Nausea and vomiting are some of the most common symptoms during pregnancy. Severity should be assessed with a tool such as the Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) score. In severe cases, additional medical history should be obtained to rule out possible secondary causes. Treatment depends on the severity of symptoms, beginning with behavioral modification such as trigger avoidance and dietary changes for mild cases. Modification includes meals that are small, frequent, bland, dry, and high in protein. First-line pharmacologic management for mild or moderate cases is vitamin B6 with or without doxylamine. When conservative measures are ineffective or not tolerated, additional pharmacologic options include other antihistamines or dopamine antagonists. Metoclopramide and ondansetron are considered second-line treatments for persistent symptoms. Dehydration and electrolyte abnormalities should be corrected and may necessitate hospitalization if oral intake is not possible. Treatment of refractory or severe symptoms include the consideration of corticosteroids and, in rare cases, supplemental enteral or parenteral nutrition.
Approximately 70% of pregnancies are complicated by nausea and vomiting, with approximately one-third featuring only nausea.1 Symptoms usually start between 4 and 10 weeks of gestation, and most improve by 20 weeks of gestation.2 Despite the term morning sickness, it is more common for pregnant patients to have symptoms throughout the day.3,4
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Symptom severity should be assessed with a tool such as the Pregnancy-Unique Quantification of Emesis and Nausea (PUQE) score to guide therapy.2,6 | C | Expert consensus guidelines |
| Recommended nonpharmacologic options for mild nausea and vomiting during pregnancy include ginger, P6 acupressure, and dietary changes.2,6,37–44 | C | Guideline recommendations from limited or weak evidence from randomized controlled trials and meta-analyses |
| Vitamin B6 (pyridoxine) alone or in combination with doxylamine is first-line treatment for mild to moderate nausea and vomiting during pregnancy.41,50 | B | Systematic reviews and meta-analyses |
| Metoclopramide and ondansetron are similarly effective as second-line agents in the management of nausea and vomiting during pregnancy. When choosing an agent, adverse effect profile and safety should be considered.49,58,59 | B | Consistent evidence from randomized controlled trials, systematic reviews, and meta-analyses |
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 https://www.aafp.org/afpsort.
Hyperemesis gravidarum is a more severe condition that can be diagnosed using different sets of criteria. The Windsor definition is a multistakeholder international consensus description that includes nausea, vomiting, or both; inability to eat or drink normally, which strongly affects daily activities; and onset before 16 weeks of gestation.5 Historically, a reasonable diagnosis can be made in patients with persistent nausea and vomiting that are not attributable to another cause, as well as ketonuria and some degree of weight loss (typically at least 5% of prepregnancy body weight). Additional laboratory abnormalities such as electrolyte imbalances, thyroid dysfunction, nutrient deficiencies, and elevated liver enzyme levels can occur. Incidence of hyperemesis gravidarum ranges from 0.3% to 3% of pregnancies.6
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