What is the best course of treatment for a pregnant patient with severe vomiting, sore throat, nausea, body chills, and throat closure, unresponsive to current medications?

Management of Severe Nausea, Vomiting, and Respiratory Symptoms in Pregnancy

This patient requires immediate hospitalization for intravenous fluid resuscitation, thiamine supplementation, and escalated antiemetic therapy, as she has progressed to severe hyperemesis gravidarum with concerning features including inability to maintain oral intake, worsening symptoms despite current medications, and new respiratory symptoms that require evaluation for concurrent infection. 1, 2

Immediate Assessment and Stabilization

Critical Initial Actions

• Admit for IV fluid resuscitation to correct dehydration, which is evident from her inability to keep down water for multiple days 2
• Administer thiamine 200-300 mg IV daily immediately to prevent Wernicke's encephalopathy, as she has had prolonged vomiting (pregnancy depletes thiamine stores within 7-8 weeks, and reserves can be exhausted after only 20 days of inadequate intake) 2
• Check electrolyte panel with particular attention to potassium and magnesium levels, as hypokalemia and electrolyte imbalances are common and dangerous 2
• Obtain liver function tests, as approximately 50% of hyperemesis gravidarum patients have abnormal AST and ALT 2

Diagnostic Workup for Respiratory Symptoms

• Test for COVID-19 and other respiratory infections, as her sore throat, cough, body chills, and sensation of throat closure suggest concurrent infectious process 3
• Perform physical examination focusing on signs of dehydration, throat examination for pharyngitis or airway compromise, and lung auscultation 2
• The sensation of "throat closure" is concerning and requires immediate evaluation to rule out airway compromise or severe pharyngeal inflammation 2

Antiemetic Escalation Strategy

Current Medication Failure

Her prescribed medications have been ineffective, indicating need for escalation beyond first-line therapy 1, 2

Second-Line Therapy (Immediate Implementation)

• Ondansetron 4-8 mg IV every 8 hours as she is beyond 10 weeks gestation (the concern about congenital heart defects applies primarily before 10 weeks) 1, 2, 4
• Metoclopramide 10 mg IV every 6-8 hours can be added or alternated with ondansetron, as no significant efficacy difference exists between commonly used antiemetics, but combination therapy may be more effective 2
• Switch from PRN to scheduled around-the-clock administration of antiemetics, as intermittent dosing is inadequate for severe refractory cases 2

Third-Line Therapy (If No Improvement in 24-48 Hours)

• Methylprednisolone 16 mg IV every 8 hours for up to 3 days, then taper over 2 weeks to lowest effective dose (maximum duration 6 weeks) 2
• This is reserved for severe refractory hyperemesis when both ondansetron and metoclopramide have failed 2
• After first trimester, the slight increased risk of cleft palate is less concerning, though data remain conflicting 2

Supportive Care

Fluid and Electrolyte Management

• Aggressive IV fluid replacement with electrolyte supplementation, particularly potassium and magnesium 2
• Monitor for refeeding syndrome given prolonged poor intake - start with small, frequent meals (BRAT diet: bananas, rice, applesauce, toast) and advance slowly over days 2
• Continue thiamine supplementation at 200-300 mg IV daily for at least 3-5 days, then switch to oral maintenance (50-100 mg daily) once vomiting is controlled 2

Acid Suppression for Severe Heartburn

• Add proton pump inhibitor therapy (e.g., omeprazole 20-40 mg daily) for the severe heartburn that prevents her from lying down 5
• The worsening heartburn may be contributing to her nausea and vomiting cycle 5

Treatment of Respiratory Symptoms

If COVID-19 or Bacterial Infection Confirmed

• Do not withhold necessary treatments during pregnancy - most interventions should not be withheld if deemed necessary 2
• Pregnant women with COVID-19 have increased risk of ICU admission (aRR 3.0), mechanical ventilation (aRR 2.9), and death (aRR 1.7) compared to non-pregnant women 3
• Appropriate antibiotics or antiviral therapy should be initiated based on specific diagnosis 3

Symptomatic Management

• Throat lozenges and warm fluids once able to tolerate oral intake 1
• Monitor respiratory status closely given the sensation of throat closure 2

Monitoring and Follow-Up

Objective Markers of Improvement

• Weight stabilization or gain (not continued loss) 2
• Sustained oral intake of at least 1000 kcal/day 2
• Resolution of ketonuria and normalization of electrolytes 2
• Reduced vomiting frequency to fewer than 3-5 episodes daily 2
• Use PUQE score serially to track symptom severity over time 1, 2

Discharge Criteria

• Able to tolerate oral fluids and maintain hydration 2
• Vomiting controlled to fewer than 2-3 episodes per day 2
• Electrolytes normalized 2
• Weight trajectory reversed (stabilized or gaining) 2

Common Pitfalls to Avoid

• Do not delay thiamine supplementation - Wernicke's encephalopathy can develop rapidly and is potentially fatal 2, 6
• Do not use PRN antiemetics in severe cases - scheduled around-the-clock administration is essential 2
• Do not dismiss the respiratory symptoms as secondary to reflux without ruling out infection, especially given body chills and progressive worsening 3
• Do not wait for ketonuria to diagnose severity - ketonuria is not associated with either diagnosis or severity of hyperemesis gravidarum 7
• Do not underestimate the risk of progression - early aggressive treatment prevents deterioration and reduces hospitalization rates 1, 2, 8

Multidisciplinary Coordination

Involve maternal-fetal medicine, gastroenterology, nutrition services, and mental health professionals in her care, as severe refractory hyperemesis requires multidisciplinary management, preferably at tertiary care centers 2

Mental health support is important as anxiety and depression are common with severe hyperemesis gravidarum 2

Prognosis

Most cases resolve by week 16-20 (80% of cases), though 10% may experience symptoms throughout pregnancy 2

Recurrence risk in subsequent pregnancies is high (40-92%) 2

Untreated hyperemesis is associated with low birth weight, small for gestational age infants, and premature delivery 2