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Nausea and Vomiting During Early Pregnancy

By

Emily E. Bunce

, MD, Wake Forest Baptist Health;


Robert P. Heine

, MD, Wake Forest School of Medicine

Last full review/revision Dec 2020| Content last modified Dec 2020
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Topic Resources

Nausea and vomiting affect up to 80% of pregnant women. Symptoms are most common and most severe during the 1st trimester. Although common usage refers to morning sickness, nausea, vomiting, or both typically may occur at any point during the day. Symptoms vary from mild to severe (hyperemesis gravidarum).

Pathophysiology

The pathophysiology of nausea and vomiting during early pregnancy is unknown, although metabolic, endocrine, gastrointestinal, and psychologic factors probably all play a role. Estrogen may contribute because estrogen levels are elevated in patients with hyperemesis gravidarum.

Etiology

Vomiting can also result from many nonobstetric disorders. Common causes of acute abdomen (eg, appendicitis, cholecystitis) may occur during pregnancy and may be accompanied by vomiting, but the chief complaint is typically pain rather than vomiting. Similarly, some central nervous system (CNS) disorders (eg, migraine, CNS hemorrhage, increased intracranial pressure) may be accompanied by vomiting, but headache or other neurologic symptoms are typically the chief complaint.

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Evaluation

Evaluation of patients with nausea and vomiting during early pregnancy aims to exclude serious or life-threatening causes of nausea and vomiting. Morning sickness (uncomplicated nausea and vomiting) and hyperemesis gravidarum are diagnoses of exclusion.

History

History of present illness should particularly note the following:

  • Onset and duration of vomiting

  • Exacerbating and relieving factors

  • Type (eg, bloody, watery, bilious) and amount of emesis

  • Frequency (intermittent or persistent)

Important associated symptoms include diarrhea, constipation, and abdominal pain. If pain is present, the location, radiation, and severity should be queried. The examiner should also ask what social effects the symptoms have had on the patient and her family (eg, whether she is able to work or to care for her children).

Past medical history includes questions about morning sickness or hyperemesis in past pregnancies. Past surgical history should include questions about any prior abdominal surgery, which would predispose a patient to mechanical bowel obstruction.

Drugs taken by the patient are reviewed for drugs that could contribute (eg, iron-containing compounds, hormonal therapy) and for safety of these drugs taken during pregnancy.

Physical examination

Examination begins with review of vital signs for fever, tachycardia, and abnormal blood pressure (too low or too high).

A general assessment is done to look for signs of toxicity (eg, lethargy, confusion, agitation). A complete physical examination, including pelvic examination, is done to check for findings suggesting serious or potentially life-threatening causes of nausea and vomiting (see table Relevant Physical Examination Finding in a Pregnant Patient With Vomiting Relevant Physical Examination Findings in a Pregnant Patient With Vomiting Nausea and vomiting affect up to 80% of pregnant women. Symptoms are most common and most severe during the 1st trimester. Although common usage refers to morning sickness, nausea, vomiting... read more ).

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Red flags

The following findings are of particular concern:

  • Abdominal pain

  • Signs of dehydration (eg, orthostatic hypotension, tachycardia)

  • Fever

  • Bloody or bilious emesis

  • No fetal motion or heart sounds

  • Abnormal neurologic examination

  • Persistent or worsening symptoms

Interpretation of findings

Vomiting is less likely to be due to pregnancy if it

  • Begins after the 1st trimester

  • Is accompanied by abdominal pain, diarrhea, or both

Abdominal tenderness may suggest acute abdomen. Meningismus, neurologic abnormalities, or both suggest a neurologic cause.

Vomiting is more likely to be due to pregnancy if

  • It begins during the 1st trimester.

  • It lasts or recurs over several days to weeks.

  • Abdominal pain is absent.

  • There are no symptoms or signs involving other organ systems.

Testing

Patients with significant vomiting, signs of dehydration, or both usually require testing. If hyperemesis gravidarum is suspected, urine ketones are measured; if symptoms are particularly severe or persistent, serum electrolytes are measured. If fetal heart sounds are not clearly audible or detected by fetal Doppler, pelvic ultrasonography should be done to rule out hydatidiform mole.

Treatment

Pregnancy-induced vomiting may be relieved by drinking or eating frequently (5 or 6 small meals/day), but only bland foods (eg, crackers, soft drinks, BRAT diet [bananas, rice, applesauce, dry toast]) should be eaten. Eating before rising may help.

If dehydration (eg, due to hyperemesis gravidarum) is suspected, 1 to 2 L of normal saline or Ringer’s lactate is given IV, and any identified electrolyte abnormalities are corrected.

After initial fluid resuscitation, dextrose IV may be added to maintenance fluid if oral intake remains limited. Before administration of dextrose, thiamin 100 mg IV should be given to prevent Wernicke encephalopathy.

Rarely, weight loss continues and symptoms persist despite treatment. In such cases, enteral nutrition via a nasogastric or nasoduodenal tube may be considered. Peripherally inserted central catheters are associated with a high rate of infection and thromboembolism in pregnancy and should be avoided (1 Treatment references Nausea and vomiting affect up to 80% of pregnant women. Symptoms are most common and most severe during the 1st trimester. Although common usage refers to morning sickness, nausea, vomiting... read more , 2 Treatment references Nausea and vomiting affect up to 80% of pregnant women. Symptoms are most common and most severe during the 1st trimester. Although common usage refers to morning sickness, nausea, vomiting... read more ).

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Vitamin B6 is used as monotherapy; other drugs are added if symptoms are not relieved. Extended-release doxylamine plus pyridoxine can be given to women who do not respond to initial therapy.

Ginger (eg, ginger capsules 250 mg orally 3 or 4 times a day, ginger lollipops), acupuncture, motion sickness bands, and hypnosis may help, as may switching from prenatal vitamins to a children’s chewable vitamin with folate.

Treatment references

  • 1. Holmgren C, M Aagaard-Tillery KM, Silver RM, et al: Hyperemesis in pregnancy: An evaluation of treatment strategies with maternal and neonatal outcomes. Am J Obstet Gynecol 198 (1):56.e1–4, 2008. doi: 10.1016/j.ajog.2007.06.004

  • 2. Cape AV, Mogensen KM, Robinson MK, Carusi DA: Peripherally inserted central catheter (PICC) complications during pregnancy. JPEN J Parenter Enteral Nutr 38 (5):595–601, 2014. doi: 10.1177/0148607113489994 Epub 2013 May 28. PMID: 23715775.

Key Points

  • Vomiting during pregnancy is usually self-limited and responds to dietary modification.

  • Hyperemesis gravidarum is less common but is severe, leading to dehydration, ketosis, and weight loss.

  • Consider nonobstetric causes of nausea and vomiting.

Drugs Mentioned In This Article

Drug Name Select Trade
REGLAN
PROMETHEGAN
ZOFRAN
UNISOM
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