What are the treatment options for vomiting during pregnancy?

Treatment of Vomiting During Pregnancy

Treatment should follow a stepwise approach based on symptom severity, starting with dietary modifications and vitamin B6 for mild symptoms, progressing to combination doxylamine-pyridoxine for moderate symptoms, and advancing to ondansetron, metoclopramide, or intravenous hydration with thiamine supplementation for severe symptoms or hyperemesis gravidarum. 1, 2

Assess Severity First

Use the Pregnancy-Unique Quantification of Emesis (PUQE) score to guide treatment intensity 1, 2:

• Mild symptoms: PUQE score ≤6 1
• Moderate symptoms: PUQE score 7-12 1
• Severe symptoms/Hyperemesis gravidarum: PUQE score ≥13, plus dehydration, weight loss >5% of prepregnancy weight, and electrolyte imbalances 1, 2

Mild Symptoms (First-Line Treatment)

Dietary modifications 1, 2:

• Small, frequent, bland meals (BRAT diet: bananas, rice, applesauce, toast) 1
• High-protein, low-fat meals 1
• Avoid spicy, fatty, acidic, and fried foods 1

Non-prescription supplements 1:

• Vitamin B6 (pyridoxine): 10-25 mg every 8 hours 1, 2
• Ginger: 250 mg capsules four times daily 1

Moderate Symptoms (Second-Line Treatment)

Doxylamine-pyridoxine combination is FDA-approved and should be the first pharmacologic choice for moderate symptoms 1. If doxylamine is unavailable, use alternative H1-receptor antagonists 1:

• Promethazine 3, 1
• Dimenhydrinate 1

Severe Symptoms or Hyperemesis Gravidarum (Third-Line Treatment)

Antiemetics with favorable safety profiles 3, 1:

• Ondansetron: Preferred antiemetic for severe symptoms 3
• Metoclopramide: Similar efficacy to promethazine with fewer side effects 2
• Promethazine: Alternative option 3

Supportive care is essential 3, 1:

• Intravenous hydration and electrolyte correction 3, 1
• Thiamine supplementation to prevent Wernicke's encephalopathy 3, 1
• Nutritional support as needed 1

Intravenous glucocorticoids may be considered for severe, refractory cases, but avoid before 10 weeks gestation due to increased risk of oral clefts 1.

Critical Clinical Pitfalls

Early intervention prevents progression: Symptoms typically begin at 4-6 weeks, peak at 8-12 weeks, and resolve by week 20 in most women 1, 2. Treating early prevents escalation to hyperemesis gravidarum 1, 2.

Monitor liver function: Approximately 50% of hyperemesis gravidarum cases show elevated liver enzymes (ALT > AST), but these rarely exceed 1,000 U/L and typically resolve with hydration 3, 1. Persistent liver abnormalities despite symptom resolution warrant investigation for alternative etiologies 3, 1.

Watch for electrolyte abnormalities and nutritional deficiencies, particularly in severe cases requiring hospitalization 2.

Special Populations

Women with hyperemesis gravidarum face higher risk for low birth weight and premature delivery 1. Recurrence in subsequent pregnancies is common 3. For refractory cases, coordinate care through a multidisciplinary team at a tertiary center 1.