Hyperemesis Gravidarum
Patient presentation:
MJE, a 38 year old G5P1A3 (5 pregnancies, 1 term infant, 3 miscarriages) at 36 weeks and 5 days gestation presents to Labor and Delivery holding a small bucket under her chin. She is complaining of nausea, vomiting and an 8lb weight loss this week. MJE had a pre-gravid weight of 165lbs and a current weight of 141lbs. MJE complains that it has been difficult to keep food and water down throughout the pregnancy and sometimes “eats just to taste food even though she knows it will come right back up.” MJE is also complaining of itching and a red rash on her hands, feet and torso. On physical assessment MJE has poor skin turgor, dry lips, puffy eyes and an overall disheveled appearance. Vital Signs were taken and MJE was placed on the external fetal monitor. MJE had a category I tracing (showing fetal well being) with infrequent contractions that she rates a 2/10 in pain.
MJE’s admission vital signs were BP 102/72, pulse 85bpm, RR 18, temp 36.9. MJE had no leakage of fluid or vaginal bleeding and reports positive fetal movements.
Differential Diagnosis:
Hyperemesis Gravidarum, Intrahepatic Cholestasis in Pregnancy
Diagnosis:
Labs were taken and MJE was started on IV fluids. Lab results were as follows:
CBC: Hgb 9.4mg/dL, Hct 28.2, MCV 80.3FL, MCH 26.7pg (all other CBC values wnl)
Lactic Acid 0.6mmol/L (normal 0.7-2.1).
BMP: Na+ 136mmol/L , K+ 3.5mmol/L, Cl- 96mmol/L (all other BMP values normal)
Liver Function test: Alkaline Phosphatase 149unit/L (normal 38-126), total protein 6.2gm/dL (normal 6.3-8.2), albumin 2.6 (normal 3.5-5.0) Total and direct bilirubin wnl,
UA: Specific Gravity 1.035 (normal 1.003-1.030), UA WBC 16/hpf, UA Leukocyte Esterase large (normal is negative), UA protein 100mg/dL (normal is negative), UA Ketones 10mg/dL (normal is negative).
Serum Amylase and Serum Lipase were wnl. Bile Acids 12 (normal below or equal to 10)
Due to the persistent N/V, weight loss and dehydration; a diagnosis of Hyperemesis Gravidarum was given to MJE with underlying clinical evidence of cholestasis (due to the increased bile salts and itching on hands and feet).
Treatment:
MJE was started on an electrolyte rich mix of IV fluids (1L LR consisting of 100mg thiamine, 20mEq KCL and 10mg MVI) to be run at 125ml/hr and Promethazine HCL (Phenergan) 12.5mg in 50ml NS over 15 minutes every 15 minutes for fluid restoration, nausea/vomiting. MJE was also given nalbuphine for pain and diphenhydramine HCL 25mg IV bolus every 4 hours for itching. Due to MJE’s miserable pregnancy complicated by hyperemesis and her new found cholestasis (which increases risk of Intra-uterine fetal demise); MJE was admitted to Labor and Delivery for Labor Induction. Risks and benefits for mom and baby were discussed.
Outcome:
MJE delivered a 6 pound 15 ounce baby girl the next day by vaginal delivery. MJE celebrated her new baby with a big meal that she was able to keep down for this first time. MJE was counseled on risks of hyperemesis and cholestasis in future pregnancies in addition to antenatal testing that can be done to screen for complications.
Case created by Monica Elston, 2011.