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Nausea and Vomiting of Early Pregnancy

Often called “Morning Sickness” this is one of the most common symptoms of the first trimester. I’ve noticed through the years that every pregnancy truly is different. You may have morning sickness one pregnancy but not the next. It varies in intensity without rhyme or reason, and it can be there one day and gone the next. It’s comforting to tell a patient who is afflicted with a severe case that it is a sign of a healthy pregnancy, but not having it at all is likely totally normal as well. I can only wonder what God’s intention is for this, but I’m certain the symptoms or the path taken to correct the symptoms are part of a bigger plan that modern medicine does not yet understand.

Morning sickness is thought to correlate with the human chorionic gonadotropin (HCG) concentration in the blood of the mother. HCG is secreted by the placenta and is the molecule that triggers a positive pregnancy test. These levels start low and double roughly every other day in the first several weeks of pregnancy before hitting a peak mid-first trimester and then coming back down.

Common symptoms include general loss of appetite or development of aversion to certain foods and smells, feeling queasy, increased saliva production, gagging and spitting up and even vomiting. These can lead to mild weight loss, fatigue and tiredness, constipation and mild dehydration in normal cases to severe weight loss and dehydration in more concerning situations. Just knowing that mild symptoms are normal is important. “Less often is more” in the first trimester especially and so, if tolerable, it’s often best to avoid medications. We’ll discuss use of meds later for severe cases (also called Hyperemesis Gravidarum).

There are several things a patient can do to help manage the symptoms outlined below from the American College of Obstetrics and Gynecology algorithm on treatment of Nausea and Vomiting of Pregnancy:

  1. Avoid triggers. Pay attention to what foods and smells make you sick. For some women this can even be their prenatal vitamin (keep reading for an alternative).
  2. Eat smaller and more frequent meals to avoid a completely empty or completely full stomach. Generally foods that are high in carbohydrates (not sugar) and low in fat work best. Examples are cereal, toast, crackers, and pretzels.
  3. Drink cold, clear and carbonated liquids. Sips of drinks such as ginger ale or Sprite work well.
  4. Use ginger containing foods. ~250mg of ginger four times a day works really well to help decrease nausea. Ginger can be found in most health food stores and is also available as ginger tea and ginger lollipops.
  5. B Complex: Taking 25mg of vitamin B6 every six (6) hours is the recommended dosing. I’ve found it easier to find Vitamin B Complex or Super B Complex in our grocery stores. Both of these have folic acid in addition to the B6 and other B vitamins. B vitamins are water soluble, meaning its hard to get toxic levels as your body will excrete the excess. Taking a B complex vitamin in place of the prenatal vitamin can reduce the nausea by up to 75% and gives a feeling of more energy. It contains the necessary folic acid that is needed in the first trimester and can replace the prenatal vitamin during the first trimester.
  6. Doxylamine: This is an over-the-counter sleep aid under the brand Unisom® or Aldex®. It comes in 25mg pills. It is a type of antihistamine. Taking half a pill three times a day with the Vitamin B6 is similar to a commercially produced morning sickness medicine available by prescription. It does cause some mild sleepiness the first few days of usage but those seem to go away.
  7. Dramamine®: This over-the-counter medicine can be taken once every four to six hours for more severe symptoms.
  8. I’ve also had patients find relief with Preggie Pops® and motion bands.

Sometimes the symptoms cannot be controlled or tolerated with a more conservative option and a prescription is needed. The two most commonly used medications are Zofran® and PhenerganTM. Though I’ve not seen it, apparently there are some lawyer ads on TV phishing for patients who have taken these medications and had any kind of birth defects. The data* simply doesn’t support this being a major concern especially if we practice the “less is more” approach. If a patient just can’t function or is losing too much weight or has become severely dehydrated due to morning sickness, it becomes a risk benefit situation where we’ve clearly got to do something. We often use Phenergan as a gel, oral tablet or suppository, and Zofran as an oral pill or quick dissolve pill. Common side effects are sedation for the Phenergan and constipation for Zofran. These are two of the most commonly prescribed medications for more severe morning sickness though there are several other more complex options available to help manage and control the symptoms of Hyperemesis Gravidarum that are beyond the scope of this article.

In conclusion, I’d suggest that, once established, patients feel free to try some of the conservative non-prescription options outlined above first and then contact us if they are unable to keep anything down for more than 24 hours, lose more than 2% of their body weight, feel like they may be dehydrated, or are simply wanting to check in to see if more can be done to help. On a better note, it typically totally resolves by the end of the 1st trimester.

Kyle P. McMorries, M.D., FACOG


*TI
Ondansetron in pregnancy and risk of adverse fetal outcomes. Pasternak B, Svanström H, Hviid A. N Engl J Med. 2013 Feb;368(9):814-23.
Medications used to treat nausea and vomiting of pregnancy and the risk of selected birth defects. Anderka M, Mitchell AA, Louik C, Werler MM, Hernández-Diaz S, Rasmussen SA, National Birth Defects Prevention Study. Birth Defects Res A Clin Mol Teratol. 2012 Jan;94(1):22-30. Epub 2011 Nov 19.

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