What are monitored in a patient with hyperemesis gravidarum?

Nausea and vomiting of pregnancy exists in a spectrum, from what could be considered "normal" morning sickness to the severe hyperemesis gravidarum (HG) which can have significant impact on the health of the mother and fetus. HG is a complication of pregnancy characterised by intractable nausea, dehydration, electrolyte imbalance and significant weight loss. Nausea and vomiting of pregnancy will affect up to 70% of pregnant women whereas true HG is estimated to affect 0.5–2.0% of pregnancies. The underlying pathophysiology is not altogether clear but thought to be linked to a sensitivity to bHCG or oestrogens.

Índice Show

ED presentations
Diagnosis of HG
Potential complications of HG
Investigations
Acute Management of HG
Progression to HG
Risk Factors
Research Limitations
HG Assessment Packet

ED presentations

Presentations to ED with nausea and vomiting in pregnancy are common. The role of the Emergency Department clinician is to alleviate what can be extremely distressing symptoms; this can often be done with reassurance, IV fluids and anti-emetics. In the rare event of HG or suspected HG then admission may be required and supportive treatment with IV fluids, anti-emetics and vitamins to avoid levels of dehydration or malnutrition which might adversely affect the mother and baby.

Diagnosis of HG

In HG, intractable nausea will be accompanied by the triad of:

Dehydration
Electrolyte imbalance
Weight loss of 5% of pre-pregnancy weight

The diagnosis of HG requires the exclusion of other serious causes of vomiting. Conditions such as appendicitis are know to present atypically in this population, and clinicians should perform a thorough abdominal examination and consider alternative diagnoses before attributing the symptoms to HG. If concerned or uncertain, involve a senior clinician.

Potential complications of HG

Electrolyte abnormalities
Metabolic alkalosis
Mallory Weiss tear
Reflex oesaphagitis
Psychological effects, including depression
Wernickes encepaphalopathy and Central pontine myelinolysis (rare but documented)
Oesophageal rupture (rare)

Investigations

For simple and self-limiting nausea and vomiting very few investigations may be required other than urinalysis, and blood tests for renal function and electrolytes.

Investigations for HG include:

Renal function and electrolytes (note that in pregnancy an increase in eGFR of up to 50% means that a "normal" urea and creatinine level may represent relative renal impairment.
Urinalysis for ketonuria
Urine culture if UTI suspected
TFT - 60 % of women with HG will have biochemical thyrotoxicosis liver function tests
LFT
Pelvic ultrasound scan to confirm viable intrauterine pregnancy and to exclude trophoblastic pregnancy which can present with HG
Consider Lipase to exclude pancreatitis
Blood glucose level

Acute Management of HG

Dietary modification based on the woman’s own preferences is the first-line treatment which most patients will have tried prior to presentation to ED. When patients present to the ED then generally antiemetics and IV rehydration are used and for the most part this can be done within the ED or a short stay unit. Admission to hospital may be required in cases where the woman is unable to tolerate oral intake despite IV antiemetics, or in cases of true HG.

Rehydration

IV normal saline +/- potassium as required
Once vomiting is controlled, start a trial of oral fluids - small sips of fluid, often.

Antiemetics

Metoclopramide 10mg IV 8 hourly (category A)

Ondansetron 4-8mg tds (category B1)

Prochlorperazine 12.5mg intramuscular injection, or slow IV injection.

Vitamins and Minerals

IV thiamine 100mg daily should be given to all women requiring admission for prolonged vomiting, especially before parenteral dextrose
Correct hypokalaemia, hypomagnesemia hypocalcaemia

Resources

It is important to reassure the woman that hyperemesis gravidarum is a significant illness and not "just morning sickness" and that a presenation to ED was entirely appropriate. Encourage the woman to represent to ED early for IV fluids before symptoms and dehydration become severe. Reassurance that the illness will be self limiting and that 90% of these symptoms will be resolved by week 16 may help.

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Hyperemesis gravidarum (HG) begins between the fourth and sixth week of pregnancy. Half of women experience symptom resolution, or at least significant improvement, somewhere around 14-20 weeks; about 20% will continue to have significant nausea/vomiting until late pregnancy or delivery. For some, symptoms continue after delivery for weeks or months and continued treatment is needed. You can see a general idea of HG severity levels defined to understand better your HG.

