Hyperemesis Gravidarum Management

Diagnosis and Evaluation

• Hyperemesis gravidarum is characterized by intractable nausea and vomiting, dehydration, weight loss >5% of pre-pregnancy weight, and electrolyte imbalances, according to the American Gastroenterological Association 1
• Physical examination should focus on signs of dehydration and malnutrition, including orthostatic hypotension, decreased skin turgor, and dry mucous membranes, as recommended by the American Gastroenterological Association 1
• Evaluation should include a comprehensive history, physical examination for signs of dehydration, laboratory evaluation, and abdominal ultrasound to detect multiple/molar pregnancies and rule out other causes, as recommended by the American Gastroenterological Association and the American Association for the Study of Liver Diseases 1, 2
• Laboratory evaluation should include electrolytes, liver function tests, urinalysis for ketones, and thyroid function tests, which may show biochemical hyperthyroidism, according to the American Association for the Study of Liver Diseases 1, 2
• Severity of hyperemesis gravidarum can be assessed using weight loss, dehydration, electrolyte abnormalities, and ketonuria, although ketonuria is not an indicator of dehydration 2

Treatment

• The American Gastroenterological Association recommends IV fluid replacement with normal saline and glucose, correction of electrolyte abnormalities, and immediate thiamine supplementation, with a dose of 100 mg IV/IM if unable to tolerate oral medication or if clinical suspicion of acute deficiency exists, although the specific recommendation is not provided in the given reference, the general treatment approach is supported by 1
• Thiamine 200-300 mg daily orally, or 100 mg intravenously/intramuscularly if unable to tolerate oral medication or if clinical suspicion of acute deficiency exists, should be administered, as recommended by the American Association for the Study of Liver Diseases and American Gastroenterological Association 3, 2
• Vitamin supplementation, including thiamine and pyridoxine (vitamin B6) (10-25 mg every 8 hours), is recommended by the American Gastroenterological Association 1
• Metoclopramide, ondansetron, and promethazine can be used for nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) 1
• Methylprednisolone should be administered at 16 mg intravenously every 8 hours for up to 3 days, followed by tapering over 2 weeks to the lowest effective dosage, with a maximum duration of 6 weeks for severe hyperemesis gravidarum that has not responded to first-line and second-line therapies, as recommended by the American College of Gastroenterology 1
• Vitamin B6 (pyridoxine) 10-25 mg every 8 hours, doxylamine 10-20 mg at bedtime or every 8 hours, and ginger 250 mg capsule 4 times daily may be used for persistent symptoms despite lifestyle modifications, as recommended by the American Gastroenterological Association and the American Association for the Study of Liver Diseases 1, 4

Monitoring and Follow-up

• Daily monitoring should include weight, intake and output, electrolyte levels, liver function tests (if initially abnormal), and signs of thiamine deficiency, as part of standard care, although not explicitly recommended by a specific guideline society in the provided references, the approach is supported by 1
• For patients on corticosteroids, screen for gestational diabetes and monitor for signs of adrenal suppression, as part of standard care, although not explicitly recommended by a specific guideline society in the provided references, the approach is supported by 1
• Regular assessment of weight, hydration status, and electrolytes, as well as monitoring liver function tests if initially abnormal, is recommended, according to the American Gastroenterological Association and the American Association for the Study of Liver Diseases 1, 2
• Screen for gestational diabetes mellitus in women taking glucocorticoid treatment, such as methylprednisolone 5
• Monitor for signs of adrenal suppression in women taking more than 5 mg prednisolone daily for more than 3 weeks 5

Hospitalization and Complications

• Indications for hospitalization include dehydration, weight loss >5% of pre-pregnancy weight, electrolyte imbalances, and failed outpatient management, as recommended by the American Association for the Study of Liver Diseases and the American Gastroenterological Association 2, 4
• Hospital management includes IV fluid and electrolyte replacement, IV thiamine supplementation, IV anti-emetics, and IV corticosteroids may be considered for refractory cases, according to the American Association for the Study of Liver Diseases and the American Gastroenterological Association 2, 4
• Without adequate treatment, hyperemesis gravidarum can lead to Wernicke's encephalopathy, central pontine myelinolysis, low birth weight, small for gestational age, premature delivery, and rarely, maternal death, according to the American Association for the Study of Liver Diseases 2
• Early and adequate thiamine supplementation is essential to prevent serious complications, including chronic cognitive disorders, pregnancy loss, and maternal death, which can occur due to inadequate thiamine dosing, administering IV glucose without thiamine, delaying thiamine supplementation, or failing to recognize the rapid progression of thiamine deficiency in pregnancy 2
• Recurrence risk is high in subsequent pregnancies, but there is no association with chronic liver disease, according to the American Association for the Study of Liver Diseases 2

Lifestyle Modifications

• Small, frequent, bland meals, high-protein, low-fat meals, and a BRAT diet (bananas, rice, applesauce, toast) are recommended, as well as avoiding spicy, fatty, acidic, and fried foods, and identifying and avoiding specific triggers, according to the American Gastroenterological Association 1, 4
• Once vomiting is controlled, transition to oral intake with small, frequent, bland meals, high-protein, low-fat foods, and a BRAT diet (bananas, rice, applesauce, toast) is suggested, as per the American Gastroenterological Association 1