Eduovisual
Pregnancy, Childbirth & Puerperium
Nausea and vomiting of pregnancy: management
— Symptoms typically begin 4–6 weeks gestation, peak at 9–12 weeks, and resolve by 16–20 weeks in ~90%.
— New-onset nausea/vomiting after 9 weeks or persisting beyond 20 weeks should trigger evaluation for alternative etiologies.
— Persistent vomiting unrelated to other causes
— Acute starvation (usually ketonuria)
— Weight loss >5% of pre-pregnancy weight
— Often with electrolyte, acid-base, or thyroid abnormalities
— Mild ≤6, Moderate 7–12, Severe ≥13
— Drives outpatient vs inpatient management decisions
— Prior NVP/HG, molar pregnancy, multiple gestation, female fetus, history of motion sickness or migraines, family history, maternal hyperthyroidism, H. pylori infection
— Driven by hCG (peaks parallel symptoms) and estrogen; GDF15 elevation now strongly implicated
— Explains worse symptoms in molar/twin pregnancies (higher hCG)
Board pearl: New-onset vomiting after 9 weeks gestation, or any vomiting with abdominal pain, fever, headache, or neurologic findings, is not NVP — work it up. NVP is a diagnosis of exclusion when red flags are present.
Step 3 management: Early recognition matters because starting therapy early prevents progression to HG. The classic outpatient question stem opens with a 9-week gravida with morning nausea — your job is to initiate stepwise therapy before she ends up in the ED dehydrated.
— Nausea ± vomiting, often worst in morning but can be any time ("morning sickness" is a misnomer in ~80%)
— Triggered by odors, brushing teeth, prenatal vitamins (especially iron), fatty foods
— Tolerating some PO intake, urinating normally, stable weight
— Inability to keep down liquids, >5% weight loss, lightheadedness, decreased urine output, ptyalism (spitting saliva), dysgeusia
— Often misses work, multiple ED visits
— LMP and gestational age confirmation — must establish dating
— Frequency/volume of emesis, last tolerated PO intake, urine output
— Prior pregnancy NVP/HG history (recurrence risk ~80%)
— Current medications, prenatal vitamin formulation, iron content
— PUQE-24 symptom scoring
— Abdominal pain → appendicitis, cholecystitis, pancreatitis, ectopic
— Fever → pyelonephritis, gastroenteritis, cholangitis
— Headache/visual changes/BP → preeclampsia (though usually >20 wk)
— Hematemesis → Mallory-Weiss tear from forceful vomiting
— Neuro symptoms (confusion, ataxia, diplopia) → Wernicke encephalopathy from thiamine deficiency
— Heat intolerance, palpitations, tremor → gestational transient hyperthyroidism vs Graves
— NVP/HG strongly associated with depression, anxiety, PTSD, and termination of desired pregnancies in severe cases — screen and offer support
Key distinction: NVP allows some PO intake and maintained weight; HG features dehydration signs, weight loss >5%, ketonuria, and electrolyte derangements. The PUQE-24 score operationalizes this distinction and is the preferred quantitative tool on Step 3 ambulatory stems.
Board pearl: Always ask about iron-containing prenatal vitamins — switching to a folate-only formulation in the first trimester often dramatically reduces nausea and is a free intervention.
— Mild NVP: well-appearing, normal vitals, no distress
— HG: ill-appearing, fatigued, may smell ketotic
— Tachycardia (>100) — earliest sign of volume depletion
— Orthostatic hypotension — drop in SBP ≥20 or DBP ≥10, or HR rise ≥30 on standing
— Low-grade temp may reflect dehydration; true fever >38°C suggests alternate diagnosis
— BP usually preserved or low; hypertension warrants preeclampsia workup if ≥20 weeks
— Dry mucous membranes, decreased skin turgor, sunken eyes
— Capillary refill >2 sec, cool extremities in severe cases
— Decreased urine output, dark concentrated urine
— Compare to pre-pregnancy weight — >5% loss defines HG threshold
— Document at every visit for trend
— Should be benign in NVP/HG — soft, non-tender, no peritoneal signs
— Epigastric tenderness only → consider Mallory-Weiss, gastritis, pancreatitis
— RUQ tenderness → cholecystitis, hepatitis, HELLP if late
— RLQ → appendicitis (point of maximal tenderness may be displaced upward in pregnancy)
— Goiter, ophthalmopathy, hyperreflexia suggest Graves disease rather than gestational transient hyperthyroidism
— Ataxia, nystagmus, confusion = Wernicke encephalopathy — emergency in prolonged HG without thiamine replacement
— Hyporeflexia in severe hypokalemia or hypomagnesemia
Step 3 management: In any HG patient requiring IV fluids, give thiamine 100 mg IV/IM BEFORE any dextrose-containing fluid to prevent precipitating Wernicke encephalopathy. This is a classic CCS misstep where dextrose is ordered first.
