eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Hyperemesis Gravidarum: Differential Diagnoses & Workup

Author: Susan Renee Wilcox, MD, Resident, Department of Emergency Medicine, Harvard Medical School
Coauthor(s): Alison Edelman, MD, Assistant Professor, Department of Obstetrics and Gynecology, Oregon Health Sciences University; Judith R Logan, MD, MS, Assistant Professor, Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University
Contributor Information and Disclosures

Updated: Dec 10, 2008

Differential Diagnoses

Appendicitis, Acute
Ovarian Torsion
Cholecystitis and Biliary Colic
Pancreatitis
Diabetic Ketoacidosis
Pregnancy, Preeclampsia
Gastritis and Peptic Ulcer Disease
Urinary Tract Infection, Female
Gastroenteritis
Hepatitis
Obstruction, Small Bowel

Other Problems to Be Considered

Pyelonephritis
Molar pregnancy
Pseudotumor cerebri
Acute fatty liver of pregnancy

Workup

Laboratory Studies

  • Obtain electrolyte levels.
  • Measure urine gravity and ketones.
  • Perform liver function tests (LFTs) if hepatitis is a concern. Of note, LFTs can be slightly elevated with hyperemesis gravidarum.
  • Perform a complete blood count and urinalysis to rule out other causes, with particular concern for pyelonephritis.
  • Hyperthyroidism causing nausea and vomiting is rare, a T3 and T4 level should be drawn if this is a concern. (Thyroid-stimulating hormone [TSH] can be suppressed in hyperemesis gravidarum.)
  • Obtain serum amylase-to-creatinine ratio if pancreatitis is a concern.
  • Serum hCG levels are not clinically useful in a patient with a known intrauterine pregnancy (IUP) and hyperemesis.

Imaging Studies

  • The patient should have an ultrasonographic evaluation of her pregnancy to look for molar pregnancy or multiple gestations.

More on Pregnancy, Hyperemesis Gravidarum

Overview: Pregnancy, Hyperemesis Gravidarum
Differential Diagnoses & Workup: Pregnancy, Hyperemesis Gravidarum
Treatment & Medication: Pregnancy, Hyperemesis Gravidarum
Follow-up: Pregnancy, Hyperemesis Gravidarum
References
[ CLOSE WINDOW ]

References

  1. ACOG (American College of Obstetrics and Gynecology). ACOG (American College of Obstetrics and Gynecology) Practice Bulletin: nausea and vomiting of pregnancy. Obstet Gynecol. Apr 2004;103(4):803-14. [Medline].

  2. Aikins Murphy P. Alternative therapies for nausea and vomiting of pregnancy. Obstet Gynecol. Jan 1998;91(1):149-55. [Medline].

  3. Bailit JL. Hyperemesis gravidarium: Epidemiologic findings from a large cohort. Am J Obstet Gynecol. Sep 2005;193(3 Pt 1):811-4. [Medline].

  4. Bashiri A, Neumann L, Maymon E. Hyperemesis gravidarum: epidemiologic features, complications and outcome. Eur J Obstet Gynecol Reprod Biol. Dec 1995;63(2):135-8. [Medline].

  5. Boone SA, Shields KM. Treating pregnancy-related nausea and vomiting with ginger. Ann Pharmacother. Oct 2005;39(10):1710-3. [Medline].

  6. [Best Evidence] Borrelli F, Capasso R, Aviello G, et al. Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstet Gynecol. Apr 2005;105(4):849-56. [Medline].

  7. Carmichael SL, Shaw GM. Maternal corticosteroid use and risk of selected congenital anomalies. Am J Med Genet. Sep 17 1999;86(3):242-4. [Medline].

  8. Cedergren M, Brynhildsen J, Josefsson A, et al. Hyperemesis gravidarum that requires hospitalization and the use of antiemetic drugs in relation to maternal body composition. Am J Obstet Gynecol. Apr 2008;198:412.e1-5. [Medline].

  9. Chan NN. Thyroid function in hyperemesis gravidarum. Lancet. Jun 26 1999;353(9171):2243. [Medline].

  10. Child TJ. Management of hyperemesis in pregnant women. Lancet. Jan 23 1999;353(9149):325. [Medline].

  11. Chiossi G, Neri I, Cavazzuti M. Hyperemesis gravidarum complicated by wernicke encephalopathy: background, case report, and review of the literature. Obstet Gynecol Surv. Apr 2006;61(4):255-68. [Medline].

