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Guidelines for the Management of Hyperemesis Gravidarum

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Hyperemesis gravidarum is persistent vomiting in pregnancy which causes weight loss (> 5% of body wt ) and ketosis. Untreated or inadequately treated it may lead on to Wernicke’s encephalopathy, central pontine myelinosis and maternal death.

Clinical Features

Though the common clinical presentation is in the 1st trimester of pregnancy a certain number of patients may present in the second trimester. Other problems must be ruled out before a confident diagnosis of hyperemesis gravidarum is made.

  • Pregnancy and persistent nausea/vomiting.
  • Dehydration
  • Tachycardia
  • Postural Hypotension
  • Weight loss
  • Hematemesis
  • Mental changes of confabulation and retrograde amnesia in severe cases
  • Abdominal Pain is NOT a common feature and its presence should alert the examiner to the differential diagnosis.

Common Differential diagnosis


  • Multiple Pregnancy
  • Molar Pregnancy

Non Pregnancy Related

  • UTI
  • Hepatitis
  • Thyrotoxicosis
  • Hyperparathyroidism
  • Diabetic ketoacidosis
  • Addison’s ds
  • Appendicitis
  • Cholecystitis
  • Pancreatitis

Clinical History and Examination

  • Establish LMP and pregnancy status
  • Establish duration and amount of vomiting
  • Ask about urine output and dysuria
  • Clinically look for jaundice, goitre and evidence of thyroid problems
  • Clinical examination of chest and abdomen to rule out other causes of persistent nausea and vomiting
  • Look for evidence of dehydration
  • Does the uterus correspond to dates?

Investigations (5)

  • Urine
  • Ketones – to be checked daily
  • MSU
  • Bloods
  • U & E s – check daily

Hyponatremia, Hypokalemia and low serum urea are the usual findings. Adjust IV fluid cationic balance accordingly.
Please check Serum Calcium to rule out hyperparathyroidism

  • LFTs – baseline
  • Elevated aminotransferases and bilirubin are common in upto 50% of patients.
  • FBC – baseline
  • Thyroid function tests – baseline
  • Pelvic Ultrasound Scan
  • To diagnose pregnancy and to rule out multifetal and molar pregnancies.
  • Body weight – twice a week

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