QuestionSBA
QuestionChoice
This usually occurs after 20 weeks gestation and would involve hypertension with proteinuria. Symptoms may include headache, visual disturbances, epigastric pain and marked oedema. Proteinuria 1+ in this scenario may suggest preexisting renal disease as she is at an early gestational stage
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Pre-eclampsia
QuestionChoice
This usually occurs in the 3rd trimester, and patients may have abdominal pain, pruritus and features of cholestasis (pale stools, dark urine, steatorrhoea). In pregnancy, ALP levels are usually raised by about 1.5 to 2 times the normal level, as is the case in this question
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Cholestasis of pregnancy
QuestionChoice
This usually occurs after 20 weeks gestation and would involve hypertension with proteinuria. Symptoms may include headache, visual disturbances, epigastric pain and marked oedema. Proteinuria 1+ in this scenario may suggest preexisting renal disease as she is at an early gestational stage
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HELLP syndrome
QuestionChoice
Nausea and vomiting is a common symptom that affects women mostly in the 1st trimester. The aetiology is multifactorial and may be due to a combination of hormonal changes, abnormal gastrointestinal motility and genetic factors. It is also important to consider other differentials for nausea and vomiting that may occur due to conditions unrelated to pregnancy
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Nausea and vomiting of pregnancy
QuestionChoice
This is the more severe end of the spectrum of nausea and vomiting in pregnancy, which usually occurs in the first trimester and resolves by 20 weeks. While there are no clear cut clinical criteria for this condition, it is typically based on the following factors - persistent vomiting, weight loss >5% of pre-pregnancy body weight and ketonuria
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Hyperemesis gravidarum
QuestionComment
Does anyone know why she has an elevated ALP?

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QuestionComment
Can be raised in normal pregnancy apaz 
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Metabolism Myotonia
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My understanding is that ALP is produced by the placenta so levels can go up during pregnancy
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Hypertension Hallux
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Anterior Intubation
QuestionComment
Why does she have low platelets?
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Lateral Kinase
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# Summary

Hyperemesis gravidarum is a severe form of nausea and vomiting that occurs before 20 weeks of gestation, often requiring hospital admission. Key signs and symptoms include relentless vomiting, dehydration, and metabolic disturbances. It is typically diagnosed through exclusion. Differential diagnoses involve various infections, gastrointestinal issues, metabolic conditions, drug toxicity, and molar pregnancy. Investigations may include urine tests, blood tests, and ultrasound. Management strategies encompass fluid and electrolyte replacement, anti-emetic medications, thiamine and folic acid supplementation, antacids, and venous thromboembolism prophylaxis.


# Definition


Hyperemesis gravidarum is a condition characterized by severe nausea and vomiting, commencing before the 20th week of gestation. It is intense enough to necessitate hospital admission and is diagnosed through the process of exclusion.


# Differential Diagnosis



Differential diagnoses for severe vomiting during pregnancy include:

- Infections: Gastroenteritis, urinary tract infection, hepatitis, and meningitis
- Gastrointestinal problems: Appendicitis, cholecystitis, bowel obstruction
- Metabolic conditions: Diabetic ketoacidosis, thyrotoxicosis
- Drug toxicity
- Molar pregnancy: Characterized by abnormally high levels of beta-hCG due to gestational trophoblastic disease, which can cause severe nausea and vomiting


# Management


Management of hyperemesis gravidarum primarily includes supportive care, such as:

- Fluid replacement therapy to correct dehydration
- Potassium chloride to address hypokalaemia resulting from excessive vomiting
​- Anti-emetic medications, including cyclizine (first line), or prochlorperazine. In severe cases, ondansetron (2nd line), metoclopramide (2nd line) or domperidone may be utilized.
- Thiamine and folic acid supplementation to prevent the onset of Wernicke's encephalopathy
- Antacids to alleviate epigastric discomfort
- Thromboembolic (TED) stockings and low molecular weight heparin to mitigate the increased risk of venous thromboembolism due to a combination of pregnancy, immobility, and dehydration.

# Complications

Potential complications of hyperemesis gravidarum include:

- Gastrointestinal problems: Mallory-Weiss tears, malnutrition, and anorexia
- Dehydration leading to ketosis and venous thromboembolism
- Metabolic disturbances, such as hyponatraemia, Wernicke's encephalopathy, kidney failure, and hypoglycaemia
- Psychological sequelae, including depression, PTSD, and resentment towards the pregnancy
- Severe conditions may impact the foetus due to maternal metabolic disturbance, leading to low birth weight, intrauterine growth restriction, and premature labour.

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Hyperemesis gravidarum
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Obstetrics
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Hyperemesis gravidarum
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Hyperemesis gravidarum
Nausea and vomiting of pregnancy
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Nausea and vomiting of pregnancy (NVP) is common and mild, while hyperemesis gravidarum (HG) is a severe form with persistent vomiting, leading to dehydration, weight loss, and requiring medical treatment and hospitalization.
A 30-year-old primigravida at seven weeks gestation presents with a ten-day history of morning nausea and vomiting, often unable to tolerate breakfast but managing a light lunch.


Observations: Temperature 37.0°C, pulse 90, blood pressure 140/90, respiratory rate 20, SpO2 99% on room air



Liver function tests:



||||
|---------------------------|:-------:|--------------------|
|Albumin|40 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|21 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|32 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|210 IU/L|25 - 115|
|Bilirubin|7 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|20 U/L|9 - 40|




Full blood count:

||||
|--------------|:-------:|---------------|
|Haemoglobin|121  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|6.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|110x10<sup>9</sup>/L|150 - 400|


Urine dip:



  - protein negative
  - blood negative
  - nitrites negative
  - leucocytes negative
  - ketones negative



Clinical examination reveals a soft and non-tender pregnant abdomen appropriate for gestational age.



Which of the following is the most likely differential?
a