Obstetric Anaesthesia Annual Scientific Meeting 2026

Severe Hyperemesis Gravidarum Presenting in Active Labour with Profound Multi-System Derangement

Carnaby, Georgina1; Adamson, Mike2

1 Health Education in Wales , ² Cardiff and Vale Health Board

Introduction

•Hyperemesis gravidarum (HG) affects ~3% of pregnancies¹

•Typically resolves by 20 weeks²

•Severe/prolonged HG is rare

•Risk of severe metabolic derangement with prolonged HG

•Rarely presents with multi-system derangement at term

Case Summary

Presentation :

19 year old, G2P1

Presented at 36+3 in spontaneous labour

5cm dilated at presentation

Antenatal Hx:

Recurrent vomiting throughout pregnancy

Up to 10 episodes/day by 32 weeks

PMHx:

Asthma, eczema, cyclical vomiting syndrome

SHx:

Regular cannabis use

DHx:

Symbicort, Ventolin, Ondansetron, Prochlorperazine

Investigations:

Severe derangement on routine admission bloods (see table)

Profound metabolic, renal and hepatic involvement

ECG signs of severe hypokalaemia seen

Woring diagnosis:

Severe HG with malnutrition and severe biochemical disturbance

Differentials:

Acute fatty liver of pregnancy

Conns syndrome

Pancreatitis

Biochemical markers:

Parameter	Value	Significance
Na+	126mmol/L	Hyponatraemia
K+	2.5mmol/L	Severe Hypokalaemia
Creatinine	242umol/L	AKI
PO4+	0.27mmo/L	Starvation
Albumin	23g/L	Malnutrition
ALT	437IU/L	Hepatic involvement

Clinical course

Immediate:

•Urgent MDT input on labour ward

•Commenced peripheral electrolyte replacement

•Invasive blood pressure monitoring

•Uncomplicated vaginal delivery within few hours

Hours:

•48hour admission to ICU

•Central electrolyte replacement

•Cautious nutritional support + Thiamine

•Continuous ECG monitoring

Days:

•Biochemistry normalised within 48hours

•Day 5 postpartum two self limiting tonic-clonic seizures – unclear the underlying cause

Discussion

•Rare but severe presentation of HG persisting to term

•Severe multi-organ involvement due to prolonged starvation

•This case highlighted an extremely high risk of refeeding syndrome

•Contributing factors include cyclical vomiting syndrome, cannabis use, limited nutritional reserve

•

•Possible link to Cannabinoid hyperemesis syndrome (CHS)

→CHS may co-exist with or exacerbate HG

→Cannabis use is associated with increased severity, delayed diagnosis and treatment resistance in vomiting of pregnancy/HG

→Increase in use of cannabis among the pregnant population¹

→Cannabis used in general population as anti-emetic

→Most effective management is cannabis cessation

Key learning points

•HG can persist to term with life threatening metabolic complications

•Early MDT input improves patient outcomes

•We must consider cannabis-related vomiting syndromes

•Consideration for overlapping obstetric pathology

•Patient and medical education is key for early recognition

•We must learn from missed opportunities for management

•Patients must feel listened to and heard

References

1.Galvin SL, Coulson CC. Addressing cannabis consumption among patients with hyperemesis gravidarum. AJOG Glob Rep. 2023 May;3(2):100180.

2.Nana M, Painter R, Williamson C, Nelson-Piercy C. Hyperemesis gravidarum. Lancet. 2026;407(10523):78–89.

Obstetric Anaesthesia Annual Scientific Meeting 2026

Severe Hyperemesis Gravidarum presenting in active labour with multi-system derangement.

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