deficiency) — ophthalmoplegia, ataxia, confusion
  • Esophageal tears (Mallory-Weiss, Boerhaave)
  • Acute kidney injury, rhabdomyolysis
  • Prenatal: low birth weight, preterm, SGA
  • Maternal: PTSD, depression, pregnancy termination (historically)

Prognosis

Peaks 9–13 wks; resolves by 20 wks in 90%; persists to delivery in 10–20%. Early aggressive treatment improves outcomes.

If you cannot keep fluids down for 24 hrs, feel dizzy, or have dark urine — seek care immediately.

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