Management of Nausea and Vomiting in Pregnancy

Understanding Nausea and Vomiting in Pregnancy (NVP)

NVP affects 30-90% of pregnant women, typically beginning at 4-6 weeks, peaking at 8-12 weeks, and subsiding by week 20 1
NVP is commonly associated with elevated levels of human chorionic gonadotropin, estrogen, and changes in gastrointestinal motility 1
Progesterone can inhibit GI and small bowel motility, leading to delayed gastric emptying 1
The severity of NVP can be quantified using the Motherisk Pregnancy-Unique Quantification of Emesis (PUQE) score 1

Eating small, frequent, bland meals can help manage NVP 1
Following a BRAT diet (bananas, rice, applesauce, toast) can help manage NVP 1
Consuming high-protein, low-fat meals can help manage NVP 1
Avoiding spicy, fatty, acidic, and fried foods can help manage NVP 1
Identifying and avoiding specific triggers (certain foods with strong odors or activities) can help manage NVP 1
Separating solid and liquid intake to reduce gastric distension can help manage NVP 1

The American College of Obstetricians and Gynecologists (ACOG) recommends doxylamine (an H1-receptor antagonist) for persistent NVP refractory to non-pharmacologic therapy 1
Combination of doxylamine and pyridoxine (available in 10 mg/10 mg and 20 mg/20 mg combinations) can be used to manage NVP 2
Ginger (250 mg capsule 4 times daily) can be used to manage NVP 1
Vitamin B6 (pyridoxine, 10-25 mg every 8 hours) can be used to manage NVP 1
Metoclopramide can be used as a second-line therapy for moderate to severe NVP 1
Ondansetron can be used as a second-line therapy for moderate to severe NVP 1

HG affects 0.3-2% of pregnant women, characterized by intractable vomiting leading to dehydration, weight loss, and electrolyte imbalances 3, 4
Comprehensive history, including previous pregnancies and pre-existing conditions, is essential for evaluating HG 5
Physical examination focusing on signs of dehydration and malnutrition is essential for evaluating HG 5, 3
Laboratory evaluation for dehydration, nutritional deficiencies, and electrolyte imbalances is essential for evaluating HG 3
Hospitalization may be required for HG 3
Intravenous hydration and electrolyte replacement can be used to treat HG 3
Thiamine supplementation (300 mg daily with vitamin B compound) can be used to prevent Wernicke's encephalopathy in HG 6
More aggressive antiemetic therapy can be used to treat HG 1
Nutritional support as needed can be used to treat HG 3

Early intervention is crucial as NVP can progress to HG if untreated 1
For pregnant women with a history of bariatric surgery and vomiting, adjustable gastric bands should be deflated to prevent band slippage and nutrient deficiencies 7, 6
Prolonged vomiting may require intravenous thiamine and vitamin B complex supplementation 6
Monitoring for vitamin deficiencies, especially in severe or prolonged cases, is essential 6