A 31-year-old woman, gravida 1 para 0, at 8 weeks gestation is brought to the emergency department due to persistent nausea, nonbloody vomiting, epigastric pain, and dizziness. The patient has been unable to tolerate any oral intake for the past day. This pregnancy was conceived through intrauterine insemination with donor sperm. She has a history of esophageal reflux for which she takes an over-the-counter antacid. Temperature is 36.7 C (98 F), blood pressure is 100/70 mm Hg, and pulse is 104/min. Current weight is 55 kg (121.3 lb), a decrease of 2 kg (4.4 lb) from her prepregnancy weight. Cardiac examination shows tachycardia but a regular rhythm with no murmurs. The thyroid is nonenlarged and has no palpable masses. Abdominal examination shows epigastric tenderness with deep palpation but no rebound, guarding, or palpable masses. Ultrasound confirms an 8-week intrauterine gestation with a normal fetal heartbeat. Which of the following is the best next step in management of this patient?
Hyperemesis gravidarum | |
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Laboratory abnormalities |
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Treatment |
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This patient's nausea and vomiting in pregnancy may be due to hyperemesis gravidarum (HG). Risk factors include multiple gestation, hydatidiform mole, and HG in a prior pregnancy. HG is diagnosed clinically when patients have severe, persistent nausea and vomiting, signs of dehydration (eg, dry mucous membranes, orthostatic hypotension), or weight loss of >5% of prepregnancy weight.
However, in patients with a subtler clinical presentation, such as this patient with dizziness and nausea/vomiting for a day but relatively normal vital signs, HG can be differentiated from typical nausea and vomiting of pregnancy by laboratory evaluation. HG typically causes electrolyte abnormalities (eg, hypochloremic metabolic alkalosis, hypokalemia) and elevated serum aminotransferases due to severe, persistent vomiting.
Patients with HG can also develop prolonged hypoglycemia due to inadequate oral intake; this can lead to ketoacidosis and ketones on urinalysis. Ketonuria suggests more severe disease and is an indication for hospital admission for intravenous antiemetics, rehydration, and electrolyte repletion (vs considering antiemetic therapy, oral hydration, and potential discharge home from the emergency department if improved). Therefore, the best next step in management of this patient is urinalysis for ketonuria, which will guide management.
(Choice A) 24-hour urine protein collections are used to diagnose preeclampsia or establish baseline renal function in patients at high risk for preeclampsia (eg, multiple gestation, type 1 diabetes mellitus). Although preeclampsia can present with epigastric pain, nausea, and vomiting, the diagnosis requires the presence of hypertension. In contrast, this patient is normotensive, and her epigastric pain is likely due to persistent vomiting.
(Choice B) A markedly elevated quantitative β-hCG level suggests a hydatidiform mole, which can also present with hyperemesis gravidarum. However, the normal gestation seen on this patient's ultrasound excludes this diagnosis and therefore a β-hCG level is not indicated.
(Choice C) Hyperemesis gravidarum can present with transient hyperthyroidism (eg, thyrotoxicosis of hyperemesis) due to stimulation of the thyroid by elevated hCG levels. Thyroid studies are indicated only if there are overt signs of hyperthyroidism (eg, heat intolerance, enlarged thyroid or nodule), which are not seen in this patient.
(Choice D) Upper endoscopy is indicated for the evaluation of hematemesis or esophageal tears or perforation. Although this patient has epigastric pain, she does not have hematemesis and her physical examination is benign.
Educational objective:
Hyperemesis gravidarum is a severe, persistent form of nausea and vomiting of pregnancy characterized by weight loss of >5% of prepregnancy weight, serum electrolyte abnormalities, and ketonuria.