Hyperemesis Gravidarum at 12 Weeks with Haematemesis - Complete Clinical Review

BACKGROUND & DEFINITION

• Weight loss >5% of pre-pregnancy body weight
• Ketonuria
• Dehydration and electrolyte imbalance

ETIOLOGY

1. Hormonal Factors

• hCG (beta-HCG): Peak levels correlate with peak HG symptoms. The alpha subunit of hCG shares homology with TSH - this causes thyroid-stimulating activity, transient gestational thyrotoxicosis, and suppressed TSH with mildly elevated free T4, seen in ~two-thirds of HG patients. Conditions with elevated hCG (multiple gestation, gestational trophoblastic disease, trisomy 21, hydrops fetalis) increase HG risk.
• Estrogen: Elevated estrogen (e.g., obesity) is associated with HG; estrogen and progesterone alter gastric motility and slow GI transit time.
• Gut hormones: Ghrelin and leptin are also implicated.

2. GI Dysmotility

3. Helicobacter pylori Infection

4. Psychosocial/Sensory Triggers

5. Genetic Predisposition

Risk Factors

• Young, nulliparous women; non-Caucasian ethnicity (especially Asian, Middle Eastern)
• Female fetus or multiple gestation
• Personal/family history of HG
• Gestational trophoblastic disease, fetal trisomy 21, hydrops fetalis
• Pre-existing hyperthyroidism, psychiatric disorders, diabetes, GI disorders, asthma

HAEMATEMESIS IN HG - SPECIFIC ETIOLOGY

1. Mallory-Weiss tear (most common): Longitudinal mucosal laceration at the gastroesophageal junction from forceful, repeated retching/vomiting. Classic history is initial nonbloody vomiting followed by bloody emesis. Pregnancy, retching, and increased intra-abdominal pressure are direct causative factors.
2. Boerhaave syndrome (rare but life-threatening): Full-thickness esophageal rupture from severe vomiting - a rare but serious complication.
3. Peptic ulcer disease (less common in pregnancy; use of NSAIDs rare)
4. Esophagitis/GERD: Up to 80% of pregnant women experience heartburn; severe retching can cause mucosal trauma.

• Sleisenger and Fordtran's Gastrointestinal and Liver Disease, p. 655 explicitly lists "Mallory-Weiss tears with upper GI bleeding" as a severe maternal complication of HG.

EVALUATION

Clinical Assessment

• Detailed history: onset, frequency, severity of vomiting; quantify using PUQE score (Pregnancy-Unique Quantification of Emesis and Nausea - assesses hours of nausea and episodes of emesis/retching per day)
• Assess for haematemesis: volume, color (bright red vs. coffee-ground), associated melaena
• Weight (compare to pre-pregnancy weight), vital signs (hypotension, tachycardia), mucous membranes, skin turgor, urine output

Laboratory Workup

Imaging / Endoscopy

• Obstetric ultrasound: Rule out molar pregnancy, multiple gestation, confirm fetal viability and gestational age
• Upper GI endoscopy (EGD): Indicated in this case given haematemesis - to identify the source (Mallory-Weiss tear, peptic ulcer, esophagitis). EGD is safe in pregnancy when clinically indicated. Defer non-urgent endoscopy to second trimester if possible, but active significant bleeding warrants prompt evaluation.

Differential Diagnosis for Vomiting in Pregnancy (must exclude before diagnosing HG)

• Peptic ulcer disease
• Cholecystitis / biliary colic
• Acute pancreatitis
• Appendicitis
• Pyelonephritis / UTI
• Gastroparesis
• Hepatitis
• Hyperthyroidism (primary, not gestational)
• Central nervous system pathology
• Addison's disease

MANAGEMENT

Step 1: Non-Pharmacologic (Outpatient, mild cases)

• Frequent, small meals; avoid empty stomach (triggers nausea)
• High-carbohydrate, dry starchy foods
• Avoid offensive odors; separate solid and liquid intake
• Ginger (extract): RCT evidence shows benefit vs. placebo regardless of dose/preparation
• Pyridoxine (Vitamin B6) + doxylamine (Diclegis/Bonjesta): First-line pharmacologic therapy per guidelines
• Acupressure (P6 pressure point): modest evidence for symptom benefit

