The Management of Nausea and Vomiting of Pregnancy

Objectives: To review the evidence-based management of nausea and vomiting of pregnancy and hyperemesis gravidarum. Evidence: MEDLINE and Cochrane database searches were performed using the medical subject headings of treatment, nausea, vomiting, pregnancy, and hyperemesis gravidarum. The quality of evidence reported in these guidelines has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on Preventative Health Care. Benefits: Nausea and vomiting of pregnancy has a profound effect on women's health and quality of life during pregnancy as well as a financial impact on the health care system, and its early recognition and management is recommended. Cost: Costs, including hospitalizations, additional office visits, and time lost from work, may be reduced if nausea and vomiting in pregnancy is treated early. Recommendations 1. Women experiencing nausea and vomiting of pregnancy may discontinue iron-containing prenatal vitamins during the first trimester and substitute them with folic acid or adult or children's vitamins low in iron. (II-2A) 2. Women should be counselled to eat whatever pregnancy-safe food appeals to them and lifestyle changes should be liberally encouraged. (III-C) 3. Ginger may be beneficial in ameliorating the symptoms of nausea and vomiting of pregnancy. (I-A) 4. Acupressure may help some women in the management of nausea and vomiting of pregnancy. (I-B) 5. Mindfulness-based cognitive therapy as an adjunct to pyridoxine therapy may be beneficial. (I-B) 6. Pyridoxine monotherapy or doxylamine/ pyridoxine combination therapy is recommended as first line in treating nausea and vomiting of pregnancy due to their efficacy and safety. (I-A) 7. Women with high risk for nausea and vomiting of pregnancy may benefit from preemptive doxylamine/pyridoxine treatment at the onset of pregnancy. (I-A) 8. H-1 receptor antagonists should be considered in the management of acute or chronic episodes of nausea and vomiting of pregnancy. (I-A) 9. Metoclopramide can be safely used as an adjuvant therapy for the management of nausea and vomiting of pregnancy. (II-2B) 10. Phenothiazines are safe and effective as an adjunctive therapy for severe nausea and vomiting of pregnancy. (I-A) 11. Despite potential safety concerns of ondansetron use in pregnancy, ondansetron can be used as an adjunctive therapy for the management of severe nausea and vomiting of pregnancy when other antiemetic combinations have failed. (II-1C) 12. Corticosteroids should be avoided during the first trimester because of possible increased risk of oral clefting and should be restricted to refractory cases. (I-B) 13. When nausea and vomiting of pregnancy is refractory to initial pharmacotherapy, investigation of other potential causes should be undertaken. (III-A).