A 30-year-old primigravida at seven weeks gestation presents with a ten-day history of morning nausea and vomiting, often unable to tolerate breakfast but managing a light lunch.


Observations: Temperature 37.0°C, pulse 90, blood pressure 140/90, respiratory rate 20, SpO2 99% on room air



Liver function tests:



||||
|---------------------------|:-------:|--------------------|
|Albumin|40 g/L|35 - 50|
|Alanine Aminotransferase (ALT)|21 IU/L|10 - 50|
|Aspartate Aminotransferase (AST)|32 IU/L|10 - 40|
|Alkaline Phosphatase (ALP)|210 IU/L|25 - 115|
|Bilirubin|7 µmol/L|< 17|
|Gamma Glutamyl Transferase (GGT)|20 U/L|9 - 40|




Full blood count:

||||
|--------------|:-------:|---------------|
|Haemoglobin|121  g/L|(M) 130 - 170, (F) 115 - 155|
|White Cell Count|6.5x10<sup>9</sup>/L|3.0 - 10.0|
|Platelets|110x10<sup>9</sup>/L|150 - 400|


Urine dip:



  - protein negative
  - blood negative
  - nitrites negative
  - leucocytes negative
  - ketones negative



Clinical examination reveals a soft and non-tender pregnant abdomen appropriate for gestational age.



Which of the following is the most likely differential?

Options:
explanation: This usually occurs after 20 weeks gestation and would involve hypertension with proteinuria. Symptoms may include headache, visual disturbances, epigastric pain and marked oedema. Proteinuria 1+ in this scenario may suggest preexisting renal disease as she is at an early gestational stage
name: Pre-eclampsia
label: b
answer: no
explanation: This usually occurs in the 3rd trimester, and patients may have abdominal pain, pruritus and features of cholestasis (pale stools, dark urine, steatorrhoea). In pregnancy, ALP levels are usually raised by about 1.5 to 2 times the normal level, as is the case in this question
name: Cholestasis of pregnancy
label: c
answer: no
explanation: This usually occurs after 20 weeks gestation and would involve hypertension with proteinuria. Symptoms may include headache, visual disturbances, epigastric pain and marked oedema. Proteinuria 1+ in this scenario may suggest preexisting renal disease as she is at an early gestational stage
name: HELLP syndrome
label: d
answer: no
explanation: Nausea and vomiting is a common symptom that affects women mostly in the 1st trimester. The aetiology is multifactorial and may be due to a combination of hormonal changes, abnormal gastrointestinal motility and genetic factors. It is also important to consider other differentials for nausea and vomiting that may occur due to conditions unrelated to pregnancy
name: Nausea and vomiting of pregnancy
label: a
answer: yes
explanation: This is the more severe end of the spectrum of nausea and vomiting in pregnancy, which usually occurs in the first trimester and resolves by 20 weeks. While there are no clear cut clinical criteria for this condition, it is typically based on the following factors - persistent vomiting, weight loss >5% of pre-pregnancy body weight and ketonuria
name: Hyperemesis gravidarum
label: e
answer: no

Correct answer: a

Nausea and vomiting of pregnancy

Learning point: Nausea and vomiting of pregnancy (NVP) is common and mild, while hyperemesis gravidarum (HG) is a severe form with persistent vomiting, leading to dehydration, weight loss, and requiring medical treatment and hospitalization.