Board pearl: A pregnant patient with HG and new ataxia/confusion is Wernicke until proven otherwise — even without alcohol history.
— Often no labs needed; clinical diagnosis
— Urine dipstick for ketones and specific gravity if borderline
— CBC — hemoconcentration (elevated Hct) from dehydration
— BMP/CMP
– Hypokalemia, hyponatremia, hypochloremic metabolic alkalosis (classic from vomiting gastric HCl)
– BUN/Cr ratio >20 (prerenal)
– Elevated AST/ALT (mild, <300) in up to 50% of HG — normalizes with treatment
— Urinalysis — ketonuria, elevated specific gravity
– Note: ketonuria correlates poorly with HG severity per recent ACOG guidance but still commonly tested
— Urine culture — rule out occult UTI/pyelonephritis as trigger
— TSH, free T4 — biochemical hyperthyroidism in 60% of HG (gestational transient thyrotoxicosis from hCG cross-reactivity)
– Usually suppressed TSH with normal/mildly elevated FT4, no antibodies, no goiter
— Beta-hCG quantitative — markedly elevated suggests molar or multiple gestation
— Pelvic ultrasound is mandatory in significant HG
– Confirms intrauterine pregnancy, dating, rules out molar pregnancy (snowstorm/cluster of grapes) and multiples
— Abdominal US if RUQ pain/elevated LFTs (cholecystitis, choledocholithiasis)
— Orthostatic vitals, weight, urine ketones, glucose
Board pearl: Always order a pelvic ultrasound in HG before attributing severe symptoms to "just bad NVP" — missing a complete hydatidiform mole is a high-yield miss. Theca lutein cysts and absent fetal parts seal the diagnosis.
Key distinction: Gestational transient hyperthyroidism = no TRAb, no goiter, no ophthalmopathy, resolves by 18–20 wk. Do not treat with antithyroid drugs — treat the HG and the thyroid normalizes.
— Repeat pelvic ultrasound for interval growth, viability, completing anatomy if appropriate
— Lipase — pancreatitis (pregnancy is a risk for gallstone pancreatitis)
— GGT, alkaline phosphatase, bilirubin — cholestasis (though intrahepatic cholestasis of pregnancy is later, presents with pruritus)
— Ammonia if encephalopathy — acute fatty liver of pregnancy (third trimester, but consider)
— Stool studies (C. diff if antibiotic exposure, ova/parasites if exposure)
— H. pylori testing — strongly associated with refractory HG; stool antigen or urea breath test preferred in pregnancy (avoid endoscopy unless essential)
— Hepatitis serologies if transaminitis >5x normal
— RUQ ultrasound — cholelithiasis, hepatic pathology
— MRI abdomen/pelvis without gadolinium — preferred over CT for suspected appendicitis, SBO, or unclear pathology in pregnancy
— Non-contrast CT only if MRI unavailable and benefit outweighs fetal radiation
— Clinical diagnosis — do not delay treatment for imaging
— MRI brain may show mammillary body, periaqueductal enhancement (confirmatory, not required)
— Serum thiamine level is slow and unreliable acutely
— Reserved for hematemesis, refractory symptoms, suspected ulcer — safe in pregnancy with sedation precautions
— PHQ-9, GAD-7 screening in protracted HG — major depression coexists in 20–30%
Step 3 management: In refractory HG not responding to standard antiemetics, test and treat H. pylori (amoxicillin + metronidazole + PPI — clarithromycin avoided due to first-trimester concerns). This step is increasingly emphasized on Step 3.
Board pearl: Avoid radiation when possible; MRI without gadolinium is the imaging modality of choice for complex abdominal pain in pregnancy.
