Treatment of Nausea in Pregnancy

Assessment of Severity

The Motherisk Pregnancy-Unique Quantification of Emesis (PUQE) score is used to quantify severity, with scores categorized as mild (≤6), moderate (7-12), and severe (≥13) 1, 2, 3
Hyperemesis gravidarum is characterized by intractable vomiting, dehydration, weight loss >5% of prepregnancy weight, and electrolyte imbalances, and is evaluated using the PUQE score 1, 2, 3

Dietary modifications, such as eating small, frequent, bland meals (e.g., BRAT diet), choosing high-protein, low-fat meals, and avoiding spicy, fatty, acidic, and fried foods, are recommended for mild symptoms 4, 2
Non-prescription supplements, including ginger 250 mg capsules four times daily and vitamin B6 (pyridoxine) 10-25 mg every 8 hours, may be used to alleviate mild symptoms 4, 2

The doxylamine and pyridoxine combination is an FDA-approved treatment for moderate symptoms, and other H1-receptor antagonists, such as promethazine and dimenhydrinate, may be used if doxylamine is not available 4, 1, 2

Additional pharmacologic options, including ondansetron, metoclopramide, and intravenous glucocorticoids, may be used to treat severe symptoms or hyperemesis gravidarum 4, 2
Supportive care, such as electrolyte replacement and nutritional support, is crucial for women with severe symptoms or hyperemesis gravidarum 3

Early intervention is critical to prevent progression to hyperemesis gravidarum, and nausea and vomiting typically begins at 4-6 weeks, peaks at 8-12 weeks, and subsides by week 20 in most women 4, 2
The American College of Gastroenterology recommends that women with severe nausea or vomiting be treated promptly to prevent complications, and that 30-90% of pregnant women experience nausea and vomiting during pregnancy 2

Women with hyperemesis gravidarum may be at higher risk for adverse pregnancy outcomes, including low birth weight and premature delivery, and a multidisciplinary approach involving maternal-fetal medicine specialists may be necessary for refractory cases 3, 5

Hyperemesis gravidarum affects 0.35-2% of pregnancies and is characterized by persistent vomiting, weight loss >5% of prepregnancy weight, dehydration, and ketonuria 6
Nausea and vomiting typically begins at 4-6 weeks, peaks at 8-12 weeks, and subsides by week 20 in most women 7

Intravenous hydration and correction of electrolyte abnormalities 6
Thiamine supplementation to prevent Wernicke's encephalopathy 6
Intravenous glucocorticoids may be required in severe cases, but should be avoided before 10 weeks gestation due to increased risk of oral clefts 7

Early intervention is crucial to prevent progression to hyperemesis gravidarum 7
Liver enzyme abnormalities occur in approximately 50% of hyperemesis gravidarum cases but rarely exceed 1,000 IU/mL and typically resolve with hydration 6
Persistent liver chemistry abnormalities despite symptom resolution should prompt investigation for another etiology 6
For pregnant patients with complex conditions, coordination of care by a multidisciplinary team at a tertiary care center is recommended 7