Behind the Knife: Hyperemesis Gravidarum

Nicholas Burns (0:03)

Behind the Knife, premium.

Fei Cai (0:06)

Today's topic is Hyperemesis Gravidarum, written by Faye Cai and performed by Nick and Faye.

So this is a case of a 32-year-old G1. She's at six week, four days, confirmed by her recent ultrasound, who presents to you for her initial prenatal visit. She has a history of migraine, but is otherwise healthy, and she denies vaginal bleeding or abdominal pain, but states that she has significant nausea and vomiting in the mornings. She states that the nausea usually abates in the late morning or early afternoon, and she is able to eat her lunch and dinner usually. She would like to know what you would recommend for her nausea. So based off of what she's telling you, what is your initial differential?

Nicholas Burns (0:49)

So this differential is pretty broad, but the most likely diagnoses from a pregnancy perspective at least is nausea and vomiting of pregnancy.

Possible GI conditions that might be going on include things like gastroenteritis, pancreatitis, or inflammatory bowel disease. She could also have genetic urinary issues, things like pile nephritis or kidney stones. And then she's also got this history of migraines, and that might also be contributory to her nausea and vomiting.

Fei Cai (1:20)

So how would you work her up to figure out her diagnosis here?

Nicholas Burns (1:24)

So I would want to start with a detailed history and physical exam. I want to ask her about the onset of her symptoms, treatments she may have used, and if there are any things that are associated with her nausea and vomiting, things like different exposures or pain.

For her physical exam, I would want to get a full set of vital signs. I would focus really on her abdominal exam to see if she has any tenderness, guarding, or rebound.

Fei Cai (1:52)

The patient tells you that this nausea and vomiting started about one week ago, and has steadily gotten worse. She denies new foods, travel, or other exposures, and she has in fact decreased her food variety to bland foods such as crackers and rice, because she hasn't been able to tolerate other foods. And she states that she's tried some ginger tea, which is sometimes helpful, and she denies fevers, chills, no other abdominal pain. She also denies dysuria, and diarrhea, and constipation, and she says that her migraines have actually improved during her pregnancy.

And on your exam, her vitals are within normal limits. Her exam is overall within normal limits as well. So what is your next step in management here?

Nicholas Burns (2:28)

So based on this, I would order usual prenatal labs. It seems like I'm convinced here this is nausea and vomiting of pregnancy. I'd recommend treatment with ginger, followed by doxylamine and purexidium or vitamin B6, up to four times a day.

If she's having nausea and vomiting, I'd recommend that she start on red gland for symptom control, or medical provide for symptom control.

Fei Cai (2:56)

Okay, so the patient starts on this treatment. Several days later, your office receives a call from her, and she says that her nausea and vomiting have gotten significantly worse. She's not able to keep anything down, and she's not taking her medications because she's not able to take anything by mouth without vomiting. And she says that the last time she's had solid food or water that stayed down was about 24 hours ago.

So what's your next step in management here?

Nicholas Burns (3:19)

So with how bad her symptoms are, the fact that she's not been able to keep anything down for 24 hours, I would recommend she be seen in the emergency room.

Fei Cai (3:28)

All right. So she goes to OB triage per your recommendation. What's your work up at this time?

Nicholas Burns (3:34)

I would again want to complete a detailed history and physical as I earlier described.

Fei Cai (3:40)

The patient tells you she's tried the treatment that you recommended for her for approximately two days. However, her symptoms worsened significantly after that, and she wasn't able to keep down the medication.

She denies fevers or chills. She says she's burning abdominal pain under her ribs and feels burning in her chest under the sternum. She also says she's been very tired. And on exam, her vitals show a temperature of 36.5, a pulse of 110, blood pressure of 94 over 52, and she's adding 100 percent on room air. She's pale, she's got dry mucous membranes, and several times she has to lean over and vomit a small amount of fluid into the emesis basin, but otherwise her exam is within normal limits. What is your next step in work up or management here?