Patient education: Nausea and vomiting of pregnancy (Beyond the Basics)
- Judith A Smith, PharmD, BCOP, CPHQ, FCCP, FISOPP
Judith A Smith, PharmD, BCOP, CPHQ, FCCP, FISOPP
- Associate Professor and Director
- Women's Health Integrative Medicine Research Program, Department of Obstetrics and Gynecology
- Jerrie S Refuerzo, MD
Jerrie S Refuerzo, MD
- Associate Professor
- Division of Maternal Fetal Medicine
- Department of Obstetrics and Gynecology
- University of Texas Health Science Center at Houston
- Susan M Ramin, MD
Susan M Ramin, MD
- Section Editor — Obstetrics
- The American Board of Obstetrics and Gynecology (ABOG)
Nausea and vomiting of pregnancy commonly occur between 5 and 18 weeks of pregnancy. Between 50 and 90 percent of women have some degree of nausea, with or without vomiting. The severity of these symptoms can vary.
"Morning sickness" is the term often used to describe mild nausea and vomiting while "hyperemesis gravidarum" is the term used to describe a more severe condition. Hyperemesis may cause you to vomit multiple times throughout the day, lose weight, and usually requires treatment in the hospital.
This article discusses treatments available for nausea and vomiting during pregnancy. A more detailed article is available by subscription. (See "Clinical features and evaluation of nausea and vomiting of pregnancy" and "Treatment and outcome of nausea and vomiting of pregnancy".)
MORNING SICKNESS VERSUS HYPEREMESIS
Morning sickness — Nausea and vomiting often develop by five to six weeks of pregnancy. The symptoms are worst around nine weeks, and typically improve by 16 to 18 weeks of pregnancy. However, symptoms continue until the third trimester in 15 to 20 percent of women and until delivery in 5 percent of women . Although mild pregnancy-related nausea and vomiting is often called "morning sickness," you may feel sick at any time of day and many women (80 percent) feel sick throughout the day.
Interestingly, women with mild nausea and vomiting during pregnancy experience fewer miscarriages and stillbirths than women without these symptoms.
Hyperemesis gravidarum — Hyperemesis gravidarum is the term used to describe more severe nausea and vomiting during pregnancy. Women with hyperemesis often vomit every day and may lose more than 5 percent of their pre-pregnancy body weight. In most cases, women with hyperemesis gravidarum will have blood and urine tests that show evidence of dehydration.
CAUSE OF NAUSEA AND VOMITING IN PREGNANCY
The cause of pregnancy-related nausea and vomiting is not clear. Several theories have been proposed, although none have been definitively proven. Increased hormone levels, slowed movement of the stomach contents, and psychological factors are among the more common theories.
Some women are more likely to develop nausea and vomiting of pregnancy, including women who:
●Developed these symptoms in a previous pregnancy
●Experience nausea and vomiting while taking estrogen (for example, in birth control pills) or have menstrual migraines
●Experience motion sickness
●Have a history of gastrointestinal problems (ie, reflux, ulcers)
WHEN TO SEEK HELP
Many women, especially those with mild to moderate nausea and/or vomiting, do not need to see a healthcare provider for treatment of nausea and vomiting. The suggestions below may help to reduce symptoms and prevent dehydration. (See 'Treatment of nausea and vomiting in pregnancy' below.)
Women with more severe nausea and vomiting sometimes need to be evaluated by their primary care or obstetrical doctor or nurse. Seek help if you have one or more of the following:
●Signs of dehydration, including infrequent urination, dark-colored urine, or dizziness with standing
●Vomiting repeatedly throughout the day, especially if you see blood in the vomit
●Abdominal or pelvic pain or cramping
●If you are unable to keep down any food or drinks for more than 12 hours
●You lose more than 5 pounds (2.3 kg)
One or more tests may be recommended to investigate the cause and determine the severity of the nausea and vomiting, including blood tests, urine tests, or an ultrasound.
