What is the recommended evaluation and management for a 34-week pregnant patient with hyperemesis gravidarum, presenting with worsening symptoms of fatigue, vomiting, peripheral edema, and arthralgias?

Evaluation and Management of Hyperemesis Gravidarum at 34 Weeks Gestation

This patient requires immediate assessment for alternative diagnoses and complications, as hyperemesis gravidarum typically resolves by week 20 in 80% of cases—persistent symptoms at 34 weeks warrant investigation for other causes while providing symptomatic management and work restrictions. 1

Critical Initial Assessment

At 34 weeks gestation, persistent vomiting is atypical for hyperemesis gravidarum and demands evaluation for:

• Check liver function tests (AST/ALT elevated in 50% of hyperemesis cases, but persistent elevation despite symptom control suggests alternative etiology like HELLP syndrome or acute fatty liver of pregnancy) 1
• Electrolyte panel with particular attention to potassium and magnesium levels (hypokalemia can cause fatigue and muscle aches) 1, 2
• Urinalysis for ketonuria to assess nutritional status 1, 2
• Abdominal ultrasonography to rule out hepatobiliary causes (gallstones/cholecystitis), assess fetal growth, and evaluate for other pathology 1, 2
• Thyroid function tests (hyperthyroidism associated with hyperemesis can cause diarrhea and cramping) 1

The peripheral edema and arthralgias at 34 weeks raise concern for preeclampsia or other third-trimester complications rather than typical hyperemesis gravidarum. 1

Immediate Stabilization

Fluid and Electrolyte Management

• Administer IV fluid resuscitation to correct dehydration, which often improves associated liver enzyme abnormalities 2
• Replace electrolytes with particular attention to potassium and magnesium levels 1, 2
• Start thiamine 100 mg daily for minimum 7 days, then 50 mg daily maintenance to prevent Wernicke encephalopathy; if vomiting persists or patient cannot tolerate oral intake, switch immediately to IV thiamine 200-300 mg daily 1, 2

Antiemetic Therapy

First-line: Doxylamine-pyridoxine combination (10-20 mg doxylamine + 10-20 mg pyridoxine every 8 hours), safe throughout pregnancy and breastfeeding 1, 2

Second-line (if first-line fails):

• Metoclopramide 5-10 mg orally every 6-8 hours is the preferred second-line agent with fewer side effects than promethazine 1, 2
• Ondansetron 8 mg orally every 8 hours (or 16 mg once daily, then 8 mg twice daily) can be used at this gestational age without first-trimester concerns 1, 2

Third-line (severe refractory cases only):

• 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 1, 2

Dietary Modifications

• Small, frequent, bland meals (BRAT diet: bananas, rice, applesauce, toast) 1
• High-protein, low-fat meals 1
• Avoidance of strong odors and specific food triggers 1
• Ginger supplementation 250 mg capsule four times daily may be considered 1

Work Restrictions and Medical Certificate

A one-week medical certificate for rest is appropriate given:

• Symptoms at 34 weeks require investigation and stabilization 1
• Fatigue, vomiting, and peripheral edema impair functional capacity 1
• Early intervention prevents progression and maternal morbidity 1

Medication Renewal

Renew current antiemetics based on the stepwise algorithm above, ensuring:

• Scheduled around-the-clock dosing rather than PRN for better symptom control 1
• Thiamine supplementation is included (critical at this stage with prolonged symptoms) 1, 2
• Acid suppression and laxatives may be needed as adjunctive therapy 3

Monitoring and Follow-Up

• Serial PUQE (Pregnancy-Unique Quantification of Emesis) scores to track symptom severity 1, 2
• Weight monitoring (stabilization or gain indicates improvement, not continued loss) 1
• Fetal growth monitoring with ultrasound given prolonged symptoms and risk of small for gestational age infant 1
• Reassessment in 1-2 weeks to evaluate treatment response 1

Red Flags Requiring Immediate Escalation

• Neurologic symptoms (confusion, ataxia, eye movement abnormalities suggesting Wernicke's encephalopathy) 1
• Persistent liver enzyme elevation despite symptom resolution (investigate alternative etiology) 1
• Progressive weight loss ≥5% of pre-pregnancy weight despite treatment 1
• Inability to maintain oral intake of 1000 kcal/day for several days (consider enteral feeding) 1

Common Pitfalls to Avoid

• Do not assume all vomiting at 34 weeks is hyperemesis gravidarum—10% experience symptoms throughout pregnancy, but alternative diagnoses (preeclampsia, HELLP, acute fatty liver) must be excluded 1
• Do not use PRN antiemetics in refractory cases—switch to scheduled around-the-clock administration 1
• Do not skip thiamine supplementation—pregnancy increases thiamine requirements and reserves can be exhausted after only 20 days of inadequate intake 1
• Do not withhold necessary imaging or procedures—most interventions should not be withheld if deemed necessary during pregnancy 1

Multidisciplinary Involvement

Given symptom persistence at 34 weeks, consider involving:

• Maternal-fetal medicine for high-risk pregnancy management 1
• Gastroenterology if alternative diagnoses suspected 1
• Nutrition services for dietary counseling 1
• Mental health professionals (anxiety and depression common with severe hyperemesis) 1