What are the treatment options for nausea in pregnancy?

Treatment of Nausea in Pregnancy

The treatment of nausea in pregnancy should follow a stepwise approach beginning with diet and lifestyle modifications, followed by vitamin B6 and doxylamine, and progressing to other antiemetics for moderate to severe cases that don't respond to initial therapy. 1

Assessment of Severity

• Use the Motherisk Pregnancy-Unique Quantification of Emesis (PUQE) score to quantify severity:

  • Mild: score ≤6
  • Moderate: score 7-12
  • Severe: score ≥13 1

• Evaluate for signs of hyperemesis gravidarum (HG), which includes:

  • Intractable vomiting
  • Dehydration
  • Weight loss >5% of prepregnancy weight
  • Electrolyte imbalances 1

First-Line Interventions (Mild Symptoms)

Dietary Modifications:

• Eat small, frequent, bland meals (BRAT diet: bananas, rice, applesauce, toast) 1
• Choose high-protein, low-fat meals 1
• Avoid spicy, fatty, acidic, and fried foods 1
• Identify and avoid specific food triggers and strong odors 1, 2

Lifestyle Modifications:

• Rest adequately and avoid fatigue 2
• Identify and avoid non-food triggers (e.g., certain activities) 1
• Seek emotional support and validation 2

Non-Prescription Supplements:

• Ginger 250 mg capsules four times daily 1
• Vitamin B6 (pyridoxine) 10-25 mg every 8 hours 1, 3

Second-Line Interventions (Persistent or Moderate Symptoms)

Pharmacologic Options:

• Doxylamine and pyridoxine combination (FDA-approved, available in 10 mg/10 mg and 20 mg/20 mg combinations) 1
• Other H1-receptor antagonists if doxylamine is not available:
  • Promethazine
  • Dimenhydrinate 1

Third-Line Interventions (Severe Symptoms or Hyperemesis Gravidarum)

Additional Pharmacologic Options:

• Ondansetron (5-HT3 receptor antagonist) 1, 4
• Metoclopramide 1, 5
• Promethazine (if not used earlier) 1
• Intravenous glucocorticoids for refractory cases 1

Supportive Care:

• Intravenous hydration 6
• Electrolyte replacement 1
• Nutritional support 1
• Hospitalization for severe cases with dehydration, weight loss, or electrolyte disturbances 6

Important Clinical Considerations

• Early intervention is critical to prevent progression to hyperemesis gravidarum 1, 7
• Nausea and vomiting typically begins at 4-6 weeks, peaks at 8-12 weeks, and subsides by week 20 in most women 1
• 30-90% of pregnant women experience nausea and vomiting during pregnancy 1
• Only about 1% develop hyperemesis gravidarum 3

Common Pitfalls to Avoid

• Delaying treatment - Early intervention may prevent progression to more severe symptoms 1, 7
• Dismissing symptoms as "normal morning sickness" - Undertreating can lead to significant morbidity and reduced quality of life 7, 8
• Patient reluctance to use medications - Counsel patients about the safety of recommended treatments during pregnancy 7, 8
• Failing to rule out other causes of nausea and vomiting unrelated to pregnancy, especially with atypical presentations 3

Special Considerations

• For women with severe nausea or vomiting, consider a multidisciplinary approach involving maternal-fetal medicine specialists, especially if symptoms are refractory to standard treatments 1
• Women with hyperemesis gravidarum may be at higher risk for adverse pregnancy outcomes including low birth weight and premature delivery 1

Remember that the woman's perception of symptom severity is important in determining treatment approach, and early intervention can prevent more serious complications 7, 8.