Board Review: OBGYN/SURGERY
A 28 year old female G2P0010 at 9wga by LMP presents to the ED with nausea and vomiting for the past 3 weeks. She reports that since she found out she was pregnant she has felt nauseated nearly every day. She comes to the ED today because she has begun vomiting and is unable to eat or drink much for the past week. What do you order?
A. NS IVF + zofran IV
B. LR IVF + haldol IV
C. D5W IVF + vitamin B6 + dicyclomine
D. D5W IVF + vitamin B1
Answer: C. Nausea and vomiting of pregnancy is very common and often starts after 6 weeks of gestation. It peaks around 9 weeks and often decreases by the 2nd trimester, although some women experience nausea for the entirety of their pregnancy. The most severe end of this spectrum is labeled “hyperemesis gravidarum.” The most effective and safest treatment (pregnancy class A) for this diagnosis is B6 supplementation and dicyclomine. In the ED, the patient should also receive fluids containing dextrose if her PO intake has been severely compromised. Zofran and haldol are pregnancy class B and C, respectively, and therefore should be used with caution or avoided. Vitamin B1, or thiamine, supplementation should also be considered to prevent Wernicke encephalopathy for patients who have been vomiting for more than 3 weeks, although it is not a treatment itself for nausea. *Of note, nausea and vomiting of pregnancy are not associated with abdominal pain, so if the patient is tender on exam, consider other diagnoses!
ACOG Practice Bulletin No. 189: Nausea And Vomiting Of Pregnancy. Obstet Gynecol. 2018;131(1):e15-e30. doi:10.1097/AOG.0000000000002456.