Vomiting may be prolonged, frequent, and severe, and a list of potentially fatal complications is given in Table 54-2. Various
TABLE 54-2. Some Serious and Life-Threatening Complications of Recalcitrant Hyperemesis Gravidarum
Acute kidney injury-may require dialysis Depression-cause versus efect? Diaphragmatic rupture
Esophageal rupture-Boerhaave syndrome Hypoprothrombinemia-vitamin K deficiency Hyperalimentation complications Mallory-Weiss tears-bleeding, pneumothorax, pneumomediastinum, pneumopericardium Rhabdomyolysis degrees of acute kidney injury from dehydration are encountered (Nwoko, 2012). An extreme example was a woman we cared for who required 5 days of dialysis when her serum creatinine level rose to 10.7 mg/dL (Hill, 2002). One complication from continuous retching is a Mallory-Weiss tear. Others are pneumothorax, pneumomediastinum, diaphragmatic rupture, and gastroesophageal rupture-Boerhaave syndrome (American College of 0bstetricians and Gynecologists, 2015; Chen, 2012).
At least two serious vitamin deiciencies have been reported with hyperemesis in pregnancy. One is Wernicke encephalopathy from thiamine deiciency that has been recognized with increasing frequency (Di Gangi, 2012; Palacios-vIarques, 2012). In two reviews, ocular signs, confusion, and ataxia were common, but only half had this triad (Chiossi, 2006; Selitsky, 2006). With this encephalopathy, an abnormal electroencephalogram (EEG) may be seen, and usually MR imaging shows findings (Vaknin, 2006; Zara, 2012). At least three maternal deaths have been described, and long-term sequelae include blindness, convulsions, and coma (Selitsky, 2006). he second is vitamin K deicieny that has been reported to cause maternal coagulopathy and fetal intracranial hemorrhage, as well as vitamin K embryopathy (Kawamura, 2008; Lane, 2015; Sakai, 2003).
One algorithm for management of nausea and vomiting of pregnancy is shown in Figure
Most women with mild
Mild Dietary management; Ginger extract; Vitamin 86 plus doxylamine, diphenhydramine, or dimenhydrinate Moderate Severe Promethazine, Intravenous hydration prochlorperazine, with thiamine; trimethobenzamide, Parenteral: chlorpromazine, metoclopramide, metoclopramide, or promethazine, or ondansetron ondansetron (oral, rectal, parenteral) Intractable Enteral or parenteral nutrition ment of hyperemeSis gravidarum.
TABLE 54-3. Medications for Gastric Disorders in Pregnancy
At bedtime; up to 4 times daily 12.5-25 mg 1M, IV, PO, PR 1M, IV, PO, PR
IV, PO 1M, IV, PO