A 25-year-old woman, gravida 1 para 0, at 8 weeks gestation comes to the emergency department due to nausea and vomiting. The patient has had nausea and vomiting once or twice a day for the past 2 weeks; today, she has vomited 3 times, but has been able to tolerate liquids and small snacks. She has no fever, chills, diarrhea, or sick contacts. The patient has had no vaginal bleeding, dysuria, or abdominal pain. She has gastroesophageal reflux disease, and has been following a diet of small, frequent, bland meals. The patient takes a daily prenatal vitamin and H₂ receptor antagonist. Temperature is 36.7 C (98.1 F), blood pressure is 100/60 mm Hg, and heart rate is 80/min. Weight is 50 kg (110.2 lb), a 0.8-kg (1.8-lb) increase from her prepregnancy weight. Mucous membranes are moist. Cardiac examination shows a regular rate and rhythm with no murmurs. The abdomen is soft, nontender, and nondistended. Serum electrolytes are normal. Urine dipstick is negative for ketones. Transvaginal ultrasound reveals an intrauterine pregnancy with cardiac activity at 160/min, and a crown-rump length consistent with an 8-week gestation. Which of the following is the most appropriate management for this patient?

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Explanation: 11ec2b69_c029_d532_8f63_ab1bbb9f685a_MD0005_00 Nausea and vomiting in pregnancy can range from mild discomfort to severe hyperemesis gravidarum. Young primigravid patients are at increased risk, as are women with a history of nausea and vomiting in a previous pregnancy or those who experience nausea secondary to motion or estrogen-based medications. This patient has nausea and vomiting but no laboratory abnormalities or dehydration, suggestive of mild disease. Lack of ketonuria suggests adequate caloric intake. By contrast, clinical manifestations of hyperemesis gravidarum would include persistent vomiting, a >5% loss in body weight, and dehydration. Patients with mild disease are managed on an outpatient basis and reevaluated if symptoms worsen. Patients are recommended to eat small, frequent, bland meals. Initial pharmacotherapy is with oral vitamin B₆ and an H₁ antihistamine. Second-line therapies include dopamine antagonists (eg, metoclopramide) and serotonin antagonists (eg, ondansetron). Patients with severe nausea and vomiting in pregnancy (eg, hyperemesis gravidarum) typically do not respond to outpatient treatment, and therefore require admission to the hospital. Initial inpatient therapy is with intravenous hydration and antiemetics (Choice C). Patients with refractory disease may require glucocorticoid therapy, although glucocorticoids are typically reserved until after 10 weeks gestation due to the risk of cleft palate formation (Choice B). Finally, those who are refractory to all therapies require nutritional support with total parenteral nutrition or tube feedings (Choice A). The majority of cases of nausea and vomiting in pregnancy resolve by 20 weeks gestation and do not cause long-term sequelae to the mother or fetus. Even with protracted hyperemesis gravidarum, most studies have not demonstrated adverse effects on birth weight or neurological development. (Choice E) Acid-reducing agents alleviate some symptoms associated with nausea and vomiting of pregnancy. H₂ antagonists are effective and safe in pregnancy. Proton pump inhibitors are equally efficacious but have not been investigated as thoroughly in pregnancy as H₂ antagonists. Educational objective: Nausea and vomiting in pregnancy can range from mild disease to severe hyperemesis gravidarum. Mild disease has no associated laboratory abnormalities or signs of dehydration. Initial treatment for mild disease is outpatient therapy with oral vitamin B₆ and an H₁ antihistamine. ₆ References: The management of nausea and vomiting of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/27986189) Demonstration of early efficacy results of the delayed-release combination of doxylamine-pyridoxine for the treatment of nausea and vomiting of pregnancy. (http://www.ncbi.nlm.nih.gov/pubmed/27881103)

A 25-Year-Old Woman, Gravida 1 Para 0, at 8 Weeks