From the Guidelines
For nausea and vomiting in pregnancy, the safest first-line treatment is a combination of vitamin B6 (pyridoxine) 10-25mg three times daily and doxylamine 12.5mg at night, which can be increased if needed, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1.
Key Considerations
- The combination of vitamin B6 and doxylamine can be taken separately or as the combination product Diclegis/Diclectin.
- If these are insufficient, prescription antiemetics like ondansetron (Zofran) 4-8mg every 8 hours, metoclopramide (Reglan) 10mg three times daily, or promethazine (Phenergan) 12.5-25mg every 4-6 hours can be used, as suggested by recent clinical practice updates 1.
- Ginger supplements (250mg four times daily) may also help as a natural remedy.
- It's essential to stay hydrated and eat small, frequent meals to manage symptoms.
- Severe cases may require IV fluids and hospitalization.
Safety Profiles
- These medications have been extensively studied in pregnancy and have good safety profiles, with doxylamine and pyridoxine being US Food and Drug Administration–approved and recommended by ACOG for persistent NVP refractory to non-pharmacologic therapy 1.
- However, it's crucial to consult with a healthcare provider before starting any medication during pregnancy, as they can tailor recommendations to the specific situation and severity of symptoms.
Additional Guidance
- The European Association for the Study of the Liver (EASL) clinical practice guidelines also support the use of doxylamine, pyridoxine, and other antiemetics in pregnancy, with careful consideration of the benefits and risks 1.
- Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum, emphasizing the importance of prompt and effective management 1.
From the Research
Safe Medications for Nausea and Vomiting in Pregnancy
The following antiemetic drugs are considered safe for use in pregnancy:
- Ginger 2
- Vitamin B6 2, 3, 4
- Antihistamines 2, 4, 5
- Metoclopramide (for mild symptoms) 2, 6, 4, 5
- Pyridoxine-doxylamine 2, 6, 4, 5
- Ondansetron (for moderate symptoms) 2, 4, 5
- Promethazine 2, 4, 5
- Corticosteroids (for severe cases) 2, 4, 5
Dosage and Administration
- Vitamin B6: oral intake of 10mg four times a day, alone or in combination with doxylamine 3
- Metoclopramide: should be used as second-line therapy due to the risk of extrapyramidal effects, and intravenous doses should be administered by slow bolus injection over at least 3 minutes 5
- Ondansetron: can be used as a second-line antiemetic if first-line antiemetics are ineffective, and women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester 5
Treatment Guidelines
- The Pregnancy-Unique Quantification of Emesis (PUQE) and HyperEmesis Level Prediction (HELP) tools can be used to classify the severity of NVP and HG 5
- Ketonuria is not an indicator of dehydration and should not be used to assess severity 5
- Combinations of different drugs should be used in women who do not respond to a single antiemetic 5
- Thiamine supplementation should be given to all women admitted with vomiting, or severely reduced dietary intake, especially before administration of dextrose or parenteral nutrition 5