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Hyperemesis gravidarum
Nausea and vomiting are common symptoms experienced during pregnancy, particularly in the first trimester. The onset of nausea typically occurs within 4 weeks after the last menstrual period, with the problem peaking around 9 weeks of gestation. While most cases resolve by the end of the first trimester (60%) or by 20 weeks of gestation (91%), some cases can be more severe and require medical intervention.
Hyperemesis gravidarum is a condition characterized by intractable nausea and vomiting, leading to fluid, electrolyte, and acid-base imbalances, as well as nutrition deficiency and significant weight loss during early pregnancy. It is defined by persistent vomiting, weight loss of more than 5%, ketonuria, electrolyte abnormalities (hypokalemia), and dehydration. The occurrence of more than three episodes of vomiting per day with ketonuria and more than 3 kg or 5% weight loss is considered diagnostic.
The diagnosis of hyperemesis gravidarum is primarily clinical, supported by the presence of ketones in blood or urine. In contrast, nausea and vomiting of pregnancy is considered less severe, with no ketosis or severe weight loss.
Workup for hyperemesis gravidarum may include urinalysis for ketones, assessment of electrolytes and renal function. If the patient has abdominal pain, other etiologies should be considered and worked up, such as ectopic or molar pregnancy, cholecystitis, cholelithiasis, HELLP syndrome, pancreatitis or hepatitis, appendicitis, or pyelonephritis or cystitis.
Treatment for hyperemesis gravidarum involves fluid replacement with dextrose solutions, to correct dehydration and electrolyte imbalances. Anti-emetics are also an essential part of the treatment regimen. If the diagnosis is uncertain or there is intractable vomiting, persistent ketone or electrolyte abnormalities, or weight loss of more than 10% of pre-pregnancy weight, admission for intravenous fluid and anti-emetic administration may be necessary.
For nausea and vomiting of pregnancy, the initial approach involves non-pharmacological measures, such as avoiding trigger odors, consuming small, frequent meals, and staying well-hydrated. Anti-emetics may also be used, and dietary modifications like the inclusion of ginger or pyridoxine can be helpful.
Anti-emetics are classified into several categories based on their potential risk during pregnancy. Class A medications, such as Ginger and Pyridoxine, are considered safe and the first line of treatment. Class B medications, such as ondansetron and metoclopramide, have demonstrated no risk in human studies but may be considered second-line options. Class C medications, like promethazine, have shown potential risks in animal studies but may be used if the benefits outweigh the risks. It is important to carefully weigh the risks and benefits when prescribing anti-emetics during pregnancy.