How should a pregnant woman who smokes marijuana and presents with massive hematemesis (approximately half a cup of bright red blood) be managed?

Management of Massive Hematemesis in a Pregnant Marijuana User

This pregnant patient presenting with massive hematemesis (half cup of bright red blood) requires immediate resuscitation and stabilization while simultaneously evaluating for both upper gastrointestinal bleeding sources and cannabinoid hyperemesis syndrome (CHS) as a potential underlying trigger, with complete cannabis cessation being essential for both maternal and fetal safety. 1, 2

Immediate Resuscitation and Stabilization

Activate massive hemorrhage protocol immediately given the volume of hematemesis in pregnancy:

• Establish two large-bore IV lines and initiate aggressive volume resuscitation with warmed blood products 1
• Send baseline labs: complete blood count, coagulation panel (PT, aPTT, fibrinogen), type and crossmatch, electrolytes, and liver function tests 1
• Transfuse packed red blood cells, fresh frozen plasma, and platelets in a 1:1:1 ratio if ongoing hemorrhage 1
• Keep patient warm (>36°C) as hypothermia impairs clotting factors 1
• Position in left lateral tilt to avoid aorto-caval compression and maintain placental perfusion 1

Diagnostic Evaluation for Bleeding Source

Upper endoscopy should be performed urgently to identify the bleeding source, as this is safe in pregnancy when medically indicated 1:

• Most likely sources include Mallory-Weiss tears (from repeated vomiting), esophagitis, or gastric varices if underlying liver disease exists 1, 3
• Use midazolam judiciously for sedation; propofol is also safe in pregnancy 1
• Avoid terlipressin if variceal bleeding is identified, as it can cause uterine contraction and placental abruption 1
• Octreotide and broad-spectrum antibiotics should be initiated if variceal bleeding is suspected 1

Cannabinoid Hyperemesis Syndrome Evaluation

Obtain detailed cannabis use history immediately, as CHS is likely the precipitating cause of the vomiting that led to hematemesis 2, 3:

• Ask specifically about: frequency of use (>4 times/week), duration (>1 year), and compulsive hot water bathing behavior (present in 44-71% of CHS cases) 2
• Recognize that the hematemesis is likely secondary to Mallory-Weiss tears or esophagitis from CHS-induced hyperemesis, not a primary GI pathology 2, 3, 4
• CHS diagnostic criteria: stereotypical episodic vomiting ≥3 times annually, cannabis use >1 year before symptoms, frequency >4 times/week 2

Acute Management of CHS-Related Symptoms

Benzodiazepines are first-line for CHS-related nausea and vomiting once hemodynamic stability is achieved 2:

• Lorazepam 0.5-2 mg IV every 4-6 hours is most effective for acute CHS symptoms 2
• Haloperidol is second-line if benzodiazepines are insufficient 2
• Topical capsaicin 0.1% cream to abdomen may provide additional relief 2
• Avoid opioids entirely as they worsen nausea, carry addiction risk, and do not address the underlying pathophysiology 2, 5

Critical Pregnancy-Specific Considerations

Complete and permanent cannabis cessation is mandatory for both maternal CHS resolution and fetal safety 2, 6:

• Cannabis use in pregnancy is associated with low birthweight, preterm birth, and increased NICU admissions 7
• The American College of Obstetricians and Gynecologists strongly discourages all cannabis use during pregnancy 6
• Symptoms will only resolve after 6+ months of complete abstinence 2
• Any resumption of cannabis will trigger symptom recurrence 2

Multidisciplinary Team Involvement

Assemble a multidisciplinary team including obstetrics, gastroenterology, and addiction medicine 1:

• Obstetrics should monitor fetal well-being continuously during acute hemorrhage 1
• Consider ICU admission postoperatively given the extensive resuscitation and pregnancy status 1
• Refer to addiction medicine or psychiatry for cannabis cessation support and management of withdrawal symptoms 2, 5

Long-Term Management Strategy

Initiate amitriptyline for CHS prophylaxis once acute bleeding is controlled 2:

• Start at 25 mg at bedtime, increase by 25 mg weekly to reach 75-100 mg nightly 2
• This is safe in pregnancy and serves as the mainstay of long-term CHS prevention 2
• Provide structured cannabis cessation counseling with motivational interviewing techniques 5

Cannabis Withdrawal Management

Anticipate cannabis withdrawal syndrome beginning 24-72 hours after cessation 5:

• Symptoms include irritability, anxiety, insomnia, decreased appetite, and GI distress 5
• Peak symptoms occur days 2-6, with acute phase lasting 1-2 weeks 5
• Loperamide for diarrhea, ondansetron for nausea (though often limited efficacy) 5
• Consider gabapentin or nabilone for severe withdrawal symptoms in consultation with addiction medicine 5

Common Pitfalls to Avoid

Do not pursue exhaustive GI investigations once CHS is suspected and acute bleeding source is identified 2:

• The esophagitis/Mallory-Weiss tears are consequences of vomiting, not primary pathology 2, 3
• Repeated endoscopy should be avoided unless new concerning symptoms develop 2
• Do not accept patient denial of the cannabis-symptom link; many patients attribute vomiting to other causes 2
• Never prescribe opioids for abdominal pain in CHS patients 2

Follow-Up Requirements

Schedule close outpatient follow-up within 1 week of discharge 2:

• Monitor for recurrent bleeding, ongoing CHS symptoms, and cannabis abstinence 2
• Assess for concurrent mental health disorders (anxiety, depression) which are common comorbidities 5
• Coordinate care between obstetrics, gastroenterology, and addiction medicine 2
• Reinforce that symptom resolution requires sustained abstinence equal to at least 3 typical vomiting cycles or 6+ months 2