A 26-year-old primigravid patient at 8 weeks gestation comes to the office to establish prenatal care. She has felt intermittently nauseous for the past 2 weeks, resulting in vomiting once every morning. Her appetite is unpredictable; at times, she does not eat breakfast or lunch and then eats more than she intended for dinner. The patient shares that she has noticed that she already looks pregnant, and that she recently had to switch to wearing maternity clothing. She does not use tobacco, alcohol, or illicit drugs. The patient takes a prenatal vitamin every morning. Vital signs are normal. Weight has decreased by 2 kg (4.4 lb) compared to her prepregnancy weight; BMI is 21 kg/m². Physical examination shows no abnormalities. Transvaginal ultrasound shows a single intrauterine gestation with a heart rate of 150/min. Complete blood count and comprehensive metabolic panel are normal. Urinalysis is negative for ketones. Which of the following is the best next step in management of this patient's vomiting?

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Quizplus · Accepted Answer

Explanation: Nausea and vomiting during pregnancy affects many women in the first trimester and is relatively mild with no associated weight loss, hypovolemia, or electrolyte abnormalities. Most cases of nausea and vomiting during pregnancy typically resolve by the mid-second trimester; therefore, management is usually supportive with dietary modifications (eg, small, scheduled meals; taking medications with food/at night) and vitamin B₆ (pyridoxine) therapy (Choices A, C, D, and E). ₆ However, some cases of nausea and vomiting during pregnancy can mask an underlying eating disorder, as in this patient with potential concerning findings, including: Weight loss with an already relatively low BMI Unpredictable appetite (suggesting dysregulated eating habits) with skipping meals (suggesting possible caloric restriction) followed by episodes of overeating (suggesting possible binge eating) Distorted view of body weight and shape, evidenced by the perception of "looking pregnant" despite her early gestational age (when the uterus is still below the pubic symphysis) and her switch to maternity clothing despite weight loss Therefore, this patient requires additional evaluation for disordered eating behaviors (eg, self-induced vomiting, purging, excessive exercise). In some women with eating disorders, pregnancy is an added stressor that increases disordered eating behaviors. These patients are at increased risk for obstetric complications (eg, spontaneous abortion, low birth weight, microcephaly). Therefore, patients with an eating disorder during pregnancy will benefit from nutritional counseling, setting expectations for pregnancy-related changes in body weight and size, and psychotherapy to establish or reinforce normal eating patterns. Educational objective: Mild nausea and vomiting during pregnancy is common in the first trimester. However, patients with concerning findings (eg, weight loss, distorted body image, disordered eating behaviors) require evaluation for an underlying eating disorder. References: Nausea and vomiting of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/25162163) Patterns of remission, continuation and incidence of broadly defined eating disorders during early pregnancy in the Norwegian Mother and Child Cohort Study (MoBa). (http://www.ncbi.nlm.nih.gov/pubmed/17493296)

A 26-Year-Old Primigravid Patient at 8 Weeks Gestation Comes to the Office