Step 2: Pharmacologic Antiemetics

Step 3: IV Fluid Resuscitation (Hospital admission indicated when: hypotension, tachycardia, ketosis, weight loss, muscle wasting, inability to tolerate oral intake)

• Lactated Ringer's solution 2 L over 3-5 hours (500 mL/hr); then adjust to maintain urine output >100 mL/hr
• Thiamine 100 mg IV BEFORE any dextrose infusion - mandatory to prevent Wernicke encephalopathy
• Follow with D5/0.45% NaCl until ketones clear or oral intake resumes
• Correct hypokalemia (add K+ to IV fluids as needed)
• Correct hypomagnesemia, hypocalcemia - monitor ionized calcium
• Correct hyponatremia slowly (risk of central pontine myelinolysis with rapid correction)

Step 4: Management of Haematemesis (specific to this case)

• Assess hemodynamic stability
• Active resuscitation if unstable (IV access x2, type and crossmatch, hemodynamic monitoring)
• EGD when stable to identify and potentially treat the source
• Mallory-Weiss tears: most stop bleeding spontaneously; endoscopic therapy (injection, clips, thermal) if active bleeding
• PPI therapy (omeprazole or pantoprazole) - note omeprazole has animal fetal toxicity data; pantoprazole often preferred in pregnancy
• Maintain NPO if active bleeding; nasogastric tube if needed

Step 5: Refractory Hyperemesis

• Corticosteroids: Methylprednisolone 16 mg PO/IV q8h for 3 days (with 2-week taper) - reduces hospital readmission vs. promethazine; last-line agent; avoid in first trimester if possible (weak association with oral clefts - ~1-2 per 1000 treated women); use with caution before 10 weeks
• IV hydrocortisone 300 mg/day for 3 days followed by taper is an alternative
• H. pylori eradication if infection confirmed (use non-teratogenic regimen)

Step 6: Nutritional Support

• Enteral nutrition via nasogastric or nasoenteric tube: Preferred over TPN when oral intake fails
• Total parenteral nutrition (TPN): Last resort; significant complications - catheter sepsis (25%), venous thrombosis (3%); peripherally inserted central catheters have 50% overall complication rate; use only when enteral route has failed
• Thiamine, folate, multivitamins supplementation

COMPLICATIONS TO WATCH FOR

ADMISSION CRITERIA (for this patient)

1. Haematemesis (2 episodes) - requires evaluation and monitoring
2. 12 weeks gestational age (peak HG period)
3. Risk of significant dehydration and electrolyte disturbance
4. Need for IV fluids, IV antiemetics, electrolyte correction
5. Need for EGD to evaluate haematemesis source

SUMMARY FLOWCHART

12-week antenatal with HG + haematemesis
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Stabilize: IV access, vitals, fluid resuscitation
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Labs: CBC, CMP, TFT, urinalysis, beta-hCG, lipase, H. pylori
Ultrasound: confirm fetal viability, rule out molar/multiple gestation
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Thiamine 100mg IV → LR 2L → D5/0.45NS → correct electrolytes
IV antiemetics: metoclopramide / promethazine / ondansetron
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EGD (when stable): evaluate haematemesis source
→ Likely Mallory-Weiss tear → PPI therapy, endoscopic Rx if active bleed
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If refractory: methylprednisolone (after 10 weeks if possible)
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If unable to maintain nutrition: NG tube enteral feeds
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TPN: last resort only

• Sleisenger and Fordtran's Gastrointestinal and Liver Disease, p. 654-655 (Hyperemesis Gravidarum complications) and p. 3888-3948 (Nausea, Vomiting, and Hyperemesis Gravidarum chapter)
• Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice, p. 1563-1564 (Management)
• Rosen's Emergency Medicine: Concepts and Clinical Practice, p. 3363-3364 (Diagnostic testing and management)
• Yamada's Textbook of Gastroenterology 7e (Mallory-Weiss tear in pregnancy)