Hyperemesis Gravidarum ConcernAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

615 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Vaginal Discharge Hyperemesis Gravidarum Concern Hypertensive Disorders Of Pregnancy Symptoms Postpartum Hemorrhage Concern Postpartum Infection Concern Sexual Assault Medical Evaluation Overview Pelvic Pain Vaginal Bleeding, Nonpregnant Vaginal Bleeding In Pregnancy Pelvic Pain In Pregnancy Post Procedure Or Post Abortion Complications Concern

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx92

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

02Alarm Features/alarm46

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

03Medications/meds39

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

04Diet/diet20

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

05Review of Systems/ros29

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

06Collateral History and Family History/chafh17

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)

07Risk Factors/rf23

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

08Differential Diagnosis/ddx55

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

09Past Medical History/pmh17

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

10Physical Exam/exam29

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

11Lab Studies/labs43

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

12Imaging/img34

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 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

13Special Tests/spec11

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

14ECG/ecg11

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

15Assessment/ax29

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

16Plan/plan51

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

17Disposition/dispo29

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

18Discharge Instructions/di25

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

19References/r15

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Hyperemesis Gravidarum ConcernAPPROACH

WOMEN'S HEALTH, PREGNANCY, AND GU · 19 SECTIONS

⚲

615 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx92

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

02Alarm Features/alarm46

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

03Medications/meds39

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

04Diet/diet20

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

05Review of Systems/ros29

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

06Collateral History and Family History/chafh17

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)

07Risk Factors/rf23

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

08Differential Diagnosis/ddx55

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

09Past Medical History/pmh17

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

10Physical Exam/exam29

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

11Lab Studies/labs43

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

12Imaging/img34

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 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

13Special Tests/spec11

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

14ECG/ecg11

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

15Assessment/ax29

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

16Plan/plan51

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

17Disposition/dispo29

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

18Discharge Instructions/di25

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

19References/r15

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.