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History
Presentation pattern
Pattern
Gestational age and trimester
Onset relative to pregnancy recognition
Trajectory
Progressive worsening
Plateau
Improving
Frequency
Emesis episodes per day
Days per week
Triggers
Odors
Motion
Meals
Prenatal vitamins
Oral tolerance
Fluids
Solids
Weight change since pre pregnancy
Percent body weight loss
Time window
Urine output
Oliguria
Dark urine
Prior pregnancies
Prior hyperemesis gravidarum
Prior admissions
OPQRST
Onset
First day of symptoms
Abrupt onset
Gradual onset
Provocation/Palliation
Worse with
Smells
Motion
Meals
Prenatal vitamins
Improved with
Antiemetics
IV fluids
Avoidance of triggers
Quality
Nausea predominant
Vomiting predominant
Retching predominant
Region/Radiation
Abdominal pain
Epigastric
Right upper quadrant
Lower abdominal
Chest pain
Pleuritic
Retrosternal burning
Severity
Functional impact
Unable to work
Unable to care for self
Dehydration markers
Thirst
Dizziness
Timing
Morning predominant
All day
Post prandial
Associated symptoms
GI symptoms
Hematemesis
Bilious emesis
Diarrhea
Constipation
GU and pregnancy symptoms
Vaginal bleeding
Pelvic pain
Dysuria
Neuro symptoms
Headache
Visual changes
Confusion
Weakness
Infection symptoms
Fever
Sore throat
Endocrine symptoms
Heat intolerance
Palpitations
Key context
Pregnancy context
Confirmed intrauterine pregnancy
Multiple gestation risk context
Molar pregnancy risk context
Prior care
Prior ED visits
Prior antiemetic trials
Prior IV fluid response
Alarm Features
Immediate escalation triggers
Escalation triggers
Hemodynamic instability
SBP < 90 mmHg
HR > 120
Altered mental status
Confusion
Somnolence
Severe dehydration
Anuria
Syncope
Concern for Wernicke encephalopathy
Ataxia
Ophthalmoplegia
Confusion
GI bleeding
Hematemesis
Melena
Abdominal surgical abdomen concern
Peritoneal signs
Persistent focal pain
High risk historical features
High risk features
Weight loss
> 5 percent pre pregnancy weight
Rapid loss over days
Inability to tolerate oral intake
No fluids for > 24 hours
No solids for > 48 hours
Recurrent presentations
Multiple ED visits same week
Prior admission this pregnancy
Hyperthyroid symptoms with severe vomiting
Palpitations
Tremor
High risk exam findings
High risk findings
Orthostatic intolerance
Symptomatic standing
Marked HR rise with standing
Dry mucous membranes
No tears
Sunken eyes
Abdominal tenderness
Right upper quadrant
Epigastric
Neurologic signs
Nystagmus
Gait instability
Medications
Medication reconciliation
Current therapies
Prenatal vitamin formulation
Iron containing
Non iron
Antiemetics used
Doxylamine pyridoxine
Dimenhydrinate
Metoclopramide
Ondansetron
Promethazine
Acid suppression
H2 blocker
Proton pump inhibitor
Laxatives
Polyethylene glycol
Senna
High risk medication exposures
Exposures
Cannabis use
Daily use pattern
Symptom relief with hot showers
QT prolonging medications
Methadone
Macrolides
Nephrotoxins
NSAIDs
ACE inhibitors
Medication dosing examples
Common dosing examples
Doxylamine pyridoxine
Local protocol dependent dosing
Escalation steps per product formulation
Dimenhydrinate
25 to 50 mg PO or IV every 4 to 6 hours
Maximum daily dose per local protocol
Metoclopramide
10 mg IV or PO every 6 to 8 hours
Extrapyramidal risk
Ondansetron
4 mg IV or ODT every 6 to 8 hours
QT prolongation risk
Diet
Intake and hydration pattern
Intake pattern
Fluids
Water
Electrolyte solutions
Solids
Bland starches
Protein tolerance
Meal pattern
Small frequent
Large meals trigger
Dietary triggers
Trigger exposures
Odor triggers
Cooking smells
Perfumes
Fatty foods
Fried foods
High fat dairy
Caffeine
Coffee
Energy drinks
Review of Systems
System review
Constitutional
Fever
Chills
Weight loss
HEENT
Headache
Visual changes
Sore throat
Cardiopulmonary
Chest pain
Dyspnea
Palpitations
GI
Abdominal pain
Diarrhea
Constipation
GU
Dysuria
Flank pain
Vaginal bleeding
Neuro
Dizziness
Syncope
Weakness
Pertinent negatives that change management
Management changing negatives
No vaginal bleeding
No severe focal abdominal pain
No fever
No bilious emesis
Collateral History and Family History
Collateral and supports
Collateral
Source
Partner
Family
Reliability concerns
Language barrier
Limited prenatal care
Social support
Home supports available
Ability to return for care
Family history
Family conditions
Thyroid disease
Graves disease (E05.00)
Hashimoto thyroiditis (E06.3)