TREATMENT OF NAUSEA AND VOMITING IN PREGNANCY
The treatment of pregnancy-related nausea and vomiting aims to help you feel better and allow you to eat and drink enough so that you do not lose weight.
Treatment may not totally eliminate your nausea and vomiting. You may need to try several types of treatment over a period of weeks before finding what works best for you. Fortunately, symptoms generally resolve by mid-pregnancy, even if you do not use any treatment. (See "Treatment and outcome of nausea and vomiting of pregnancy".)
Dietary changes — Avoiding food or not eating may actually make nausea worse. Try eating before or as soon as you feel hungry to avoid an empty stomach, which may aggravate nausea. Eat snacks frequently and have small meals (eg, six small meals a day) that are high in protein or carbohydrates and low in fat. Drink cold, clear, and carbonated or sour fluids (eg, ginger ale, lemonade) and drink these in small amounts between meals. Smelling fresh lemon, mint, or orange or using an oil diffuser with these scents may also be useful.
Avoid triggers — One of the most important treatments for pregnancy-related nausea and vomiting is to avoid odors, tastes, and other activities that trigger nausea. Eliminating spicy foods helps some women. Other examples of triggers include:
●Odors (eg, perfume, chemicals, coffee, food, smoke)
●Heat and humidity
●Visual or physical motion (eg, flickering lights, driving)
●Consuming large amounts of high-sugar foods/snacks
●Consuming spicy foods and high-fat foods
Brushing teeth after eating may help prevent symptoms. Avoid lying down immediately after eating and avoid quickly changing positions.
If you take a prenatal vitamin with iron and this worsens your symptoms, try taking them at bedtime. If symptoms persist, stop the vitamins temporarily. If you stop taking your prenatal vitamin, take a supplement that contains 400 to 800 micrograms of folic acid until you are at least 14 weeks pregnant to reduce the risk of birth defects.
Medications — Medications that reduce nausea and vomiting are effective in some women and are safe to take during pregnancy. None of the medications discussed below are known to be harmful. Make sure you talk with your healthcare provider before taking any new over the counter or prescription medications, including nutritional and herbal supplements.
●Vitamin B6 and doxylamine — Vitamin B6 supplements can reduce symptoms of mild to moderate nausea, but do not usually help with vomiting. Doxylamine is a medication that can reduce vomiting, and may be combined with vitamin B6. Doxylamine is available in the United States in some non-prescription sleep aids (eg, Unisom, Good Sense Sleep Aid) and as a prescription antihistamine chewable tablet (Aldex AN). Combinations of vitamin B6 and doxylamine formulations are available for the initial treatment of nausea (eg, Diclectin in Canada and Diclegis in the United States).
●Antihistamines and other anti-nausea medications — Antihistamines and other anti-nausea medications are safe and effective treatments for pregnancy-related nausea and vomiting. The following medications may be recommended:
•Diphenhydramine (Benadryl), but this drug may cause drowsiness
•Meclizine (Bonine), but this drug may also cause drowsiness
●Other anti-nausea medications that are available by prescription include:
•Promethazine (Phenergan) — Promethazine is available in pill, oral solution, injectable solution, or rectal suppository form. It is usually taken every four hours, and may cause drowsiness and dry mouth. Rare side effects include muscle contractions that cause twisting or jerking movements.
•Metoclopramide (Reglan) — Metoclopramide speeds emptying of the stomach and may help to reduce nausea and vomiting. It is available in a pill, oral solution, and injectable usually taken 30 minutes prior to meals and at bedtime.
•Ondansetron (Zofran) — Ondansetron is an anti-nausea medication that is usually taken by mouth or injection every eight to 12 hours. Ondansetron is an expensive anti-nausea medication (approximately $500 for 30 pills in the United States) and it may not be covered by some insurance plans.
