Brian Bond and Ashley Peterson
History of present illness
A 25-year-old gravida 1, para 0 woman at 8 weeks’gestation presents with 2 weeks of daily nausea. The nausea persists for several hours each day and is associated with vomiting once or twice a day with temporary relief. She has been able to tolerate some small meals and has been drinking plenty offluids. She denies dizziness, lightheadedness, fevers, chills, abdominal pain, back pain, changes in bowel habits, or urinary symptoms.
She denies weight loss, sick contacts, or recent antibiotic use.
Prior to this pregnancy, she was healthy with no significant medical or surgical history. She has a full-time job and has been arriving late to work and feeling less productive than usual.
Physical examination
Vital signs:
Temperature: 37.0°C Pulse: 80 beats/min
Blood pressure: 110/70 mmHg Respiratory rate: 18 breaths/min Oxygen saturation: 99% on room air BMI: 21 kg/m2
Neck:Supple, thyroid not enlarged
Cardiovascular:Regular rate and rhythm without rubs, murmurs, or gallops
Lungs:Clear to auscultation bilaterally
Abdomen:Soft, nondistended, nontender, normoactive bowel sounds
Pelvic:Eight-week-sized nontender uterus, no adnexal masses, no vaginal bleeding
Extremities:No clubbing, cyanosis, edema, normal skin turgor, no skin tenting
Laboratory studies:Urinalysis is negative for ketones, protein, WBCs, leukocyte esterase, nitrites, and specific gravity was 1.005 (normal 1.002–1.030)
Imaging:Pelvic ultrasound shows a single viable intrauterine pregnancy with a crown–rump length measuring 1.6 cm consistent with 8 weeks’0 days gestational age
How would you manage this patient?
The patient described is exhibiting findings consistent with nausea and vomiting of pregnancy. Given the absence of signs or symptoms of dehydration, the patient should be managed as
an outpatient with dietary modification, avoidance of triggers, and pharmacologic therapy. The patient should be started on scheduled doses of first-line agents such as pyridoxine (vitamin B6) 10 mg PO TID and doxylamine 12.5 mg PO TID. If her symptoms do not improve, promethazine 12.5 mg PO every 6 hours and metoclopramide 5 mg PO every 8 hours as needed, can be added to the regimen. In this scenario, her symptoms improved within a week and completely resolved by 18 weeks of gestation and medications were discontinued.
Nausea and vomiting of pregnancy
Nausea and vomiting of pregnancy is a common complaint during early pregnancy affecting approximately three quar- ters of the nearly four-million pregnant women in the United States annually. Although often referred to as “Morning Sickness,” the symptoms of nausea and vomiting of preg- nancy can occur at any time of the day and range in severity from mild (minimal effect on daily life) to severe (significant effects on daily life, resulting in dehydration often requiring hospitalization) [1].
Nausea and vomiting of pregnancy tends to be more common in younger women, primigravidas, women with less than 12 years of education, nonsmokers, and obese women. Risk factors that have been reported in the literature include women who have a past medical history of motion sickness, nausea and vomiting with oral contraceptive use, migraines, or a prior pregnancy complicated by nausea and vomiting. A higher incidence of nausea and vomiting is reported with multiple gestations as compared with women with singleton pregnancies (87% vs. 73%) [2]. Patients taking a prenatal vitamin prior to conception as well as smokers have a decreased risk of nausea and vomiting of pregnancy [3].
There are no set criteria for the diagnosis of nausea and vomiting of pregnancy; however, symptoms typically manifest after 4 and before 9 weeks of gestation and resolve by 16–20 weeks of gestation [4]. In cases where nausea and vomiting present for thefirst time after nine weeks of gestation or in the presence of abdominal pain, fever, and headache, other causes must be evaluated such as appendicitis, peptic ulcer disease, and pyelonephritis. There is a wide range in the severity of nausea and vomiting associated with early pregnancy and it is difficult to evaluate objectively. The patient’s perception of the severity of her symptoms and desire for treatment often directs clinical decision-making.
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
Appropriate initial evaluation includes a history and physical examination. Orthostatic vital signs, serum electro- lytes, and a urinalysis may assist in evaluation of dehydra- tion but is often not necessary in the initial management in cases of mild or moderate nausea and vomiting. Laboratory evaluation becomes necessary in women with persistent nausea and vomiting that is not responding to medical management and demonstrating signs of dehydration. An obstetric ultrasound can confirm an intrauterine pregnancy, gestational age, and evaluate for multiple gestations or gesta- tional trophoblastic disease, but is often not necessary in the initial diagnosis and management of nausea and vomiting of pregnancy.
Treatment of nausea and vomiting of pregnancy incorpor- ates both nonpharmacologic and pharmacologic therapies.
Despite a lack of strong supporting evidence, providers often recommend dietary modification [5]. Recommendations include frequent small meals of bland or dry foods, protein rich snacks, avoiding an empty stomach, eliminating spicy and fatty foods, discontinuing iron supplements, and using ginger supplements. Heartburn and acid reflux should be treated as they are associated with increased severity of nausea and vomiting of pregnancy [6]. P6 acupressure wristbands and nerve stimulation therapy are commercially available products, although evidence has suggested limited benefit with a large placebo effect.