— Tailored to PUQE-24 severity and ability to tolerate PO
— Small frequent meals, bland/dry carbs (crackers before rising), avoid triggers
— Discontinue iron-containing prenatal vitamins in first trimester; substitute folic acid alone
— Ginger 250 mg PO QID — evidence-based, safe in pregnancy
— Acupressure (P6/Neiguan wristbands) — low-cost adjunct
— Hydration with small sips, electrolyte-containing beverages
— Vitamin B6 (pyridoxine) 10–25 mg PO every 6–8 hours
— Add doxylamine 12.5 mg if pyridoxine alone insufficient
— Available as combination delayed-release Diclegis/Bonjesta (pyridoxine-doxylamine) — only FDA-approved drug for NVP
— Dimenhydrinate, diphenhydramine, meclizine (H1 antihistamines)
— Metoclopramide (dopamine antagonist) — watch for EPS, tardive dyskinesia
— Promethazine, prochlorperazine (phenothiazines) — caution for sedation, EPS
— Ondansetron 4–8 mg PO/IV q8h — first-line in refractory cases
– Pre-10 weeks: small absolute risk of cleft palate (1 in 1000 baseline → ~1.4 in 1000); discuss risk/benefit
– QT prolongation — check ECG/electrolytes
— IV hydration with NS or LR, electrolyte repletion, thiamine before dextrose
— Methylprednisolone (avoid before 10 weeks — oral cleft signal)
— Enteral or parenteral nutrition if persistent weight loss
— Inpatient admission
CCS pearl: On a CCS-style case, advance the location to ED → inpatient ward when the patient cannot tolerate PO, has ketonuria, or has lost >5% weight. Order NS bolus + IV ondansetron + IV thiamine + electrolyte repletion, then advance the clock.
— 10–25 mg PO every 6–8 hours (max ~200 mg/day)
— Pregnancy category A; safe in all trimesters
— Mechanism unclear; consistently reduces nausea more than vomiting
— 12.5 mg PO with each pyridoxine dose, or 25 mg at bedtime
— Sedating — counsel about driving, daytime drowsiness
— Combination delayed-release pyridoxine 10 mg + doxylamine 10 mg (Diclegis): 2 tabs at bedtime, can increase to 4 tabs/day (1 AM, 1 mid-afternoon, 2 bedtime)
— Dimenhydrinate 50–100 mg PO/IV/PR q4–6h
— Diphenhydramine 25–50 mg PO/IV q6h
— Meclizine 25 mg PO q6h
— Metoclopramide 5–10 mg PO/IV q6–8h — preferred prokinetic in pregnancy
– Limit to <12 weeks of therapy (tardive dyskinesia risk)
– Watch for acute dystonia — treat with diphenhydramine
— Promethazine 12.5–25 mg PO/PR/IV q4–6h — IV must be diluted and given in a large vein (extravasation causes tissue necrosis; black box)
— Prochlorperazine 5–10 mg PO/IM/IV q6–8h
— 4–8 mg PO/ODT/IV q8h
— Most effective single agent for refractory NVP
— Counseling points:
– Small increased risk of cleft palate with use before 10 weeks (absolute risk remains <0.2%)
– QT prolongation — caution with other QT-prolonging drugs, electrolyte derangements
– Constipation common
— Methylprednisolone 16 mg PO q8h × 3 days, then taper over 2 weeks
— Avoid before 10 weeks due to oral cleft association
— Reserve for true refractory HG
Board pearl: Pyridoxine + doxylamine is the answer for first-line pharmacologic management of NVP on Step 3 — even when ondansetron seems tempting. Reserve ondansetron for failure of first-line agents or significant dehydration.
