Nausea and Vomiting of Pregnancy



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Nausea and vomiting of pregnancy affects nearly 75% of pregnant women. The exact cause is unknown. In most cases, it is a mild, self-limited condition that can be controlled with conservative measures and has no adverse fetal sequelae. About 1% of women develop hyper-emesis gravidarum, which may result in adverse outcomes for the mother and fetus. Patients with nausea and vomiting of pregnancy should be evaluated for other causes, particularly if symptoms are unremitting or presentation is atypical. Initial treatment is conservative and includes dietary changes, emotional support, and vitamin B6 supplementation. Several safe and effective pharmacologic therapies are available for women who do not improve with initial treatment. Women with hyperemesis gravidarum may require more aggressive interventions, including hospitalization, rehydration therapy, and parenteral nutrition.

Nausea and vomiting occur in up to 74% of pregnant women, and 50% experience vomiting alone.1,2 Although the term morning sickness is commonly used to describe nausea and vomiting of pregnancy, the timing, severity, and duration of symptoms vary widely. Approximately 80% of women report that their symptoms last all day, whereas only 1.8% report symptoms that occur solely in the morning.2

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Vitamin B6 should be prescribed as first-line treatment for nausea and vomiting of pregnancy.

A

32, 33

Physicians should consider prescribing doxylamine (Unisom SleepTabs) in addition to vitamin B6 for treatment of nausea and vomiting of pregnancy because the combination reduces symptoms by 70%.

C

34


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Vitamin B6 should be prescribed as first-line treatment for nausea and vomiting of pregnancy.

A

32, 33

Physicians should consider prescribing doxylamine (Unisom SleepTabs) in addition to vitamin B6 for treatment of nausea and vomiting of pregnancy because the combination reduces symptoms by 70%.

C

34


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

Women who are less educated, older, or black, and those who have lower incomes, multiple gestations, or increasing gravidity (including miscarriages) are at greater risk of nausea and vomiting of pregnancy.1 A personal history of motion sickness,3 migraine headaches,4 or nausea associated with the use of estrogen-containing contraceptives5 also increases the risk.

Hyperemesis gravidarum describes nausea and vomiting that is severe enough to cause fluid and electrolyte disturbances, and often requires hospitalization.6 It affects up to 1% of pregnant women and is associated with persistent vomiting (more than three episodes per day) that results in severe dehydration, ketonuria, electrolyte abnormalities such as hypokalemia, and weight loss of more than 5%.7,8 A personal history of hyperemesis gravidarum, gestational trophoblastic disease, fetal triploidy, fetal trisomy 21, hydrops fetalis, and multiple gestations increases the risk of this condition.9 The risk may be increased by as much as 50% if the fetus is female.10

Etiology and Pathophysiology

The causes of nausea and vomiting of pregnancy and of hyperemesis gravidarum are unknown. However, observational data indicate that these conditions correlate with levels of human chorionic gonadotropin (hCG) and the size of the placental mass, which suggests that placental products may be associated with the presence and severity of nausea and vomiting.11 Some women with complete hydatidiform molar pregnancies, in which no fetus is present, have significant nausea and vomiting, which indicates that placental factors, particularly hCG, are responsible. Women with higher hCG levels, such as those with multiple gestations, hydatidiform moles, or fetuses with Down syndrome, are at increased risk of nausea and vomiting.12

Levels of estrogen and progesterone may also be involved. Other potential etiologies include placental prostaglandins, serotonin levels, thyroid dysfunction, increased leptin levels, immune system dysregulation,

The Author

HOWARD ERNEST HERRELL, MD, is clerkship director in the Department of Obstetrics and Gynecology at East Tennessee State University in Johnson City.

Author disclosure: No relevant financial affiliations.

Address correspondence to Howard Ernest Herrell, MD, East Tennessee State University, 325 N. State of Franklin Rd., Johnson City, TN 37604 (e-mail: herrellh@etsu.edu). Reprints are not available from the author.

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