If symptoms do not improve with lifestyle modifications, it is reasonable to start oral or rectal medications to alleviate mild-to-moderate nausea and vomiting of pregnancy.
Pyridoxine (vitamin B6) 10–25 mg PO 3–4 times a day taken with or without doxylamine succinate 12.5 mg (contained in over-the-counter sleep aids) is a first-line agent that helps to alleviate mild nausea [7]. This combination was previously marketed in the United States under the trade name Bendec- tin®, but was voluntarily withdrawn due to safety concerns.
Since that time additional studies have confirmed its safety, and in 2013 it was reintroduced in the United States under the trade name Diclegis®. Other oral medications should be added
in a step-wise fashion to alleviate symptoms and changed if no effect is seen within a week or side effects of current medica- tions are intolerable. Antihistamines such as dimenhydrinate or promethazine should be added if first-line therapies have failed. The medication regimen can be expanded to include metoclopramide, promethazine, or trimethobenzamide if nausea and vomiting continue to persist and there are no signs of dehydration (Table 53.1)
Nausea and vomiting of pregnancy is a time-limited condition and is likely related to the peaking of human chorionic gonadotropin concentration. Symptoms, however, can persist for several weeks if not adequately addressed and can lead to lost wages, require hospitalization for intraven- ous rehydration and medications, and exacerbate psycho- social stressors. Prevention and adequate treatment of symptoms once they arise can improve quality of life during early pregnancy. There is no association with adverse preg- nancy outcomes such as miscarriage, perinatal mortality or fetal anomalies in patients with nausea and vomiting of pregnancy [8].
Key teaching points
Nausea and vomiting of pregnancy is a common complaint during early pregnancy affecting approximately three quarters of the nearly four-million pregnant women in the United States annually.
Nausea and vomiting of pregnancy is typically self-limiting and usually arises between 4 and 9 weeks and completely resolves by 18–20 weeks’gestation.
Early recognition of symptoms and prompt treatment with lifestyle modifications and medications is key to improving quality of life in pregnancy.
Pyridoxine with or without doxylamine succinate is the first-line treatment for nausea and vomiting of
pregnancy.
Iffirst-line treatments fail, step-wise addition of other medications may be necessary to control symptoms.
Table 53.1 Pharmacologic therapy options for management of nausea and vomiting of pregnancy
Medication (Name) Class Dose Route Frequency
Vitamin B6 (Pyridoxine) Vitamin 10–25 mg PO TID or QID
Doxylamine
(Unisom SleepTabs®) Antihistamines, 1st generation 12.5 mg PO TID or QID
Promethazine (Phenergan®) Antihistamines, 1st generation 12.5–25.0 mg PO or PR or IM Every 4 hours Dimenhydrinate (Dramamine®) Antihistamines, 1st generation 50–100 mg* PO or PR Every 4–6 hours
Metoclopramide (Reglan®) Prokinetic 5–10 mg PO or IM Every 8 hours
Trimethobenzamide (Tigan®) Anti-emetic 200 mg PR Every 6–8 hours
* Maximum daily dose 400 mg or 200 mg if used in combination with doxylamine.
IM, intramuscularly; PO,peros (orally); PR, by rectum; TID, three times daily; QID, four times daily.
References
1. American College of Obstetricians and Gynecologists. Nausea and vomiting of pregnancy. Practice Bulletin No 52.
Obstet Gynecol2004;103:803–15.
2. Lee NM, Saha S. Nausea and vomiting of pregnancy.Gastroenterol Clin North Am2011;40:309–34.
3. Czeizel AE, Dudas I, Fritz G, et al.
The effect of periconceptional multivitamin-mineral supplementation on vertigo, nausea and vomiting in thefirst trimester of pregnancy.
Arch Gynecol Obstet1992;251(4):181–5.
4. Whitehead SA, Andrews PL, Chamberlain GV. Characterisation of nausea and vomiting in early pregnancy: a survery of 1000 women.J Obstet Gynaecol 1992;12:364–9.
5. Matthews A, Dowsell T, Haas DM, Doyle M, O’Mathuna DP. Interventions for nausea and vomiting in early pregnancy.Cochrane Database Syst Rev 2010, Issue 9. Art. No.:CD007575. DOI:
10.1002/14651858.CD007575.pub2.
6. Gill SK, Maltepe C, Mastali K, Koren G. The effect of acid- reducing pharmacotherapy on
the severity of nausea and vomiting of pregnancy.Obstet Gynecol Int 2009;2009:585269.
7. Sahakian V, Rouse D, Sipes S, Rose N, Niebyl J. Vitamin B6 is effective therapy for nausea and vomiting of pregnancy: A randomized, double-blind placebo-controlled study.Obstet Gynecol1991;
78:33–6.
8. Weigel MM, Weigel RM. Nausea and vomiting of early pregnancy and pregnancy outcome. A meta-analytical review.Br J Obstet Gynaecol1989;
96(11):1304–11.
Case 53: Nausea and vomiting at eight weeks’gestation