— Inability to tolerate PO for >24 hours, weight loss >5%, intractable vomiting, electrolyte derangement, suspected Wernicke, failure of outpatient regimens
— Normal saline or lactated Ringer's bolus 1–2 L, then maintenance
— Avoid dextrose-containing fluids until thiamine 100 mg IV given — Wernicke prophylaxis
— Add 5% dextrose to maintenance fluids once thiamine on board to reverse ketosis
— Replace K+, Mg2+, phosphate aggressively; monitor for refeeding syndrome
— IV ondansetron 4–8 mg q8h scheduled
— Add IV metoclopramide or promethazine
— Add methylprednisolone 16 mg IV q8h if refractory >48 h and >10 weeks gestation
— 100 mg IV daily × 2–3 days prophylactically in any HG patient with prolonged vomiting (>3 weeks) or before any glucose load
— Higher doses (500 mg IV TID × 2 days) if Wernicke suspected
— Trial small frequent oral intake; if failure >5–7 days:
– Enteral nutrition via nasoduodenal/nasojejunal tube — preferred over TPN
– TPN only if enteral fails — high risk of CLABSI, thrombosis, hepatic dysfunction; one of the leading causes of HG-related maternal mortality
— Mirtazapine 15 mg qHS — emerging evidence for refractory HG (off-label)
— Gabapentin — limited but growing evidence
— Pregnancy + dehydration + immobility = high VTE risk; mechanical prophylaxis routinely; consider LMWH in prolonged admission
— Tolerating PO ≥24 h, stable weight, normalized electrolytes, ketone-negative urine, established outpatient regimen and follow-up
CCS pearl: In a refractory HG CCS case, your order set should include NS + KCl + IV thiamine + IV ondansetron + scheduled metoclopramide + DVT mechanical prophylaxis + daily weights + strict I/O + nutrition consult. Re-check BMP daily and shift location back to outpatient once stable for 24 h.
— Dose adjustments:
– Metoclopramide — reduce by 50% if CrCl <40 (CNS toxicity, dystonia risk)
– Ondansetron — generally no adjustment for renal; max 8 mg/day if severe hepatic disease
– Promethazine — caution in renal impairment (active metabolite accumulation)
— Monitor BUN/Cr daily during HG admission; HG can precipitate prerenal AKI that resolves with hydration
— Avoid NSAIDs for any indication in pregnancy after 20 weeks (premature ductal closure, oligohydramnios) — relevant for headache adjuncts
— Mild transaminitis is common in HG and does not require drug discontinuation; ALT >300 should prompt alternative diagnosis search
— Avoid hepatotoxic agents; cap acetaminophen at 2 g/day if baseline LFTs elevated
— Methylprednisolone — caution with active hepatic disease
— Ondansetron QT prolongation — obtain baseline ECG in patients with structural heart disease, electrolyte abnormalities, or concomitant QT-prolonging meds
— Pregnancy itself shortens QTc slightly; corrected formulas (Bazett) still apply
— Pre-existing Graves disease: differentiate from gestational transient hyperthyroidism by TRAb positivity, goiter, ophthalmopathy — treat with PTU in first trimester, methimazole in second/third
— Type 1 diabetics with HG are at high risk for DKA at lower glucose thresholds (euglycemic DKA) — check ketones aggressively, lower threshold for insulin drip
— Resume long-acting insulin even when NPO; cover with D5 in IV fluids
Step 3 management: In a type 1 diabetic pregnant patient with HG, measure beta-hydroxybutyrate — pregnancy-associated euglycemic DKA can occur with glucose <200 and demands prompt insulin + dextrose + fluids.
Board pearl: HG-related AKI is almost always prerenal and reversible — aggressive crystalloid is the answer, not nephrology consult first.
— Highest teratogen-avoidance window (organogenesis weeks 3–8)
— Drugs to avoid before 10 weeks:
– Corticosteroids (oral cleft signal)
– Ondansetron ideally avoided pre-10 wk; if needed, document shared decision-making (absolute risk small)
— Drugs considered safe across first trimester: pyridoxine, doxylamine, antihistamines, metoclopramide, promethazine
— Persistent vomiting beyond 20 weeks: rethink the diagnosis — workup for preeclampsia, HELLP, acute fatty liver, cholecystitis, pancreatitis, intracranial pathology
— Late-pregnancy steroids generally safe; ondansetron concerns abate
— Higher hCG → worse NVP/HG; threshold for early aggressive therapy is lower
— Earlier dietary counseling, earlier escalation to combination antiemetics
— HG with markedly elevated hCG, uterus larger than dates, no fetal heart tones, snowstorm US = gestational trophoblastic disease
— Management: suction D&C, then serial hCG monitoring weekly until undetectable × 3, then monthly × 6 months
— Contraception during surveillance to avoid confounding hCG
— Higher rates of late prenatal care, food insecurity, and psychosocial stress amplifying HG
— Confidentiality and consent: most states allow minors to consent to prenatal care without parental notification
— Screen for intimate partner violence, depression, and educational disruption
— Recurrence risk ~80% — counsel preconception
— Start pyridoxine ± doxylamine prophylactically before symptom onset (around 5–6 weeks) in next pregnancy
Board pearl: First-trimester vomiting + uterine size > dates + hCG >100,000 → order pelvic ultrasound for molar pregnancy before treating as HG.