Diabetes mellitus
Type 1 diabetes mellitus (E10.9)
Type 2 diabetes mellitus (E11.9)
Risk Factors
Pregnancy and medical risks
Pregnancy related risks
Multiple gestation
Prior ultrasound suggesting twins
Assisted reproduction
Molar pregnancy risk context
Prior molar pregnancy (O02.0)
Very rapid uterine size increase
First pregnancy
Nulliparity
Younger maternal age
Patient risks
Prior hyperemesis gravidarum (O21.0)
Prior admission
Prior tube feeding
Thyroid disease
Hyperthyroidism (E05.90)
Prior thyroiditis
Exposure risks
Infection exposures
Sick contacts
Foodborne exposure
Substance exposures
Cannabis
Alcohol
Differential Diagnosis
Life threatening
Life threatening
Ectopic pregnancy (O00.9)
Vaginal bleeding
Pelvic pain
Molar pregnancy (O02.0)
Markedly elevated beta hCG
Uterine size larger than dates
Diabetic ketoacidosis in pregnancy (O24.0 with E10.10)
Polyuria
Ketosis with metabolic acidosis
Sepsis
Fever
Hypotension
Acute pancreatitis (K85.9)
Epigastric pain
Lipase elevation
Hepatitis
RUQ pain
Transaminitis
Common
Common
Nausea and vomiting of pregnancy (O21.9)
Mild symptoms
Maintained oral intake
Hyperemesis gravidarum (O21.0)
Weight loss
Ketonuria
Gastroenteritis (A09)
Diarrhea
Sick contacts
UTI and pyelonephritis (N39.0, N10)
Dysuria
Flank pain
Less common
Less common
Cannabinoid hyperemesis syndrome
Chronic cannabis use
Relief with hot showers
Biliary colic or cholecystitis (K80.20, K81.0)
RUQ pain after meals
Fever
Appendicitis (K35.80)
Migratory pain
Peritoneal signs
Intracranial pathology
Severe headache
Focal neurologic deficits
Key distinguishing clues
Clues
Hyperemesis gravidarum
Early pregnancy timing
Dehydration
DKA in pregnancy
Tachypnea
High anion gap metabolic acidosis
Molar pregnancy
Very high beta hCG
Abnormal ultrasound
Past Medical History
Conditions and prior care
Prior pregnancy complications
Hyperemesis gravidarum
Gestational age at onset
Prior IV hydration frequency
Gestational diabetes (O24.4)
Treatment
Complications
GI history
GERD (K21.9)
Peptic ulcer disease (K27.9)
Endocrine history
Hyperthyroidism (E05.90)
Diabetes mellitus
Baseline status
Baseline function
Baseline weight
Baseline oral intake pattern
Baseline medications
Physical Exam
General and vitals
General
Toxic appearance
Distress
Dry mucous membranes
Vitals pattern
Tachycardia
Hypotension
Fever
Orthostatic physiology
Symptomatic orthostasis
HR rise on standing
HEENT and neuro
HEENT
Mucous membranes
Scleral icterus
Neuro
Mental status
Gait
Nystagmus
Ophthalmoplegia
Cardiopulmonary and abdomen
Cardiopulmonary
Perfusion
Respiratory effort
Abdomen
Tenderness location
Peritoneal signs
Hepatomegaly
Pelvic if indicated
Bleeding
Cervical motion tenderness
Lab Studies
Core labs for severity and mimics
Core labs
Electrolytes
Sodium
Potassium
Chloride
Bicarbonate
Renal function
Creatinine
Urea
Glucose
Hypoglycemia
Hyperglycemia
CBC
Hemoconcentration
Leukocytosis
LFTs
AST
ALT
Bilirubin
Pregnancy specific and targeted labs
Pregnancy labs
Beta hCG quantitative
Markedly elevated level
Comparison to gestational age
Urinalysis
Ketones
Specific gravity
Targeted labs by presentation
Lipase
Epigastric pain
Pancreatitis mimic
TSH and free T4
Severe symptoms
Hyperthyroid features
Acid base and ketosis
Ketosis and acidosis assessment
Serum ketones
Beta hydroxybutyrate
Starvation ketosis vs DKA
Venous blood gas
pH
pCO2
Anion gap
Elevated in DKA
Elevated in starvation ketosis
Imaging
Scoring Systems
Risk stratification tools
Not routinely indicated scoring systems
Use clinical severity markers instead
Local protocol dependent pathways
Severity markers
Weight loss > 5 percent
Ketonuria
MRI
MRI indications
Abdominal pathology with ultrasound nondiagnostic
Appendicitis evaluation when CT avoided
MRI considerations
Gadolinium
Avoid unless essential
Local protocol dependent
Protocol
Non contrast abdomen pelvis
Targeted appendix protocol
CT
CT role
Life threatening abdominal pathology when MRI unavailable
Pulmonary embolism evaluation if indicated by symptoms
CT considerations
Ionizing radiation
Use when benefits outweigh risks
Document decision making
Contrast
Renal function review
Allergy history
Ultrasound
Obstetric ultrasound
Intrauterine pregnancy confirmation
Multiple gestation assessment
Molar pregnancy features
RUQ ultrasound
Cholelithiasis
Cholecystitis features
Special Tests
Bedside assessments
Bedside tests
Point of care glucose
Pregnancy test if status uncertain
