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Hyperemesis gravidarum — MRCEM SBA MCQ

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EasyObstetric and gynaecological emergenciesHyperemesis gravidarumMRCEM SBA

A 29-year-old woman at 10+4 weeks’ gestation attends the emergency department with persistent vomiting. A scan has confirmed a single intrauterine pregnancy. Despite two recent visits for ambulatory intravenous fluids and antiemetics, she has been unable to retain food, fluids or tablets for three days. She is alert but clinically dehydrated. Her blood pressure is 112/72 mmHg, pulse 104/min, sodium 136 mmol/L, potassium 3.1 mmol/L and glucose 5.2 mmol/L; renal function is normal. What is the most appropriate management plan now?

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Correct answer: A — Admit for intravenous 0.9% saline with potassium, parenteral antiemetics and thiamine.

Persistent vomiting with dehydration and hypokalaemia despite ambulatory treatment warrants inpatient assessment and treatment rather than another planned discharge. Intravenous 0.9% saline with potassium addresses her fluid and electrolyte losses; potassium replacement should be guided by repeat electrolyte measurements. Because she cannot retain tablets, antiemetics should be given by a non-oral route. Prolonged poor intake also makes thiamine supplementation important, particularly before any dextrose is administered. ([pubmed.ncbi.nlm.nih.gov](https://pubmed.ncbi.nlm.nih.gov/38311315/?utm_source=openai)) B offers reasonable initial treatment for someone who improves sufficiently with ambulatory care, but she has already failed that approach and remains unable to drink. C reverses the important sequence: dextrose given before thiamine can precipitate Wernicke encephalopathy in a thiamine-deficient patient. D uses appropriate fluid replacement, but oral medication is unreliable while she cannot retain tablets. E proposes corticosteroids before an adequate inpatient trial of standard supportive treatment and antiemetics; they are not the next step in this presentation. ([pubmed.ncbi.nlm.nih.gov](https://pubmed.ncbi.nlm.nih.gov/38311315/?utm_source=openai))

Reference: RCOG Green-top Guideline No. 69: The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (June 2024) — https://pubmed.ncbi.nlm.nih.gov/38311315/ NICE NG201: Antenatal care, recommendations 1.4.5–1.4.7 (2021) — https://www.nice.org.uk/guidance/ng201/chapter/recommendations