Nausea and Vomiting in Pregnancy

Nausea and vomiting of pregnancy (NVP) also known as morning sickness” is one of the most common conditions of pregnancy that affect approximately 80% of pregnant women. Although the cause is still unknown (many theories exist), we do know that most women have resolution of symptoms by the time they are 16 weeks pregnant. However, 20% of women continue to experience symptoms throughout their pregnancy. Severe symptoms leading to dehydration and hospitalization is known as “hyperemesis gravidarum." Initial treatment of NVP should always be conservative. Conservative treatment involves dietary changes as well as emotional support.  If conservative treatment does not work and symptoms persist or worsen, then pharmacologic treatment should be sought.
 
Non-Medication Advice:
 
Diet: 
Do not mix solids and liquids. Mixing solids and liquids can cause the stomach to feel full and increase the nausea and vomiting. In some women, mixing solids and liquids can also cause acid reflux, gas, and bloating.
 
Eat small portions of food every 1-2 hours to avoid feeling full; and therefore, reduce the nausea and vomiting symptoms. Remember to separate solids and liquids. 
 
Fluids:
Drink plenty of fluids to keep well hydrated. Pregnant women should take approximately 2 liters of fluid a day. Popsicles and ice chips might be easier to tolerate.
 
 
Spitting:
If you feel as if you have excessive saliva, it is better to spit it out than to swallow it. Swallowing it can increase the sympoms of nausea and vomiting
 
 
Medication Advice
 
Prenatal vitamins:
Vitamins can sometimes make the nausea worse mostly because of their size and the amount of iron they contain. The most important thing, if you cannot tolerate your multivitamins, is to take folic acid alone or take a multivitamin that does not have iron. Once the nausea and vomiting get better then you can resume taking the regular prenatal vitamins.
 
Antacids:
Acid reflux can make the nausea and vomiting during pregnancy worse. 
 
Treatent of minor symptoms: calcium carbonate containing antacids (i.e. Tums, Maalox, Mylanta, Rolaids, Riopan). Make sure these are Sodium-free.
 
Treatment of persistent symptoms: H2 blockers and proton pump inhibitors.
 
 
OTC Nausea Medication: 
The use of doxylamine and pyridoxine used in combo is preferred. (Unisom with Vitamin B6 or Diclectin outside the U.S., the normal dose is two tabs at night, each tablet containing 10mg doxylamine/10mg pyridoxine)
Emetrol- 15-30ml (1-2 tablespoons) at 15 min intervals as needed. Do not take for more than one hour without consulting your physician. Contraindicated in Diabetics due to its high sugar content. Avoid diluting the medicine or taking oral fluids before or 15 min. after taking a dose.
 
Vitamin B6 (pyridoxine)- 25 mg (by mouth) every 8 hours
Unisom, Sleep Aid (doxylamine)- 25 mg (by mouth) once a day or 12.5 mg twice a day, divide scored tablets. 
Benadryl (diphenhydramine)- 25-50 mg orally every 4-8 hours as needed
Antivert (meclizine)- 25 mg (by mouth) every 4-6 hours
Prescription Medications:
Metoclopramide- 5-10 mg (by mouth) every 8 hours
Ondansetron- 8 mg (by mouth) every 8-12 hours
Methylprednisolone- 16 mg orally 3 times a day; then taper
 
 
References:
 
1. Einarson A, Maltepe C, Boskovic R, Koren G. Treatment of nausea and vomiting in pregnancy: an updated algorithm. Can Fam Physician. Dec 2007;53(12):2109-2111.

2. Quinla JD, Hill DA. Nausea and vomiting of pregnancy. Am Fam Physician. Jul 1 2003;68(1)121-128.  

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