Obgyn · Year 3 · from Obgyn

Case 2: Hyperemesis Gravidarum in Early Pregnancy

Patient Demographics

  • Age: 32 years
  • Sex: Female
  • Occupation: Accountant

Chief Complaint

"I can't stop vomiting and I feel extremely weak."

History of Present Illness

The patient is at 9 weeks gestation and reports severe, persistent nausea and vomiting for the past 3 weeks that has progressively worsened. She is vomiting 8-10 times daily and unable to keep down food or liquids. She has lost 8 pounds (7% of pre-pregnancy weight). She feels dizzy when standing and has not urinated much in the past 24 hours. Ginger and vitamin B6 have not helped. She denies fever, diarrhea, or abdominal pain.

Past Medical History

  • Anxiety disorder treated with counseling (no medications)
  • No prior surgeries

Obstetric History

  • G2P1001 (one prior uncomplicated term delivery)
  • Mild nausea in first pregnancy that resolved by 12 weeks

Physical Examination Findings

  • Vital Signs: BP 95/60 mmHg, HR 105 bpm, Temperature 98.4F, BMI 22 kg/m2
  • General: Ill-appearing, fatigued female, dry mucous membranes
  • Cardiovascular: Tachycardic, regular rhythm
  • Abdomen: Soft, mildly tender epigastrium, no distension
  • Skin: Decreased turgor, dry lips

Diagnostic Workup

  • Urinalysis: Specific gravity 1.035, 3+ ketones, no protein, no blood
  • Serum Electrolytes: Na 132 mEq/L (low), K 3.2 mEq/L (low), Cl 95 mEq/L (low)
  • BUN/Creatinine: 22/1.0 mg/dL (elevated BUN indicating dehydration)
  • TSH: 0.3 mIU/L (low, consistent with gestational hyperthyroidism)
  • Free T4: 1.8 ng/dL (upper normal)
  • Liver Enzymes: AST 48, ALT 52 (mildly elevated)
  • Transvaginal Ultrasound: Single viable intrauterine pregnancy at 9 weeks, normal placenta, no molar pregnancy

Diagnosis

Hyperemesis Gravidarum with:

  • Dehydration (ketonuria, elevated BUN)
  • Electrolyte abnormalities (hyponatremia, hypokalemia)
  • Weight loss >5% pre-pregnancy weight
  • Gestational hyperthyroidism (hCG-mediated, transient)

Management Plan

Immediate Treatment (Hospitalization):

  1. IV fluid resuscitation with lactated Ringer's solution
  2. Electrolyte replacement (potassium supplementation)
  3. Thiamine 100 mg IV daily (CRITICAL - prevents Wernicke encephalopathy)
  4. NPO initially, then advance diet as tolerated

Antiemetic Therapy:

  1. Ondansetron 4 mg IV every 8 hours
  2. Metoclopramide 10 mg IV every 6 hours as needed
  3. Promethazine 12.5-25 mg IV every 6 hours as needed

Monitoring:

  1. Daily weights
  2. Strict intake and output
  3. Daily electrolytes until normalized
  4. Urine ketones until cleared

Discharge Criteria:

  • Tolerating oral intake
  • Ketones cleared
  • Electrolytes normalized
  • Weight stable

Counseling Points:

  • Hyperemesis typically improves by 14-16 weeks
  • Fetal outcomes are generally good with appropriate treatment
  • May require readmission if symptoms recur
  • Home IV therapy may be considered for recurrent admissions

Clinical Image

Image Description: Clinical photograph or illustration depicting the pathophysiology of hyperemesis gravidarum, showing the cascade from persistent vomiting to dehydration, ketonuria, and electrolyte abnormalities.

Attribution: Illustration adapted from medical education resources. Public domain.

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