Orthostatic vitals
Bedside pitfalls
Ketonuria timing
Early DKA with modest hyperglycemia in pregnancy
Obstetric considerations
Obstetric assessment
Fetal heart rate when gestational age appropriate
Uterine tenderness
Cervical exam if bleeding
ECG
Indications and patterns
ECG indications
Severe electrolyte disturbance concern
Syncope
Palpitations
Key findings
QTc prolongation
Antiemetic related risk
Hypokalemia related risk
Hypokalemia patterns
U waves
ST depression
Assessment
Working diagnosis and severity
Hyperemesis gravidarum (O21.0)
Features supporting
Persistent vomiting
Weight loss
Dehydration
Severity stratification
Mild
Moderate
Severe
Complications to address
Electrolyte derangements
Hypokalemia
Metabolic alkalosis
Starvation ketosis
Elevated beta hydroxybutyrate
Normal or mildly elevated glucose
Thiamine depletion risk
Prolonged poor intake
Neurologic symptoms
Alternative diagnoses
Alternate diagnoses
Molar pregnancy (O02.0)
Very high beta hCG
Abnormal ultrasound
DKA in pregnancy
High anion gap metabolic acidosis
Hyperglycemia or euglycemic DKA
Biliary disease
RUQ pain
Ultrasound findings
Plan
First 5 minutes and stabilization
Immediate priorities
Monitoring
Cardiac monitor if severe
Frequent vitals
IV access
Large bore peripheral
Two lines if shock
Fluids
Isotonic crystalloid bolus
Repeat bolus if ongoing hypovolemia
Antiemetic initiation
One agent
Add second class if refractory
Fluids vitamins electrolytes
Volume and nutrition support
Thiamine before dextrose
100 mg IV
Repeat daily if ongoing risk
Dextrose containing fluids
After thiamine if ketosis
Glucose monitoring
Electrolyte repletion
Potassium repletion
Magnesium repletion if low
Diet advancement
Clear fluids to bland solids
Small frequent intake
Antiemetic strategy
Stepwise antiemetics
First line
Doxylamine pyridoxine
H1 antihistamines
Second line
Metoclopramide
Promethazine
Refractory
Ondansetron
Consider steroid course after first trimester per obstetric guidance
Safety considerations
QT prolongation risk
Correct electrolytes first
Avoid multiple QT prolonging agents when possible
Reassessment loop
Reassessment
Timing
Every 30 to 60 minutes initially
After each medication change
Targets
Symptom control allowing oral fluids
HR improvement
Urine output improvement
Repeat labs
Electrolytes after repletion
Ketones if severe ketosis
Disposition
Admission criteria
Admission indications
Persistent inability to tolerate oral intake
Ongoing ketonemia or ketonuria with dehydration
Refractory electrolyte abnormalities
Potassium not correctable in ED
Severe hyponatremia
Acute kidney injury
Rising creatinine
Oliguria
Concern for alternative diagnosis
Abdominal pathology
DKA
Neurologic symptoms
Wernicke concern
Severe headache
Observation and discharge criteria
Observation pathway
IV fluids and antiemetic response
Repeat electrolytes acceptable
Discharge criteria
Tolerating oral fluids
Improved symptoms with oral regimen
Stable vitals
Reliable follow up
Follow up timing
Follow up
Obstetrics
Within 24 to 72 hours if persistent symptoms
Routine prenatal follow up if improved
Primary care
Within 1 week for medication review
Discharge Instructions
Copy discharge instructions
Summary
Diagnosis
Dehydration treated with IV fluids
Medications
Antiemetic plan
Scheduled first line medication
Breakthrough medication
Prenatal vitamin adjustment
Consider non iron formulation until improved
Resume standard formulation when tolerating diet
Hydration and diet
Small frequent sips
Oral rehydration solutions
Small frequent bland meals
Return to ED now
Unable to keep down fluids for 24 hours
Fainting
Severe abdominal pain
Vaginal bleeding
Fever
Confusion
Vision changes
Follow up
Obstetric follow up timing
Medication review timing
References
Guidelines and key sources
American College of Obstetricians and Gynecologists
Practice Bulletin
Nausea and vomiting of pregnancy
Royal College of Obstetricians and Gynaecologists
Green top guideline
Management of nausea and vomiting of pregnancy and hyperemesis gravidarum
Society of Obstetric Medicine of Australia and New Zealand
Guideline statement
Nausea and vomiting in pregnancy
UpToDate
Hyperemesis gravidarum management overview
Local protocol dependent adaptation
Cochrane reviews
Antiemetic effectiveness in nausea and vomiting of pregnancy
Evidence quality limitations
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.