What is the recommended treatment for nausea in pregnancy?

Treatment for Nausea in Pregnancy

For nausea and vomiting in pregnancy (NVP), start with diet and lifestyle modifications, followed by vitamin B6 (pyridoxine) and doxylamine as first-line pharmacologic therapy; more severe cases may require additional medications such as ondansetron, metoclopramide, promethazine, or intravenous glucocorticoids. 1

Understanding NVP

• NVP affects 30-90% of pregnant women, typically beginning at 4-6 weeks, peaking at 8-12 weeks, and subsiding by week 20 1
• NVP is associated with elevated levels of human chorionic gonadotropin, estrogen, and changes in GI motility 1
• Severity can be assessed using the Motherisk Pregnancy-Unique Quantification of Emesis (PUQE) score 1

Treatment Algorithm

Step 1: Non-pharmacologic Interventions

• Dietary modifications:
  • Eat small, frequent, bland meals 1
  • Follow 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 triggers (foods with strong odors, certain activities) 1

Step 2: First-line Pharmacologic Therapy

• Ginger: 250 mg capsule four times daily 1
• Vitamin B6 (pyridoxine): 10-25 mg every 8 hours 1, 2
• Doxylamine (H1-receptor antagonist): 10-20 mg combined with pyridoxine 1, 3
  • Available as combination tablet (10 mg/10 mg or 20 mg/20 mg) 1
  • FDA-approved and recommended by ACOG for persistent NVP 1, 3

Step 3: Additional Pharmacologic Options for Moderate to Severe Cases

• Other H1-receptor antagonists: promethazine, dimenhydrinate 1
• For more severe cases (moderate to severe on PUQE score):
  • Ondansetron 1
  • Metoclopramide 1
  • Intravenous glucocorticoids for refractory cases 1

Special Considerations

Hyperemesis Gravidarum (HG)

• Defined as intractable NVP leading to dehydration, >5% weight loss, and electrolyte imbalances 1
• Affects 0.3-2% of pregnant women 1
• Early intervention with appropriate NVP treatment may prevent progression to HG 1
• Requires more aggressive therapy and possibly hospitalization for IV hydration 1

Safety Profile

• Doxylamine-pyridoxine combination has FDA Pregnancy Category A status (highest safety rating) 3
• Vitamin B6 is considered safe during pregnancy at doses up to 40-60 mg/day 4
• Metoclopramide can be used for nausea in pregnancy with an acceptable safety profile 1

Common Pitfalls to Avoid

• Delaying treatment due to unfounded concerns about medication safety 2, 3
• Failing to recognize and treat vitamin deficiencies (especially B1/thiamine) in women with prolonged vomiting 2
• Not escalating therapy appropriately when first-line treatments fail 1
• Overlooking the potential for NVP to progress to hyperemesis gravidarum without adequate treatment 1

Early intervention is key to preventing progression to more severe forms of NVP and improving maternal quality of life during pregnancy 1.