Please provide a detailed admission order for a first‑trimester pregnant woman presenting with 12 days of watery diarrhea, low‑back pain, and electrolyte disturbances (hypokalemia, hypomagnesemia, borderline low ionized calcium).

Detailed Admission Orders for First-Trimester Pregnant Woman with Prolonged Diarrhea and Electrolyte Disturbances

Admit this patient immediately for IV fluid resuscitation, aggressive electrolyte replacement, and thiamine supplementation to prevent Wernicke encephalopathy, as this presentation of 12 days of watery diarrhea with hypokalemia and hypomagnesemia in early pregnancy requires urgent stabilization and close monitoring for both maternal and fetal complications. 1, 2, 3

Admission Status and Location

• Admit to: Obstetric high-risk unit or medical floor with obstetric consultation
• Admission type: Inpatient observation
• Level of care: Telemetry monitoring (due to hypokalemia and risk of cardiac arrhythmias) 4
• Code status: Full code
• Attending physician: Obstetrics with Gastroenterology and Nephrology consultation

Diagnosis

• Primary: Hyperemesis gravidarum with severe electrolyte depletion, first trimester pregnancy
• Secondary: Hypokalemia, hypomagnesemia, borderline hypocalcemia, acute dehydration
• Rule out: Bartter syndrome, Gitelman syndrome, infectious diarrhea, inflammatory bowel disease 4, 5

Vital Signs and Monitoring

• Vital signs every 4 hours including orthostatic blood pressure
• Continuous cardiac telemetry monitoring for QT interval prolongation 1
• Daily weights at same time each morning
• Strict intake and output monitoring with target urine output ≥1 L/day 1
• Fetal heart rate monitoring per obstetric protocol for gestational age

IV Fluids and Resuscitation

• Lactated Ringer's solution 150-200 mL/hour IV until clinically euvolemic, then reduce to maintenance rate 1, 2
• Monitor for resolution of ketonuria as marker of adequate rehydration 1
• Avoid fluid overload; target near-zero fluid balance once initial dehydration corrected 1
• Check BUN/creatinine ratio to assess hydration status 1

Electrolyte Replacement (Critical Priority)

Potassium Replacement

• Potassium chloride 40 mEq IV in 1000 mL NS over 4 hours (repeat as needed based on levels) 4
• Target potassium ≥3.0 mmol/L (do NOT aim for complete normalization) 4, 1
• Use potassium chloride specifically—avoid potassium citrate as it worsens metabolic alkalosis 4
• Spread oral potassium supplements throughout the day once tolerating PO 4
• Monitor potassium levels every 6 hours initially, then daily once stable 4

Magnesium Replacement

• Magnesium sulfate 2-4 grams IV over 4 hours, then reassess levels 4
• Oral magnesium supplements (organic magnesium salts preferred for better bioavailability) once tolerating PO 4
• Spread magnesium supplements throughout the day 4

Calcium Replacement

• Calcium gluconate 1-2 grams IV over 2 hours if ionized calcium remains low or symptomatic 6
• Check ionized calcium levels, not just total calcium 6
• Rule out vitamin D deficiency, hypoparathyroidism, or renal calcium loss 6
• Consider oral calcium supplementation once stable

Sodium Monitoring

• Check serum sodium and correct slowly if hyponatremic (reduction rate 10-15 mmol/L per 24 hours maximum to prevent central pontine myelinolysis) 4, 7
• Avoid rapid correction—maternal and fetal neurologic complications can occur 7

Thiamine Supplementation (Mandatory to Prevent Wernicke Encephalopathy)

• Thiamine 200-300 mg IV daily for minimum 3-5 days (given prolonged vomiting >7 days) 1, 3
• Switch to thiamine 50-100 mg PO daily once vomiting controlled and tolerating oral intake 1
• If any neurologic signs (confusion, ataxia, eye movement abnormalities): increase to thiamine 500 mg IV three times daily 1
• Continue thiamine supplementation until adequate oral intake established 1, 3