  12. Czeizel AE, Dudas I, Fritz G. The effect of periconceptional multivitamin-mineral supplementation on vertigo, nausea and vomiting in the first trimester of pregnancy. Arch Gynecol Obstet. 1992;251(4):181-5. [Medline].

  13. Czeizel AE, Vargha P. A case-control study of congenital abnormality and dimenhydrinate usage during pregnancy. Arch Gynecol Obstet. Feb 2005;271(2):113-8. [Medline].

  14. Davis M. Nausea and vomiting of pregnancy: an evidence-based review. J Perinat Neonatal Nurs. Oct-Dec 2004;18(4):312-28. [Medline].

  15. Dickson MJ. Management of hyperemesis in pregnant women. Lancet. Jan 23 1999;353(9149):325. [Medline].

  16. Dodds L, Fell DB, Joseph KS, et al. Outcomes of pregnancies complicated by hyperemesis gravidarum. Obstet Gynecol. Feb 2006;107(2 Pt 1):285-92. [Medline].

  17. Fell DB, Dodds L, Joseph KS, et al. Risk factors for hyperemesis gravidarum requiring hospital admission during pregnancy. Obstet Gynecol. Feb 2006;107(2 Pt 1):277-84. [Medline].

  18. Fischer-Rasmussen W, Kjaer SK, Dahl C. Ginger treatment of hyperemesis gravidarum. Eur J Obstet Gynecol Reprod Biol. Jan 4 1991;38(1):19-24. [Medline].

  19. Frigo P, Lang C, Reisenberger K. Hyperemesis gravidarum associated with Helicobacter pylori seropositivity. Obstet Gynecol. Apr 1998;91(4):615-7. [Medline].

  20. Fukada Y, Ohta S, Mizuno K. Rhabdomyolysis secondary to hyperemesis gravidarum. Acta Obstet Gynecol Scand. Jan 1999;78(1):71. [Medline].

  21. Golberg D, Szilagyi A, Graves L. Hyperemesis gravidarum and Helicobacter pylori infection: a systematic review. Obstet Gynecol. Sept 2007;110:695-703. [Medline].

  22. Goodwin TM. Hyperemesis Gravidarum. Obstet Gynecol Clin N Am. Sept 2008;35:401-417. [Medline].

  23. Hod M, Orvieto R, Kaplan B. Hyperemesis gravidarum. A review. J Reprod Med. Aug 1994;39(8):605-12. [Medline].

  24. Holmgren C, Aagaard-Tillery KM, Silver RM, Porter TF, Varner M. Hyperemesis in pregnancy: an evaluation of treatment strategies with maternal and neonatal outcomes. Am J Obstet Gynecol. Jan 2008;198:56.e1-4. [Medline].

  25. Hoo JJ. Acupressure for hyperemesis gravidarum. Am J Obstet Gynecol. Jun 1997;176(6):1395-7. [Medline].

  26. Jacoby EB, Porter KB. Helicobacter pylori infection and persistent hyperemesis gravidarum. Am J Perinatol. 1999;16:85-8. [Medline].

  27. Jewell D, Young G. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2003;CD000145. [Medline].

  28. Kocak I, Akcan Y, Ustun C, et al. Helicobacter pylori seropositivity in patients with hyperemesis gravidarum. Int J Gynaecol Obstet. Sep 1999;66(3):251-4. [Medline].

  29. Kousen M. Treatment of nausea and vomiting in pregnancy. Am Fam Physician. Nov 15 1993;48(7):1279-84. [Medline].

  30. Lee RH, Pan VL, Wing DA. The prevalence of Helicobacter pylori in the Hispanic population affected by hyperemesis gravidarum. Am J Obstet Gynecol. Sep 2005;193(3 Pt 2):1024-7. [Medline].

  31. Meighan M, Wood AF. The impact of hyperemesis gravidarum on maternal role assumption. J Obstet Gynecol Neonatal Nurs. Mar-Apr 2005;34(2):172-9. [Medline].