Key distinction: Vomiting starting after 20 weeks is almost never NVP — pursue preeclampsia spectrum, HELLP, AFLP, surgical abdomen.
— Dehydration and electrolyte derangements
– Hypokalemia (cardiac arrhythmias, weakness)
– Hypochloremic metabolic alkalosis
– Hyponatremia — rapid correction risks central pontine myelinolysis
– Hypomagnesemia, hypophosphatemia (refeeding risk)
— Wernicke encephalopathy — thiamine deficiency from prolonged vomiting + IV glucose without thiamine; classic triad of confusion, ataxia, ophthalmoplegia; can progress to Korsakoff if untreated
— Mallory-Weiss tear — hematemesis after forceful vomiting
— Esophageal rupture (Boerhaave) — rare but lethal
— Pneumomediastinum from retching
— Acute kidney injury — prerenal, usually reversible
— Transaminitis — common, mild, reversible
— Venous thromboembolism — dehydration + immobility + pregnancy hypercoagulability
— Vitamin K deficiency — coagulopathy, rare maternal/neonatal hemorrhage
— Refeeding syndrome when nutrition restarted aggressively
— Major depression, anxiety, PTSD during and after pregnancy
— Job loss, financial strain, relationship stress
— Decision to terminate a desired pregnancy in severe HG — counsel and offer mental health support
— Most NVP: no adverse fetal effects; actually associated with lower miscarriage rates
— Severe HG with significant maternal weight loss / micronutrient deficiency:
– Small for gestational age, preterm birth, lower birth weight
– Possible neurodevelopmental implications with maternal Wernicke
— Generally no increased risk of major malformations from HG itself
— HG associated with future HG in subsequent pregnancies, and emerging data on offspring autoimmune/psychiatric risks (preliminary)
Step 3 management: Correct hyponatremia in HG slowly — no more than 8–10 mEq/L in 24 hours to avoid osmotic demyelination. This is a high-yield CCS trap when patients arrive with serum Na 118 and tempting boluses.
Board pearl: Thiamine before dextrose is the single most important order in any HG inpatient case.
— Mild-moderate symptoms, tolerating sips, no significant weight loss, normal labs, reliable follow-up
— Unable to tolerate PO >12–24 h, orthostasis, ketonuria, mild electrolyte derangement
— Often discharged after IV fluids, IV antiemetic, oral regimen optimization, 24-hour follow-up
— Persistent vomiting despite ED therapy
— Weight loss >5% pre-pregnancy weight
— Severe electrolyte/acid-base disturbance (K <3.0, Na <130, bicarb >32)
— AKI, severe transaminitis, suspected Wernicke
— Failure of outpatient regimens at maximal doses
— Psychosocial inability to maintain hydration at home
— Hemodynamic instability, severe electrolyte derangement with arrhythmia
— Wernicke with altered mental status
— Esophageal rupture, severe Mallory-Weiss with hemodynamic compromise
— TPN with sepsis/CLABSI
— Coexistent DKA in type 1 diabetics
— MFM (maternal-fetal medicine) — refractory HG, multiple gestation, molar pregnancy management
— GI — refractory symptoms, suspected ulcer/H. pylori, endoscopy
— Nutrition — TPN/enteral planning, refeeding monitoring
— Psychiatry — depression, PTSD, suicidal ideation
— Endocrine — persistent hyperthyroidism beyond 20 weeks, thyroid antibodies positive, diabetic management
— Social work — food insecurity, IPV, work accommodations
— At discharge: clear written instructions, antiemetic schedule (scheduled not PRN), follow-up in 48–72 hours, ED return precautions
CCS pearl: Schedule early outpatient follow-up (2–3 days) after HG discharge — bouncebacks are common. Order home health for IV hydration in select payers/regions if available. Always reorder home antiemetics on the scheduled dosing, not PRN.
