There is often great excitement when being newly pregnant. However, a common and very unpleasant side effect of pregnancy is nausea and vomiting. Depending on how severe the symptoms are, it can significantly affect a pregnant person’s quality of life making it difficult to work, care for other children or family members, or even do day-to-day activities.The good news is that nausea and vomiting of pregnancy (NVP) is most commonly present between 8 weeks to 14 weeks of gestation, but for some pregnant persons, it can last for several months. The most severe form of NVP is called hyperemesis gravidarum (HG). It occurs in 0.3-3.0% of pregnancies, with a recurrence rate of 15-18% in subsequent pregnancies. HG is something that is definitely not talked about enough!
HG is the term used to describe the severe end of the symptom spectrum of NVP (including weight loss exceeding 5% of pre-pregnancy body weight). The most common criteria used for diagnosis include:
*Odors, heat, humidity, noise, and flickering lights/stimuli that may provoke onset of symptoms
*P6 or Neiguan point (located three finger breadths below the wrist on the inside of the wrist in between the two tendons)
*Evidence is inconclusive with conflicting conclusions
*Consider P6 acupressure with wrist bands
*10-25 mg orally (alone or in combination with doxylamine 12.5 mg orally) 3 or 4 times per day OR
*2 tablets orally at bedtime initially, up to 4 tablets per day (1 tablet in the AM, 1 tab in the midafternoon, and 2 tablets at bedtime)
*25-50 mg every 4 to 6 hours, orally as needed (do not exceed 200 mg per day if also on doxylamine) OR
*25-50 mg every 4 to 6 hours, orally OR
*25 mg every 12 hours, rectally OR
*12.5-25 mg every 4 to 6 hours, orally or rectally
*5-10 mg every 6 to 8 hours, IM or orally
*4 mg orally every 8 hours
*12.5-25 mg every 4 to 6 hours, orally, IM or rectally
*200 mg every 6 to 8 hours, IM
*If patient vomiting for > 3 weeks
*Add IV thiamine followed by IV multivitamins are recommended to prevent Wernicke encephalopathy
*50 mg (in 50 mL saline, over 20 min) every 4 to 6 hours
*5-10 mg every 8 hours
*8 mg, over 15 minutes, every 12 hours
*12.5-25 mg every 4 to 6 hours
*25-50 mg every 4 to 6 hours IM or IV or 10-25 mg orally every 4 to 6 hours
*16 mg every 8 hours orally or IV for 3 days
*Taper over 2 weeks to lowest effective dose
*Limit duration to 6 weeks
As ACOG states, risk of HG increases with, “being pregnant with more than one fetus, a previous pregnancy with either mild or severe nausea and vomiting, your mother or sister had severe nausea and vomiting of pregnancy, a history of motion sickness or migraines, or being pregnant with a female fetus.” If you have experienced severe NVP in a previous pregnancy or have a combination of the above mentioned risk factors, you might want to discuss this with your OBGYN as soon as you find out you're pregnant to initiate medications prior to the onset of symptoms.
Once symptoms are managed with medications, you will stay on 1 or 2 medications scheduled daily, with another medication available for break-thru symptoms. Once a successful treatment regimen is established, you would stay on that regimen until out of the first trimester, then slowly taper off medications as tolerated.
Keep in mind, a patient’s perception of the severity of symptoms and one’s desire for treatment are influential in clinical decision making. There are safe and effective medications available if needed, and patients should not be expected to just “deal with it”.
Evidence is conflicting as to whether or not there is a higher incidence of small for gestational age and premature infants born to those with HG. You can rest easier, though, knowing that there is NO association noted with perinatal or neonatal mortality, and mild to moderate vomiting has little effect on pregnancy outcome. In fact, lower rates of miscarriage have been documented, likely due to healthy placenta and the protective effect of NVP. The important thing is to discuss it with your OBGYN if symptoms develop or if you are concerned that you’re at risk for developing the symptoms so treatment can be started if necessary.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
The following recommendations are based primarily on consensus and expert opinion (Level C):
Shannon M. Clark, MD, MMS is a double board certified ObGyn and Maternal-Fetal Medicine Specialist, and founder of Babies After 35. In her roles as a clinician, educator and researcher at UTMB-Galveston, she focuses on the care of people with maternal and/or fetal complications of pregnancy. Dr. Clark has taken a special interest in pregnancy after the age of 35, which according to age alone, is considered a high-risk pregnancy.
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