Antiemetic Therapy (Stepwise Approach)

First-Line

• Doxylamine 10-20 mg PO every 8 hours PLUS Pyridoxine (Vitamin B6) 10-25 mg PO every 8 hours 4, 1, 3
• Safe throughout pregnancy and breastfeeding 1, 3

Second-Line (if first-line inadequate)

• Metoclopramide 10 mg IV/PO every 6-8 hours (preferred second-line agent) 4, 1, 3
• OR Ondansetron 8 mg IV/PO every 8 hours (use with caution before 10 weeks gestation due to potential cardiac defect concerns) 4, 1, 3
• Withdraw metoclopramide immediately if extrapyramidal symptoms develop 4, 1
• Monitor QT interval with ondansetron, especially with electrolyte abnormalities 1

Third-Line (severe refractory cases only)

• Methylprednisolone 16 mg IV every 8 hours for up to 3 days, then taper over 2 weeks if needed 4, 1, 3
• Use with caution in first trimester (slight increased cleft palate risk before 10 weeks) 4, 1
• Maximum duration 6 weeks 4, 1

Gastric Protection

• Ranitidine 50 mg IV every 8 hours or equivalent H2-blocker 4
• Use gastric acid inhibitors with antiemetics to reduce gastric losses 4

Diet Orders

• NPO initially until vomiting controlled and electrolytes stabilizing
• Advance to clear liquids with glucose-electrolyte oral rehydration solution when tolerating 1, 2
• Progress to BRAT diet (bananas, rice, applesauce, toast) with small, frequent meals 4, 1
• Avoid fatty, heavy, spicy foods, caffeine, and strong odors 4, 1
• Consider avoiding lactose if diarrhea persists 2
• High-protein, low-fat meals once tolerating solid food 1

Laboratory Monitoring

Immediate (on admission)

• Complete metabolic panel (electrolytes, BUN, creatinine, glucose, calcium, magnesium, phosphorus)
• Ionized calcium level 6
• Liver function tests (AST, ALT, bilirubin, alkaline phosphatase) 1, 3
• Venous blood gas (assess for metabolic alkalosis) 1, 5
• Urinalysis with specific gravity and ketones 1, 3
• Spot urine sodium, potassium, chloride, and creatinine 4
• Calculate fractional excretion of chloride (>0.5% suggests renal salt wasting) 4
• Thyroid function tests (TSH, free T4) 1
• Complete blood count with differential
• Thiamine level (RBC or whole blood thiamine diphosphate) 1
• Vitamin D level 6

Stool Studies (if diarrhea persists or infectious etiology suspected)

• Stool culture and sensitivity
• Stool ova and parasites
• Stool Clostridioides difficile toxin
• Stool fecal leukocytes 2

Serial Monitoring

• Electrolytes (Na, K, Cl, Mg, Ca, phosphorus) every 6 hours until stable, then daily 4, 1
• Renal function (BUN, creatinine) daily 1
• Liver function tests every 2-3 days if initially abnormal 1
• Urinalysis for ketones daily until resolved 1
• Venous blood gas daily if metabolic alkalosis present 1

Genetic Testing (if Bartter/Gitelman syndrome suspected)

• Defer genetic testing until postpartum unless diagnosis will change acute management 5, 8
• Consider testing for SLC12A3 (Gitelman), KCNJ1, SLC12A1, CLCNKB mutations if renal salt wasting confirmed 4, 5

Cardiac Monitoring

• Baseline 12-lead ECG to assess QT interval 4, 1
• Repeat ECG after electrolyte correction and with any new symptoms 4
• Continuous telemetry monitoring due to hypokalemia and hypomagnesemia (risk of ventricular arrhythmias) 4, 1

