What is the management approach for hyperemesis with leukocytosis (increased white blood cell count)?

Management of Hyperemesis Gravidarum with Leukocytosis

In hyperemesis gravidarum with leukocytosis, supportive care with rehydration, electrolyte correction, and anti-emetic therapy is the primary management approach, as leukocytosis is often a physiologic response to dehydration and stress that typically resolves with treatment of the underlying hyperemesis. 1

Understanding Hyperemesis Gravidarum and Associated Leukocytosis

• Hyperemesis gravidarum (HG) is defined as excessive vomiting in pregnancy leading to weight loss of ≥5% of pre-pregnancy weight, dehydration, and ketosis 1, 2
• Liver function abnormalities occur in approximately 50-60% of HG patients, with ALT typically higher than AST 1, 2
• Leukocytosis (elevated white blood cell count) in HG is often a physiologic response to:
  • Dehydration and hemoconcentration 3
  • Physical and emotional stress from persistent vomiting 4
  • Inflammatory response to the metabolic derangements 3

Initial Assessment

• Evaluate severity of hyperemesis by checking for:

  • Degree of dehydration (skin turgor, mucous membranes) 5
  • Presence of ketones in urine 5
  • Electrolyte abnormalities, particularly potassium 1
  • Liver function tests (elevated in ~50% of HG cases) 1, 2
  • Complete blood count to assess degree of leukocytosis 3

• Rule out other causes of nausea/vomiting and leukocytosis:

  • Urinary tract infection 5
  • Thyrotoxicosis 5
  • Other gastrointestinal or hepatic disorders 1

Management Approach

First-Line Management

1. Rehydration therapy:

   • Intravenous fluids for moderate to severe dehydration 1
   • Correction of electrolyte abnormalities, particularly potassium 1
   • Oral rehydration if tolerated for milder cases 5

2. Nutritional support:

   • Thiamine supplementation to prevent Wernicke's encephalopathy 1
   • Small, frequent meals if oral intake is possible 5

3. Anti-emetic therapy:

   • First-line agents:

     • Ondansetron (5-HT3 antagonist) - has favorable pregnancy safety profile 1
     • Metoclopramide (category A) 1, 5
     • Pyridoxine (vitamin B6) 5

   • Second-line agents:

     • Promethazine (category C) 1, 5
     • Prochlorperazine (category C) 5

   • For refractory cases:

     • Corticosteroids (prednisolone, category A) - can be considered for severe disease 1, 5

Monitoring and Follow-up

• Monitor white blood cell count - leukocytosis typically resolves with hydration and resolution of vomiting 1
• Continue to assess liver function tests - these usually normalize with supportive care 1
• Monitor for complications of severe hyperemesis:
  • Wernicke's encephalopathy 1
  • Electrolyte imbalances 1
  • Malnutrition 5

Special Considerations

• Persistent leukocytosis despite adequate hydration should prompt investigation for other causes 3, 4
• Liver chemistry abnormalities typically resolve with hydration and resolution of vomiting; persistent abnormalities should prompt investigation for another etiology 1
• Unlike in leukemia where leukocytosis may require cytoreductive measures, the leukocytosis in hyperemesis is usually benign and self-limiting 6

Clinical Pearls and Pitfalls

• Pearl: Leukocytosis in hyperemesis is usually a physiologic response and not indicative of infection 3, 4
• Pitfall: Failing to provide adequate hydration can prolong the leukocytosis and worsen the patient's condition 1
• Pearl: Liver biopsy is rarely indicated in hyperemesis gravidarum 1
• Pitfall: Delaying anti-emetic therapy due to concerns about medication use in pregnancy can lead to worsening dehydration and metabolic complications 5