Symptoms

Most affected women have continuous nausea and multiple episodes of vomiting throughout the day with few if any symptom-free periods, especially during the first three months. This may lead to rapid and/or significant weight loss, dehydration, and electrolyte disturbances often requiring hospitalization.

If not treated promptly, methodically, and adequately, these can lead to fetal loss, and irreversible renal, neurologic, and hepatic damage, or even death.

MORE ON: Signs & Symptoms and Lab Tests for HG

These women present to their physicians with weight loss of 5 to 20+ pounds (2.25 to 9+ kgs); however, those who are overweight may not appear malnourished. This is especially true as the pregnancy progresses. However, they still become vitamin deficient and at risk of serious complications (e.g. Wernicke’s encephalopathy) as soon as 2 weeks after reduced intake.

Early, aggressive medical care often decreases the severity of a woman's symptoms and leads to quicker recovery.

Progression to HG

Recognizing a woman is transitioning from morning sickness to hyperemesis gravidarum is critical. The initial signs include:

Weight loss (2+ lbs [1 kg] weekly)
Recurrent ketosis
Frequent and/or severe nausea/vomiting
Dehydration
Severe fatigue
Inability to work

If these are seen early in pregnancy, hydration with vitamins, antiemetics, and close monitoring is imperative. See our HG Treatment Protocol and Assessment Tools to determine HG severity and identify possible HG complications.

Risk Factors

Study findings vary widely in determining the women most at risk for HG. It is more common in first pregnancies, and in women who weigh more than 170 pounds (77 kg), are nonsmokers, have twin (or more) pregnancies, trophoblastic disease, a high fat or low dairy diet, or are less than 20 years old. The risk may decrease after age 35. Hyperemesis often recurs in subsequent pregnancies in similar patterns.

Most significant risk factor for HG is a female relative with HG. Read our HG genetic study.

Untreated asthma
High saturated fat diet
Low or high body weight
Posttraumatic stress disorder (PTSD)
Excessive social stress (worsens existing HG)
Multiple gestation (twins or more)
Food cravings and aversions before/during pregnancy
Epilepsy
Exposure to smoking

History of:

Nausea and vomiting during pregnancy
Motion sickness
Menstrual pain (dysmenorrhea)
Sensitivity to oral contraceptives
Nausea premenstrually
Migraine headaches
Allergies
Gall bladder disease
Gastritis or ulcers
**Female relative with HG
High blood pressure
Liver disease
Kidney disease
Poor diet
Abnormal thyroid levels

** Most significant risk factor!

Research on Risk Factors Expand

PubMed Research on Risk Factors for HG

Our studies consistently find the recurrence risk exceeds 75%. Epidemiological studies indicate that women with mild nausea and vomiting in pregnancy have a statistically significant decrease in the risk of miscarriage in the first 20 weeks but may have a history of several spontaneous abortions (miscarriages). However, women with severe nausea and vomiting have a 33% risk of fetal loss.

Research Limitations

Studies have been limited by the inconsistent criteria for diagnosing HG and the global knowledge deficit of proper treatment. Without effective care and support, women will progress to more severe symptoms.

Assessing women with HG can be difficult due to fluctuating and complex symptoms. Thus, the HER Foundation developed important tools to help you effectively and efficiently evaluate HG patients.

HELP Score

The HER Foundation’s HELP Score is a tool to quantify and monitor symptom severity, especially with more complex symptoms.

Features:

Evaluation of key clinical concerns,
Quick identification of severe symptoms, and
Detection of changes in severity.

The HELP Score is automatically calculated by the HG Care App.

HG Assessment Packet

The HER Foundation developed a comprehensive assessment packet to promote standardized assessment of HG and improve recognition of comorbidities and developing complications. The Assessment Packet is divided into 3 parts:

Initial visit assessment,
Per visit assessment, and
Detailed care planning tool for clinicians.

The HER Foundation designed an innovative app that was co-developed with UCLA mHealth. This free app not only tracks symptoms and treatment, but also alerts the mother to concerning symptoms. The app summarizes the data into meaningful charts that can be printed or shared with others to help guide decision-making. Our research study is enrolling.

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