What is the management for a pregnant individual experiencing vomiting at 14 weeks of gestation?

Management of Vomiting at 14 Weeks of Pregnancy

For a pregnant individual experiencing vomiting at 14 weeks of gestation, treatment should begin with dietary and lifestyle modifications, followed by a stepwise approach with vitamin B6 and doxylamine as first-line pharmacologic therapy if needed. 1

Assessment of Severity

• First, assess severity using the Motherisk Pregnancy-Unique Quantification of Emesis (PUQE) score to guide management 1:

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

• Evaluate for signs of hyperemesis gravidarum (HG), which includes 1, 2:

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

Initial Management for Mild to Moderate Symptoms

Non-pharmacological Approaches

• Dietary modifications 1:

  • Eat small, frequent, bland meals
  • Follow BRAT diet (bananas, rice, applesauce, toast)
  • Focus on high-protein, low-fat meals
  • Avoid spicy, fatty, acidic, and fried foods

• Identify and avoid specific triggers such as foods with strong odors or activities that worsen symptoms 1

First-line Pharmacological Treatment

• Vitamin B6 (pyridoxine) 10-25 mg every 8 hours 1

• Ginger 250 mg capsules four times daily 1

• If symptoms persist, add doxylamine (available in combination with pyridoxine in 10 mg/10 mg or 20 mg/20 mg formulations) 1

  • FDA-approved and recommended by ACOG for persistent nausea and vomiting of pregnancy
  • Safe and well-tolerated during pregnancy

Management for Moderate to Severe Symptoms

• For symptoms not responding to first-line therapy, consider 1:

  • H1-receptor antagonists (promethazine, dimenhydrinate)
  • Metoclopramide (shown to have similar efficacy to promethazine with fewer side effects)
  • Ondansetron (use on case-by-case basis, especially after 10 weeks of pregnancy)

• For severe cases requiring hospitalization 1, 3:

  • Intravenous fluid and electrolyte replacement
  • Vitamin B1 (thiamine) supplementation: 100 mg daily for at least 7 days, then 50 mg daily maintenance until adequate oral intake is established
  • Intravenous glucocorticoids may be required in refractory cases

Special Considerations

• Early intervention is crucial to prevent progression to hyperemesis gravidarum 1

• At 14 weeks, symptoms may begin to improve naturally, as nausea and vomiting typically peaks at 8-12 weeks and subsides by week 20 1

• For persistent severe symptoms, consider multidisciplinary management involving obstetricians, nutritionists, psychologists, and gastroenterologists 1

• Monitor for complications of severe vomiting, including 1, 4:

  • Electrolyte abnormalities
  • Nutritional deficiencies
  • Liver function abnormalities (seen in 40-50% of HG patients)

Follow-up Recommendations

• Regular assessment of symptom severity, hydration status, and weight 1

• Adjust treatment based on symptom response and pregnancy progression 1

• For severe cases, consider ultrasonography to rule out multiple or molar pregnancies and evaluate fetal growth 1