Imaging

• Obstetric ultrasound to confirm fetal viability, assess gestational age, rule out multiple gestation or molar pregnancy 1, 3
• Abdominal ultrasound to rule out hepatobiliary causes (gallstones, cholecystitis) if liver enzymes elevated 1
• Defer other imaging unless clinically indicated 4

Consultations

• Maternal-Fetal Medicine for high-risk pregnancy management 1, 3
• Gastroenterology for persistent diarrhea and electrolyte abnormalities 1, 3
• Nephrology if Bartter/Gitelman syndrome suspected or renal dysfunction develops 4
• Nutrition Services for nutritional assessment and support 1, 3
• Mental Health/Psychiatry (anxiety and depression common with severe hyperemesis) 1

Activity

• Bed rest with bathroom privileges initially
• Advance activity as tolerated once hemodynamically stable
• Avoid straining during bowel movements 4

Medications to AVOID

• Do NOT use loperamide or antimotility agents (contraindicated in pregnancy with diarrhea) 2
• Avoid potassium citrate (worsens metabolic alkalosis) 4
• Avoid stimulant laxatives (conflicting safety data) 4
• Avoid drugs that prolong QT interval (macrolides, fluoroquinolones) in setting of electrolyte abnormalities 1
• Avoid proton-pump inhibitors if hypomagnesemia present (can worsen magnesium depletion) 1
• Avoid NSAIDs (risk of fetal ductus arteriosus constriction) 4
• Avoid thiazide diuretics (can cause severe volume depletion in Bartter syndrome) 4

Special Considerations for Bartter/Gitelman Syndrome (if suspected)

• Do NOT supplement sodium chloride if patient has secondary nephrogenic diabetes insipidus with hypernatremic dehydration 4
• If Bartter/Gitelman confirmed: consider sodium chloride supplementation 5-10 mmol/kg/day once acute phase resolved 4
• Avoid complete normalization of potassium (target ≥3.0 mmol/L adequate) 4, 1
• Plan for hospital delivery with electrolyte monitoring during labor 1

Discharge Criteria

• Sustained oral intake without vomiting for 24-48 hours 1
• Weight stabilization or gain (not continued loss) 1
• Resolution of ketonuria 1
• Electrolytes stable and within acceptable range (K ≥3.0, Mg ≥1.5) 4, 1
• Tolerating oral electrolyte supplements 4
• Adequate urine output maintained 1
• Patient able to ambulate without orthostatic symptoms
• Fetal well-being confirmed by obstetrics

Discharge Planning

• Arrange close outpatient follow-up with Maternal-Fetal Medicine within 3-5 days 1
• Continue oral electrolyte supplements (potassium chloride, magnesium, calcium as needed) 4
• Continue thiamine 50 mg PO daily until adequate nutrition established 1
• Continue antiemetics as needed (doxylamine-pyridoxine first-line) 1, 3
• Educate patient on warning signs requiring return to ED (persistent vomiting, inability to keep down fluids, decreased urine output, palpitations, muscle weakness) 4, 1
• Inform patient that symptoms typically resolve by week 16-20 in 80% of cases 1, 3
• Counsel on 40-92% recurrence risk in future pregnancies 1, 3
• Arrange genetic counseling if Bartter/Gitelman syndrome diagnosed 4, 5

Common Pitfalls to Avoid

• Do not correct hyponatremia too rapidly (maximum 10-15 mmol/L per 24 hours to prevent central pontine myelinolysis) 4, 7
• Do not skip thiamine supplementation (Wernicke encephalopathy can develop after only 20 days of inadequate intake) 1
• Do not use intermittent/PRN antiemetics in severe cases (switch to scheduled around-the-clock dosing) 1
• Do not tell patient to "drink more water" (hypotonic fluids worsen losses; use glucose-electrolyte ORS instead) 1
• Do not aim for complete potassium normalization (target ≥3.0 mmol/L adequate, over-aggressive replacement risks complications) 4, 1
• Do not administer diuretic challenge tests if Bartter syndrome suspected (risk of severe volume depletion) 4