Fluids and nutrition — If you are unable to hold down food or liquids, you may be treated with intravenous (IV) fluids. This may be done in your doctor or nurse's office or in the hospital, depending upon the severity of your vomiting. For a short time, you may be advised not to eat or drink anything, to allow the gut to rest. You can slowly begin to eat and drink again as you begin to feel better, usually within 24 to 48 hours.
If you continue to lose weight despite treatment, your doctor may consider other forms of feeding, such as the use of a nasogastric tube (a tube that is inserted through your nose into the stomach) or supplemental nutrition through an IV line.
Complementary treatments — The following treatments may be useful when used with the treatments described above.
●Acupuncture and acupressure — Acupressure wristbands (picture 1) and acupuncture have become a popular treatment for nausea and vomiting caused by pregnancy, motion sickness, and other causes. Studies have not shown these wristbands to be more effective than sham (fake, look-alike) wristbands , although some women find them helpful. Acupuncture and acupressure have no known harmful side effects.
●Hypnosis — Hypnosis has been reported to be helpful in some people. Counseling may be helpful for women with anxiety.
●Ginger — Powdered ginger or ginger tea may help to relieve nausea and vomiting in some women. However, further studies are needed to confirm that this treatment is both safe and effective. Until more data are available, we suggest the use of ginger containing foods (eg, ginger lollipops, ginger ale) for mild nausea and vomiting.
Most women with pregnancy-related nausea and vomiting recover completely without any complications. Women with mild to moderate vomiting often gain less weight during early pregnancy. This is rarely a concern for the baby unless the mother was very underweight before pregnancy (at least 10 percent under the ideal body weight).
Normal weight gain during pregnancy depends upon your pre-pregnancy weight. For women of normal weight (body mass index 18.5 to 24.9 kilogram/meter2), the recommended weight gain is between 25 and 35 pounds (11.5 to 16.0 kilograms) for a singleton pregnancy.
In women with severe nausea and vomiting (hyperemesis gravidarum) who are hospitalized multiple times and who do not gain weight normally during pregnancy, there is a small risk that the baby will be underweight or small.
Women who have hyperemesis gravidarum in one pregnancy are at risk of severe nausea and vomiting in future pregnancies. The risk is between 15 and 20 percent. Women who do not have severe nausea and vomiting in the first pregnancy are unlikely to have it in future pregnancies .
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Morning sickness (The Basics)
Patient education: Pregnancy symptoms (The Basics)
Patient education: Taking over-the-counter medicines during pregnancy (The Basics)
Patient education: Motion sickness (The Basics)
Patient education: Hyperemesis gravidarum (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Approach to the adult with nausea and vomiting
Characteristics of antiemetic drugs
Clinical features and evaluation of nausea and vomiting of pregnancy
Treatment and outcome of nausea and vomiting of pregnancy
The following organizations also provide reliable health information.
●National Library of Medicine
(www.nlm.nih.gov/medlineplus/ency/article/001499.htm, available in Spanish)
●Society of Obstetricians and Gynecologists of Canada
●Organization of Teratology Information Specialists
- Association of Professors of Gynecology and Obstetrics. Nausea and vomiting of pregnancy. https://www.apgo.org/ (Accessed on December 05, 2016).
- Matthews A, Haas DM, O'Mathúna DP, Dowswell T. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev 2015; :CD007575.
- Dodds L, Fell DB, Joseph KS, et al. Outcomes of pregnancies complicated by hyperemesis gravidarum. Obstet Gynecol 2006; 107:285.
- Magee LA, Mazzotta P, Koren G. Evidence-based view of safety and effectiveness of pharmacologic therapy for nausea and vomiting of pregnancy (NVP). Am J Obstet Gynecol 2002; 186:S256.
- Goodwin TM. Nausea and vomiting of pregnancy: an obstetric syndrome. Am J Obstet Gynecol 2002; 186:S184.
- Holmgren C, Aagaard-Tillery KM, Silver RM, et al. Hyperemesis in pregnancy: an evaluation of treatment strategies with maternal and neonatal outcomes. Am J Obstet Gynecol 2008; 198:56.e1.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.