gynecology and obstetrics
Nausea and Vomiting During Early Pregnancy
Evaluation
Evaluation of patients with nausea and vomiting during early pregnancy aims to exclude serious or life-threatening causes of nausea and vomiting. Nausea and vomiting of pregnancy (uncomplicated nausea and vomiting) and hyperemesis gravidarum are diagnoses of exclusion. History of present illnessshould particularly note the following: Estimated due date (and whether this is based on last menstrual period or ultrasonography) Any risk factors for obstetric complications and prior testing or complications during the current pregnancy Onset and duration of vomiting Exacerbating and relieving factors Frequency (intermittent or persistent) Type (eg, bloody, watery, bilious) and amount of emesis Important associated symptoms include diarrhea, constipation, and abdominal pain. If pain is present, the location, radiation, and severity should be queried. The examiner should also ask what social effects the symptoms have had on the patient and her family (eg, whether she is able to work or to care for herself or her children). should seek symptoms of nonobstetric causes of nausea and vomiting, including fever or chills, particularly if accompanied by flank pain or voiding symptoms ( Introduction to Urinary Tract Infections (UTIs) or pyelonephritis), and neurologic symptoms such as headache, weakness, focal deficits, and confusion ( Past medical historyincludes questions about morning sickness or hyperemesis in past pregnancies. Past surgical history should include questions about any prior abdominal surgery, which would predispose a patient to mechanical bowel obstruction. Medications taken by the patient are reviewed for drugs that could contribute (eg, iron-containing compounds, hormonal therapy) and for safety of these drugs taken during pregnancy. Evaluation of patients during pregnancy should include routine prenatal evaluation to assess maternal and fetal status, including Assessment of maternal vital signs Abdominal examination for fundal height Sometimes, pelvic examination Evaluation of fetal status with fetal heart rate auscultation Sometimes pelvic ultrasonography (depending on symptoms and gestational age) Examination begins with review of vital signs for fever, tachycardia, and abnormal blood pressure (too low or too high). A general assessment is done to look for signs of toxicity (eg, lethargy, confusion, agitation). A complete physical examination, including pelvic examination, is done to check for findings suggesting serious or potentially life-threatening causes of nausea and vomiting (see table). The following findings are of particular concern: No fetal motion or heart sounds Signs of dehydration (eg, orthostatic hypotension, tachycardia) Abnormal neurologic examination Fever Bloody or bilious emesis Abdominal pain Persistent or worsening symptoms Distinguishing pregnancy-related vomiting from vomiting due to other causes is important. Clinical manifestations help (see table). Vomiting is more likely to be due to pregnancy if Symptoms begin during the 1st trimester. Symptoms persist or recur over several days to weeks. Abdominal pain is absent. There are no symptoms or signs involving other organ systems. If vomiting appears to be pregnancy-related and is severe (ie, frequent, prolonged, accompanied by dehydration), Hyperemesis Gravidarum and Nonobstetric causes of nausea should be suspected if symptoms Begin after the 1st trimester Are accompanied by abdominal pain, diarrhea, or both Abdominal tenderness may suggest acute abdomen. Meningismus, neurologic abnormalities, or both suggest a neurologic cause. Patients with significant vomiting, signs of dehydration, or both usually require testing. If hyperemesis gravidarum is suspected, urine ketones are measured; if symptoms are particularly severe or persistent, serum electrolytes are measured. If fetal heart sounds are not clearly audible or detected by fetal Doppler, pelvic ultrasonography should be done to evaluate fetal status and rule out hydatidiform mole. Other tests are done based on clinically suspected nonobstetric disorders (see table). 