From the Guidelines
For nausea treatment during pregnancy, start with non-medication approaches like eating small, frequent meals, avoiding triggers, consuming ginger products, wearing acupressure wristbands, and staying hydrated. If these aren't sufficient, vitamin B6 (pyridoxine) at 10-25mg three times daily is the first-line medication option, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1. For more severe symptoms, add doxylamine (an antihistamine) 12.5mg at night, which can be increased to three times daily if needed. Prescription options include diclectin/diclegis (a combination of doxylamine and B6) or antiemetics like metoclopramide (10mg every 6-8 hours), ondansetron (4-8mg every 8 hours), or promethazine (12.5-25mg every 4-6 hours) for severe cases, as suggested by recent clinical practice updates 1. These medications are generally considered safe during pregnancy, with the benefits outweighing potential risks when nausea and vomiting are severe enough to affect nutrition and hydration, as supported by expert consensus statements 1. Key considerations include:
- Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum 1.
- The use of ondansetron in early pregnancy has not been linked to a high risk of congenital defects, but a marginal relative increase in cleft palate and cardiovascular malformations has been described 1.
- Glucocorticosteroids have been shown to cause an increase in oral clefts incidence when used before 10 weeks of gestation, and their use should be carefully considered 1. Seek medical attention immediately if you experience signs of dehydration, inability to keep any food or fluids down for 24 hours, weight loss exceeding 5% of pre-pregnancy weight, or if symptoms are accompanied by fever, abdominal pain, or headache.
From the Research
Nausea Treatment in Pregnancy
- Nausea and vomiting affects approximately 85% of pregnant women, with the most severe form, hyperemesis gravidarum, affecting up to 3% of women 2.
- The harmlessness of oral vitamin B6 during pregnancy has been established for doses up to 40-60mg/day, mainly in combination with doxylamine (40mg/40mg) 3.
- Evidence from 35 RCTs at low risk of bias indicated that ginger, vitamin B6, antihistamines, metoclopramide, pyridoxine-doxylamine, and ondansetron were associated with improved symptoms compared with placebo 2.
Treatment Options
- For mild symptoms of nausea and emesis of pregnancy, ginger, pyridoxine, antihistamines, and metoclopramide were associated with greater benefit than placebo 2.
- For moderate symptoms, pyridoxine-doxylamine, promethazine, and metoclopramide were associated with greater benefit than placebo 2.
- Ondansetron was associated with improvement for a range of symptom severity 2.
- Corticosteroids may be associated with benefit in severe cases 2.
- The combination of doxylamine succinate/pyridoxine hydrochloride is recommended as first-line pharmacologic treatment for NVP 4.
Management
- Mild cases of nausea and vomiting of pregnancy may be resolved with lifestyle and dietary changes 5, 6.
- Safe and effective treatments are available for more severe cases 5, 6.
- The woman's perception of the severity of her symptoms plays a critical role in the decision of whether, when, and how to treat nausea and vomiting of pregnancy 5, 6.
- Nausea and vomiting of pregnancy should be distinguished from nausea and vomiting related to other causes 5, 6.