What is the optimal management for nausea and vomiting in pregnancy?

Management of Nausea and Vomiting in Pregnancy: Australian Telehealth Approach

The optimal management of nausea and vomiting in pregnancy involves a stepwise approach starting with dietary and lifestyle modifications, followed by vitamin B6 (pyridoxine) alone or combined with doxylamine as first-line pharmacological treatment, with escalation to other antiemetics for moderate to severe cases. 1

Assessment of Severity

First, assess severity using the Motherisk Pregnancy-Unique Quantification of Emesis (PUQE) score:

Score	Severity
≤6	Mild
7-12	Moderate
≥13	Severe

The PUQE score evaluates three parameters over the past 12 hours:

• Duration of nausea (hours)
• Number of vomiting episodes
• Number of retching episodes

Treatment Algorithm

Step 1: Non-pharmacological Interventions

• Small, frequent meals (every 1-2 hours)
• Low-fat, bland foods (BRAT diet: bananas, rice, applesauce, toast)
• High-protein, low-fat meals
• Avoid specific triggers (strong odors, spicy/fatty foods)
• Separate solids and liquids by 20-30 minutes
• Cold foods (which have less odor)
• Adequate hydration with small amounts frequently

Step 2: First-line Pharmacological Treatment

For mild to moderate symptoms (PUQE score ≤12) not responding to non-pharmacological measures:

• Vitamin B6 (pyridoxine): 10-25 mg orally every 8 hours 1, 2
• If inadequate response after 24-48 hours, add:
• Doxylamine: 10 mg orally 3-4 times daily (can be combined with pyridoxine) 1, 3

Step 3: Second-line Treatment

For moderate symptoms not responding to first-line treatment:

• H1-receptor antagonists:
  • Promethazine: 12.5-25 mg orally/IV every 4-6 hours
  • Dimenhydrinate: 50-100 mg orally/IV every 4-6 hours

Step 4: Third-line Treatment

For severe symptoms (PUQE score ≥13) or inadequate response to second-line treatment:

• Ondansetron: 4-8 mg orally/IV every 8 hours 1
• Metoclopramide: 5-10 mg orally/IV every 6-8 hours 1

Step 5: Refractory Cases (Hyperemesis Gravidarum)

For severe, persistent symptoms with:

• Weight loss >5% of pre-pregnancy weight
• Dehydration
• Electrolyte imbalances

Management includes:

• IV hydration
• Electrolyte replacement
• Intravenous glucocorticoids: methylprednisolone or prednisolone (preferred over dexamethasone or betamethasone) 1
• Consider hospitalization for severe cases

Telehealth Considerations

For telehealth management:

1. Virtual Assessment:

   • Use the PUQE score via telehealth consultation
   • Ask patients to monitor and record weight, fluid intake, and urination frequency
   • Look for warning signs: inability to keep fluids down for >24 hours, dark urine, dizziness

2. Remote Monitoring:

   • Schedule follow-up telehealth appointments within 24-48 hours after treatment initiation
   • Instruct patients on when to seek in-person care (persistent vomiting, signs of dehydration)

3. Prescription Management:

   • E-prescribe medications with clear instructions
   • Consider longer prescription durations to minimize pharmacy visits

Safety and Efficacy Evidence

• Pyridoxine has demonstrated effectiveness in reducing nausea severity in early pregnancy with an excellent safety profile at doses up to 40-60mg/day 2, 4
• The combination of doxylamine and pyridoxine shows greater improvement in symptom scores compared to placebo, though the clinical significance may be modest 5
• Ondansetron and metoclopramide are considered safe for use in pregnancy when first-line treatments fail 1
• Methylprednisolone or prednisolone are preferred steroids after 10 weeks gestation, as they are metabolized in the placenta, unlike dexamethasone or betamethasone which have almost 100% placental passage 1

Important Considerations

• Early intervention is crucial to prevent progression to hyperemesis gravidarum 1
• Treatment should be initiated promptly rather than waiting for symptoms to worsen
• Ginger (250 mg capsule 4 times daily) may be recommended as a complementary approach 1
• For severe cases not manageable via telehealth, arrange in-person evaluation and possible IV hydration

By following this stepwise approach, most women with nausea and vomiting of pregnancy can be effectively managed, improving their quality of life and preventing more serious complications.