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Mary Jane doe, a 21 y/o pregnant female, complaint of nausea and vomiting daily for one month. The N&V started gradually in the mornings each day and lasts until just after the noon hour. There are no relieving factors or aggravating factors. There have been no treatments at this time, she states that she was told that N&V is normal during pregnancy by her mother. She states that she can not keep anything down in the mornings and for the last two weeks she eats very little at night for fear of upsetting her belly in the morning, she feels that she has been losing a lot of weight. She is 8 weeks pregnant today. This is her first pregnancy. She reports pain in the RUQ sporadically.
PMHx- Migraine headaches
PSHx- 3rd molars removed, cholecystectomy.
All-NKDA
SocialHx- Caffeine- a cup of coffee most mornings. No ETOH, No Tobacco. Exercise in the evenings with friends is usually a 1–2-mile walk.
Medication- prenatal vitamin
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DDX: Nausea and vomiting of pregnancy; hyperemesis gravidarum; Hepatitis.
Nausea and vomiting if pregnancy (NVP) is a common occurrence that affects as many as 70% of pregnant women (Fejzo et al., 2019). The symptoms usually start around the 6-8th week of gestation and usually subside near weeks 16-20 (Fejzo et al., 2019). The symptoms can last just in the morning hence the common term morning sickness or it can last the entire day in a sporadic pattern (Fejzo et al., 2019). Hyperemesis gravidarum (HG) is a more severe type of NVP characterized by severe intractable vomiting, often associated with >5% weight loss, dehydration, ketonuria, nutritional deficiencies, and electrolyte imbalance (Fejzo et al., 2019). The beginning of HG can precede that of NVP by 2 weeks or so, beginning as early as week 4 of gestation. This patient’s RUQ pain is unusual because she has had a cholecystectomy. However, it is not uncommon for a pregnant woman to develop liver diseases from HG or other conditions like intrahepatic cholestasis of pregnancy (Sasamori et al., 2020). Liver disease is a later disease process in pregnancy, usually in the third trimester but is worth investigating early if exacerbating factors exist (Sasamori et al., 2020).
The pathology of NVP and HG is largely unknown but some believe that genetics, endocrine, and gastrointestinal factors lead to the onset of the conditions (Fejzo et al., 2019). It is also believed that placental-mediated mechanisms, reproductive hormones, and gastrointestinal
dysmotility with serotonin and thyroid hormones are involved in some way (Sasamori et al., 2020). Hepatitis in pregnancy can because by HG the longer the symptoms persist eventually elevating the aspartate transaminase and alanine aminotransferase enzymes (Sasamori et al., 2020).
The demographics related to these conditions are somewhat varied. NVP was found to have no true ethnic differences although some studies found that rates were lower in Africa and Asia (Fejzo et al., 2019). HG was found to be more prevalent in non-white and non-Hispanic patients in a study of over 500 thousand births in California (Fejzo et al., 2019).
Testing
NVP does not require a test for diagnoses as it is mainly clinical.
HG would require: a comprehensive metabolic panel which will show hyponatremia and hypochloremia, elevated BUN and creatinine; Urinalysis will show ketonuria and abnormal specific gravity; TSH which can be decreased; T4 if the TSH is decreased (Fejzo et al., 2019).
Hepatitis would be ruled out with Serum LFTs (Sasamori et al., 2020).
One of the better guidelines to use if you can get your hands on it is the American College of Obstetrics and Gynecology practice bulletin no. 189: nausea and vomiting of pregnancy
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