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pregnancy

Vitamins and minerals — If the patient is experiencing persistent vomiting, it is important to

replenish low levels of vitamins (especially thiamine), electrolytes, and minerals (ie, magnesium,
calcium, and phosphorous) [89]. We provide thiamine (vitamin B1) supplementation by giving 100 mg
intravenously with the initial rehydration fluids and another 100 mg daily for the next two or three
days. Early administration of thiamine is important to prevent a rare maternal complication, Wernicke's
encephalopathy [6,90,91].

Each day we administer a multivitamin (MVI) intravenously: MVI (10 mL) plus 0.6 mg folic acid (to
bring the folic acid total to 1 mg) in one liter and vitamin B6 25 mg in every liter. The intravenous fluid
is usually dextrose 5% in 0.45% saline with 20 mEq potassium chloride given at 150 mL/hour.
Intravenous MVI has 150 micrograms of vitamin K. Additional vitamin K replacement is not necessary
unless clinically indicated to treat a coagulopathy.

Hypomagnesemia is a common cause of hypocalcemia. We first correct the low magnesium level by
giving 2 grams (16 meq) magnesium sulfate infused as a 10% solution over 10 to 20 minutes,
followed by 1 gram (8 meq) in 100 mL of fluid per hour. The repletion of magnesium is continued if the
serum magnesium level is less than 0.8 meq/L (1 mg/dL or 0.4 mmol/L). Once serum magnesium
levels are restored, we reassess the calcium level. If serum calcium is still low, we administer 1 to 2
grams calcium gluconate in 50 mL of 5% dextrose solution over 10 to 20 minutes.

If phosphorus levels are low, phosphorus can be replaced in intravenous hydration with sodium
phosphate or potassium phosphate at 20 to 40 mmol/day. If the patient can tolerate oral replacement,
phosphorus can be replaced with oral sodium phosphate/potassium phosphate one to two tablets by
mouth four times a day with full glass of water. (See "Evaluation and treatment of
hypophosphatemia".)
Fluids — Dehydration occurs when fluid output exceeds fluid intake and is often associated with
electrolyte abnormalities, fatigue, dizziness, and weakness. We correct dehydration with up to 2 L
intravenous Ringer’s lactate infused over three to five hours, supplemented with appropriate
electrolytes and vitamins. Subsequently, the infusion rate is adjusted to maintain a urine output of at
least 100 mL/hour and the solution is changed to dextrose 5% in 0.45% saline. The optimum
replacement fluid regimen has not been studied. It is prudent to avoid use of dextrose in the initial
rehydration fluid because of the theoretical concern of Wernicke’s encephalopathy with dextrose
infusion in a thiamine-deficient state [87]. We delay dextrose infusion until after the patient has
received thiamine in her initial rehydration fluid (see 'Vitamins and minerals' below). A single small
study did not observe adverse effects in 102 patients who received intravenous thiamine followed by
5% dextrose 0.9% saline for persistent nausea and vomiting of pregnancy; however, only 60 percent
of these women had severe disease (ie, weight loss ≥5 percent body weight, ketonuria 4+) [88].

Relief of symptoms is common within one to two days of rehydration [6]. Hospitalization, as well as
replenishment of fluids and electrolytes, may contribute to palliation of symptoms.