— Acute onset, often with diarrhea, fever, sick contacts
— NVP rarely causes diarrhea — its presence shifts diagnosis
— Epigastric pain related to meals, H. pylori association
— Diagnose with H. pylori testing; endoscopy if alarm features
— Worsens through pregnancy (progesterone-mediated LES relaxation, uterine pressure)
— Heartburn, regurgitation, nocturnal symptoms
— Treat with antacids, sucralfate, H2 blockers (famotidine), PPIs (omeprazole, lansoprazole)
— Pregnancy promotes biliary stasis and stone formation
— RUQ pain post-fatty meal, Murphy sign, leukocytosis, elevated AST/ALT/ALP
— US confirms; laparoscopic cholecystectomy preferred in second trimester if needed
— Most often gallstone-induced in pregnancy
— Epigastric pain radiating to back, lipase >3× ULN
— Most common surgical emergency in pregnancy
— Point of tenderness migrates upward and laterally as uterus enlarges
— MRI preferred imaging (US first if early)
— Appendectomy regardless of trimester if confirmed
— Prior surgery (adhesions), volvulus risk increases with gravid uterus
— Distension, obstipation, hyperactive→absent bowel sounds
— Imaging: MRI or limited CT
— Marked transaminase elevation (often >1000), jaundice
— Hepatitis serologies
Key distinction: NVP/HG has benign abdominal exam, no diarrhea, no fever, mild transaminitis (<300), and improves with hydration/antiemetics. Persistent or worsening pain, focal tenderness, peritoneal signs, or transaminases >300 mandate alternative workup.
Board pearl: Appendicitis in pregnancy can mimic HG early — always palpate the abdomen carefully on every visit and image with MRI if uncertain.
— Pregnancy promotes ureteral dilation and stasis (right > left)
— Fever, flank pain, dysuria, vomiting often prominent
— Treat with IV ceftriaxone; admit all pregnant pyelonephritis
— Screen all pregnant women for asymptomatic bacteriuria at first prenatal visit
— After 20 weeks: hypertension, proteinuria, headache, visual changes, RUQ pain
— HELLP: hemolysis, elevated LFTs, low platelets — vomiting common
— Definitive management: magnesium sulfate, antihypertensives, delivery
— Third trimester, malaise, vomiting, hypoglycemia, coagulopathy, hyperammonemia, elevated bilirubin
— Swansea criteria for diagnosis
— Management: prompt delivery, supportive care, may need transplant
— Often improves in pregnancy but can persist with vomiting
— Treatment: acetaminophen, metoclopramide, magnesium; avoid triptans first-trimester if alternatives available; avoid NSAIDs after 20 weeks
— New severe headache, focal deficits, papilledema → consider CVST (pregnancy hypercoagulability), pituitary apoplexy, mass lesion
— MRI brain
— Anion gap, ketosis, dehydration
— Hypotension, hyponatremia, hyperkalemia, hyperpigmentation
— Pregnancy can unmask Addison disease
— Iron in prenatal vitamins, opioids, antibiotics (especially erythromycin, metronidazole)
— Diagnosis of exclusion; history of bulimia/anorexia; screen carefully
Step 3 management: Any new severe headache in pregnancy with vomiting → MRI/MRV to rule out cerebral venous sinus thrombosis before attributing to migraine.
Board pearl: Vomiting + RUQ pain + elevated LFTs + low platelets in the third trimester = HELLP until proven otherwise — deliver promptly.
— Switch from iron-containing prenatal vitamin to folate-only preconception
— Begin pyridoxine 25 mg TID at 5–6 weeks gestation prophylactically
— Add doxylamine 12.5 mg qHS if breakthrough symptoms anticipated
— Schedule early prenatal visit (6–8 weeks) for proactive symptom management
— Scheduled, not PRN antiemetics for 1–2 weeks, then taper
— Typical regimen: Diclegis 2 tabs qHS, 1 mid-morning, 1 mid-afternoon + ondansetron 4–8 mg PO q8h PRN breakthrough + metoclopramide 10 mg PO q6h PRN as backup
— Folate-only prenatal vitamin until symptoms resolve, then resume standard
— Ranitidine alternative (famotidine) if reflux contributes
— Stool softeners (docusate) — ondansetron and opioids cause constipation
— Small frequent bland meals, avoid triggers, ginger, P6 wristbands
— Hydration goals (sip electrolyte solutions throughout day)
— Continue PHQ-9/GAD-7 monitoring
— Refer for therapy if persistent depression/anxiety
— Acknowledge HG as legitimate, debilitating condition — validate experience
— Resume standard prenatal vitamin once tolerating
— Vitamin K supplementation if prolonged HG (deficiency risk)
— Thiamine PO supplementation through pregnancy in protracted cases
— Documentation for FMLA, short-term disability, workplace adjustments
— Postpartum depression risk elevated — extended screening through 12 months postpartum
— Document HG history clearly in chart for next pregnancy counseling
Step 3 management: Scheduled dosing for 1–2 weeks after discharge is the right answer — not PRN. PRN regimens lead to symptom recurrence and readmission.