  32. Nageotte MP, Briggs GG, Towers CV. Droperidol and diphenhydramine in the management of hyperemesis gravidarum. Am J Obstet Gynecol. Jun 1996;174(6):1801-5; discussion 1805-6. [Medline].

  33. Nelson-Piercy C. Treatment of nausea and vomiting in pregnancy. When should it be treated and what can be safely taken?. Drug Saf. Aug 1998;19(2):155-64. [Medline].

  34. Newman V, Fullerton JT, Anderson PO. Clinical advances in the management of severe nausea and vomiting during pregnancy. J Obstet Gynecol Neonatal Nurs. Nov-Dec 1993;22(6):483-90. [Medline].

  35. Park-Wyllie L, Mazzotta P, Pastuszak A, et al. Birth defects after maternal exposure to corticosteroids: prospective cohort study and meta-analysis of epidemiological studies. Teratology. Dec 2000;62(6):385-92. [Medline].

  36. Petik D, Puho E, Czeizel AE. Evaluation of maternal infusion therapy during pregnancy for fetal development. Int J Med Sci. Oct 2005;2(4):137-42. [Medline].

  37. Quinlan JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. Jul 2003;68 (1):121-8. [Medline].

  38. Robinson JN, Banerjee R, Thiet MP. Coagulopathy secondary to vitamin K deficiency in hyperemesis gravidarum. Obstet Gynecol. Oct 1998;92(4 Pt 2):673-5. [Medline].

  39. Rodriguez-Pinilla E, Martinez-Frias ML. Corticosteroids during pregnancy and oral clefts: a case-control study. Teratology. Jul 1998;58(1):2-5. [Medline].

  40. Russo-Stieglitz KE, Levine AB, Wagner BA. Pregnancy outcome in patients requiring parenteral nutrition. J Matern Fetal Med. Jul-Aug 1999;8(4):164-7. [Medline].

  41. Safari HR, Alsulyman OM, Gherman RB. Experience with oral methylprednisolone in the treatment of refractory hyperemesis gravidarum. Am J Obstet Gynecol. May 1998;178(5):1054-8. [Medline].

  42. Safari HR, Fassett MJ, Souter IC. The efficacy of methylprednisolone in the treatment of hyperemesis gravidarum: a randomized, double-blind, controlled study. Am J Obstet Gynecol. Oct 1998;179(4):921-4. [Medline].

  43. Sahakian V, Rouse D, Sipes S, et al. Vitamin B6 is effective therapy for nausea and vomiting of pregnancy: a randomized, double-blind placebo-controlled study. Obstet Gynecol. Jul 1991;78(1):33-6. [Medline].

  44. Selitsky T, Chandra P, Schiavello HJ. Wernicke's encephalopathy with hyperemesis and ketoacidosis. Obstet Gynecol. Feb 2006;107(2 Pt 2):486-90. [Medline].

  45. Serrano P, Velloso A, Garcia-Luna PP. Enteral nutrition by percutaneous endoscopic gastrojejunostomy in severe hyperemesis gravidarum: a report of two cases. Clin Nutr. Jun 1998;17(3):135-9. [Medline].

  46. Sullivan CA, Johnson CA, Roach H. A pilot study of intravenous ondansetron for hyperemesis gravidarum. Am J Obstet Gynecol. May 1996;174(5):1565-8. [Medline].

  47. Verberg MF, Gillott DJ, Al-Fardan N. Hyperemesis gravidarum, a literature review. Hum Reprod Update. Sep-Oct 2005;11(5):527-39:[Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

hyperemesis gravidarum, nausea and vomiting in pregnancy, pernicious vomiting in pregnancy, uncontrollable vomiting in pregnancy, severe nausea and vomiting in pregnancy, morning sickness, miscarriage

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Susan Renee Wilcox, MD, Resident, Department of Emergency Medicine, Harvard Medical School
Susan Renee Wilcox, MD is a member of the following medical societies: Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Alison Edelman, MD, Assistant Professor, Department of Obstetrics and Gynecology, Oregon Health Sciences University
Alison Edelman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists
Disclosure: Organon Honoraria Speaking and teaching

Judith R Logan, MD, MS, Assistant Professor, Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University
Judith R Logan, MD, MS is a member of the following medical societies: American Medical Informatics Association
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.