Nausea Vomiting

Question 1

When should one be concerned about nausea and vomiting in pregnancy?

Answer 1

Onset > 10 weeks

Question 2

Treatment options nausea/vomiting in pregnancy? (6)

Answer 2

• To prevent, start prenatal vitamins before conception. Treat early to avoid hyperemesis gravidarum
• Acupuncture / acupressure
• ginger capsules, chamomile
• vitamin B6
• metoclopramide 10 mg 8 hourly
• odansetron 4-8 mg 8 hourly
• delay starting iron supplements

Question 3

Define hyperemesis gravidarum (3)

Answer 3

N+v 3 times or more per day
+ ketones in urine or acetone in blood (dehydration)
+ weight loss > 3 kg or > 5% pre-pregnancy weight

Question 4

Describe the PUQE score

Answer 4

1. On average day, how long feel nauseous

• > 6 hr (5)
• 4-6hr (4)
• 2-3h(3)
• 1 or less hr (2)
• not at all (1)

2. How many times vomit per day

• 7 or more (5)
• 5-6 (4)
• 3-4 (3)
• 1 - 2 (2)
• none (1)

3. How many times retching/dry heaves without bringing any thing up

(Same as above)

Mild: 6 or less
Moderate: 7-12
Severe: 13 or more

Question 5

Differential diagnosis hyperemesis gravidarum (diagnosis of exclusion) (5)

Answer 5

• Git: gastroparesis / ileus, gastroenteritis, cyclic vomiting syndrome, achalasia, hepatitis, appendicitis, IBD, biliary tract disease, intestinal obstruction, pancreatitis
• gut: pyelonephritis, uraemia, ovarian torsion, kidney stones, fibroid degeneration
• metabolic: DKA, porphyria, hyperthyroid, Addison’s
• misc: drug toxicity/intolerance, psychogenic, neoplasia
• pregnancy related: acute fatty liver of pregnancy, pre-eclampsia, multiple gestation…

Question 6

Treatment hyperemesis gravidarum (5)

Answer 6

1 lifestyle diet change

• avoid triggers, stop meds like iron, big vitamins. Frequent small meals, avoid empty stomach

2. Drugs/intervention

• acupressure, acupuncture, acustimulation, ginger capsules

3. Pharmacology

• vit B6
• antihistamines (cimetidine, ranitidine)
• metoclopramide 10 mg iv 8 hourly
• can consider phenergan

4.

• odansetron (Zofran) for refractory
• corticosteroids last resort. Only 3 days ( prednisolone 2mg bd po)

5. Inpatient