Board pearl: Pyridoxine prophylaxis starting at 5–6 weeks before symptom peak meaningfully reduces severity in patients with prior HG.
— Phone or in-person check within 48–72 hours
— Office visit within 1 week
— Weight, vitals, PUQE-24, urine ketones at each visit
— Repeat BMP if symptoms persist or electrolytes were significantly abnormal
— Confirm dating ultrasound 6–10 weeks
— First-trimester combined screen (NT + PAPP-A + free β-hCG) at 11–13 6/7 wk, or cell-free DNA
— Anatomy ultrasound at 18–22 weeks
— Standard glucose tolerance, anemia, Rh screening per ACOG schedule
— Weekly weight until trending upward and tolerating regular diet
— TSH/free T4 — recheck in 4–6 weeks; if biochemical hyperthyroidism persists beyond 20 weeks → endocrine
— LFTs — recheck after 1–2 weeks if elevated; should normalize
— Growth ultrasound at 28–32 weeks if significant weight loss occurred (assess for fetal growth restriction)
— Once tolerating regular diet for 1–2 weeks, taper scheduled antiemetics one agent at a time
— Many patients can discontinue by 16–20 weeks as natural resolution occurs
— Reassurance: NVP/HG does not harm the baby in most cases
— Realistic expectations: peak 9–12 weeks, resolution 16–20 weeks
— Return precautions: inability to keep fluids down for 12 hours, dizziness, dark urine, weight loss, abdominal pain, fever, neurologic symptoms
— Future pregnancy planning: 80% recurrence risk → prophylactic approach
— Confirm resolution of symptoms (HG resolves with delivery)
— Postpartum depression screening at 2 weeks, 6 weeks, and through 12 months
— Document detailed history for next pregnancy
CCS pearl: Schedule the 2-day phone follow-up and 1-week office visit at the time of discharge, not later. Step 3 cases reward proactive transition-of-care orders.
Board pearl: Persistent biochemical hyperthyroidism past 20 weeks needs endocrine workup — gestational transient hyperthyroidism should have resolved.
— Ondansetron pre-10 weeks: small absolute increase in cleft palate risk (~0.04% absolute) — document shared decision-making when benefits (preventing dehydration, weight loss, hospitalization) outweigh risks
— Corticosteroids pre-10 weeks: similar oral cleft signal — avoid unless truly refractory
— Use plain language; document patient understanding and choice
— A competent pregnant patient may refuse IV fluids, antiemetics, or admission even when clinically indicated
— Some severe HG patients seek termination of a desired pregnancy because of intolerable symptoms — counseling, validation, mental health support, and discussion of all options are standard of care
— Screen for intimate partner violence — HG and pregnancy increase IPV risk; reporting requirements vary by state (most allow but do not mandate without patient consent in competent adults)
— Substance use disorders during pregnancy: state laws vary; some require reporting, others prioritize treatment access — know your state
— Pregnancy Discrimination Act and Pregnant Workers Fairness Act (2023) require reasonable accommodations
— Provide documentation for accommodations, FMLA, short-term disability
— High readmission risk after HG discharge — explicit follow-up, medication reconciliation, return precautions
— Medication errors common: promethazine IV extravasation causes tissue necrosis (black box) — order dilute, slow IV, large vein explicitly; consider IM/PR if access poor
— Thiamine before dextrose is a recognized patient safety bundle item — include in order sets
— Most states allow minors to consent to prenatal care independently
— Confidentiality concerns with billing — counsel about explanation-of-benefits visibility
— Respect dietary preferences when designing bland-diet recommendations
— Religious considerations around medication and fasting
Step 3 management: When a patient with HG considers pregnancy termination due to symptom severity, validate suffering, optimize medical therapy aggressively, involve mental health, and respect her autonomous decision — neither pressure to continue nor to terminate.
Board pearl: If a stem mentions first-trimester vomiting + uterine size larger than dates + theca lutein cysts, the answer is suction D&C for hydatidiform mole, then weekly hCG surveillance and reliable contraception.
— 9-week gravida with persistent nausea, mild vomiting, tolerating sips, no weight loss, ketone-negative urine
— Question: best next pharmacologic step?
— Answer: pyridoxine + doxylamine (not ondansetron, not metoclopramide)
— HG patient admitted, ordered D5NS bolus, becomes confused with ataxia
— Answer: thiamine should have been given before dextrose
— Severe HG at 11 weeks, hCG 250,000, uterus 16-week size, no fetal heart tones
— Best next step: pelvic ultrasound → suction D&C with serial hCG surveillance
— HG with suppressed TSH, mildly elevated FT4, no goiter, no eye findings, no TRAb
— Answer: no antithyroid therapy needed; treat HG, recheck TSH at 18–20 weeks
— HG with Na 119, ordered aggressive 3% saline
— Answer: correct slowly (≤8–10 mEq/L per 24 h) to avoid osmotic demyelination
— NVP triggered by prenatal vitamin
— Answer: switch to folate-only formulation
— Third-trimester vomiting + RUQ pain + low platelets + elevated LFTs
— Answer: HELLP — magnesium, antihypertensives, delivery
— Patient with prior severe HG, now 6 weeks pregnant, no symptoms yet
— Answer: start pyridoxine ± doxylamine prophylactically now
— 8-week patient with refractory NVP, considering ondansetron
— Answer: discuss small absolute cleft palate risk vs benefits, document shared decision-making
— Persistent symptoms despite multi-agent therapy
— Answer: test for H. pylori (stool antigen/urea breath), treat if positive
CCS pearl: On CCS NVP/HG cases, the ordering rhythm is: PUQE-24 → urine ketones → BMP/TSH → pelvic US → pyridoxine-doxylamine → escalate antiemetics → IV fluids with thiamine first → admit if refractory → schedule 48-hour follow-up at discharge.
Nausea and vomiting of pregnancy is managed with a stepwise approach starting with dietary measures and pyridoxine-doxylamine, escalating through antihistamines, dopamine antagonists, and ondansetron, with IV hydration and thiamine-before-dextrose for hyperemesis gravidarum — always after ruling out molar pregnancy, multiple gestation, and alternative diagnoses.
— NVP peaks 9–12 weeks, resolves by 16–20 weeks; HG = persistent vomiting + ketonuria + >5% weight loss
— Use PUQE-24 to guide intensity of therapy
— Vomiting starting after 9 weeks or persisting beyond 20 weeks is not NVP — search for another cause
— Lifestyle + ginger + switch to folate-only prenatal vitamin + P6 wristbands
— First-line drug: pyridoxine ± doxylamine (Diclegis)
— Add antihistamines, then metoclopramide or promethazine, then ondansetron (counsel on small cleft palate risk pre-10 weeks)
— Refractory: methylprednisolone after 10 weeks, consider H. pylori treatment, enteral nutrition before TPN
— IV fluids (NS or LR), thiamine 100 mg IV before any dextrose, aggressive but slow electrolyte correction (Na ≤8–10 mEq/L/24 h), VTE prophylaxis, scheduled antiemetics
— Always order pelvic ultrasound to rule out molar pregnancy and multiples
— Recheck TSH — don't treat gestational transient hyperthyroidism with antithyroid drugs
— Discharge on scheduled (not PRN) antiemetics with 48–72 hour follow-up
— Recurrence risk ~80% → prophylactic pyridoxine at 5–6 weeks in next pregnancy
— Screen for depression, IPV, refeeding syndrome; postpartum depression surveillance through 12 months
Board pearl: The two highest-yield safety items on Step 3 NVP/HG questions are thiamine before dextrose and pelvic ultrasound before treating severe HG as just bad morning sickness — miss neither.