Information and Advice on Nausea and Vomiting in Pregnancy

Information and Advice on Nausea and Vomiting in Pregnancy (NVP) and Hyperemesis Gravidarum (HG) 

Introduction 

This leaflet is designed to give you some information about nausea and vomiting in pregnancy (NVP) and Hyperemesis Gravidarum (HG). It will explain what these conditions are, and will hopefully give you some tips about what you could do to help, how it can make you feel, about possible triggers and what medications you may be given if you have increased symptoms. Armed with this information we aim to help you and your family hopefully understand and cope better with these conditions. 

What is nausea and vomiting in pregnancy (NVP)? 

Nausea and or vomiting are a symptom of pregnancy that affects approximately 75% of pregnant women to some degree. It is often called ‘morning sickness’ but it can occur at any time of the day or night.  These symptoms usually begins around 6 weeks of pregnancy and generally starts to settle by about 12 – 14 weeks, although 5% of women still feel sick after 20 weeks. The cause of these symptoms is thought to be due to pregnancy hormones, however the exact cause of these symptoms are not clear, but a number of different causes have been suggested such as: 

• Increased oestrogen levels - During pregnancy the female sex hormone oestrogen levels begin to rise. They are at their highest in the first 3 months of pregnancy.  

• Increased HCG levels - After conception the body begins to produce a hormone called human chorionic gonadotropin (HCG) it is thought that this rise may cause nausea and vomiting in pregnancy. 

• Gastric problems - The hormone progesterone which is produced in pregnancy to prepare the womb may reduce movement within the stomach and small intestine which can result in nausea and vomiting. 

• Nutritional deficiency - Especially lack of vitamin B6. 

It is important that other causes of vomiting such as gastritis (inflammation of the stomach), kidney infection, appendicitis and gastroenteritis are considered and looked into, so seeing your GP may be advised; particularly if you are unwell, have pain in your tummy or that the vomiting only started after 10 weeks of pregnancy. 

What is Hyperemesis Gravidarum (HG)? 

Hyperemesis Gravidarum (HG) is a condition when nausea and vomiting in pregnancy becomes so severe that it can leads to dehydration and significant weight loss. HG is at the extreme end of the pregnancy sickness spectrum and affects approximately 1% of women with pregnancy sickness and is extremely unpleasant for sufferers. It is unclear why some women get more severe symptoms than others. However, it is more likely if:  

You have had these symptoms before. 

You are having a multiple pregnancy i.e. twins or triplets. 

You have a molar pregnancy (a rare condition where the placenta overgrows and the baby does not form correctly).  

It is important that you seek medical advice if you are unable to keep any food or fluids down as you can become dehydrated very quickly when suffering with HG. 

How can it make me feel? 

Suffering from NVP or HG can be a problematic, solitary, lonely, unhappy and emotional experience. It can affect your mood (where you may become anxious or depressed), your work and even your home situation where your ability to care for your family can be affected. We now know that psychological factors are not the cause of NVP or HG but it is the result of a woman experiencing prolonged and continuous nausea and vomiting in pregnancy.  It is not surprising that these symptoms may affect your mental health.  Many women can become socially isolated from relatives, friends and co-workers as they may be afraid of leaving their homes, worrying about vomiting in public. Therefore during pregnancy we need to ensure that you have as much support as possible from family and friends – both practically and emotionally. Women need to be able to rest and relax without feeling guilty. If you feel that you are experiencing significant mental health problems then you should mentioned this to your GP, midwife or other health professional as some women may need counselling and or other psychological therapies. 

Will it harm my baby? 

There is no evidence according to the Royal College of Obstetrics and Gynaecologist (RCOG) that NVP has no harmful effect on your baby, in fact you have a slightly lower risk of miscarriage. However clinical trials and research are on-going and the results from this research are updating, changing and developing constantly. At present research from the RCOG Green-top Clinical Guideline The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum (2016) has suggested that women with more severe cases of HG may have a baby with a lower than expected birthweight and some women may need closer monitoring and this will be a Consultant decision if required.   

What can I do to help? 

Below are some basic tips to help you with your NVP and HG, however, the list is by no means exhaustive and many women develop their own individual coping strategies. 

• Rest: NVP and HG are conditions with frequent periods of recovery and relapse therefore the key for the majority of sufferers is rest. When you feel better do not be tempted to rush and catch up on jobs that you couldn’t do before feeling unwell, as this will likely cause a relapse. Don’t feel guilty about needing help, try and depend on relatives and friends for support.  

• Avoiding Triggers: Try and avoid triggers that may cause nausea and or vomiting. Many women find that sensory stimulation such as noises, moving visual images or bright light, strong smells and even the movement of air from an open window can all trigger vomiting. Most women, if not all women suffering from NVP and HG has some aversion to a variety of food and or food smells, so knowing or being aware of what your triggers are will be helpful so that these triggers can be avoided as much as possible. 

• Eating advice: Try and avoid having an empty stomach by trying to eat small amounts but often approximately every one to two hours – meals that are high in carbohydrate and low in fat, such as potato, rice and pasta, are easier to tolerate; try plain biscuits or crackers. For early morning nausea try eating a dry biscuit or cracker before getting up. Also try and avoid spicy or fatty foods as this may exacerbate your symptoms.   

• Avoiding Dehydration: Avoid becoming dehydrated. If you can’t tolerate drinks, try sucking ice cubes made of juices, or sipping very slowly through a straw. Try freezing half a bottle of mineral water and then topping up with fridge cold water; this keeps the water freezing cold for hours. Why not try flat lemonade some women have discovered that this can assist with dehydration and can give energy as well.  Both bottled mineral water and flattened lemonade may be more palatable than tap water.  

• Coping Emotionally: As stated above NVP and HG can be a cause of mental health issues for some women so avoid thinking ahead for more than the next few days. On the days you feel better why not invite a friend over or talk to them on the phone, this will keep you occupied and not feeling lonely or isolated as some women realise they become in this situation.  

• Other alternative therapies: For some sufferers trying an alternative therapy on the market make them feel more proactive. Alternative remedies such as hypnotherapy and acupressure have been thought to be useful. Some women find self-hypnosis to be helpful when coping with symptoms; ask your GP or midwife if they know of a medical hypnotherapist. Acupressure can also be useful this is where stimulation of the P6 point, located three fingers breadth above the wrist has pressure applied to it; the use of bands worn at the wrist (e.g. Sea Bands) will apply that pressure and may help reduce the symptoms.

What anti-sickness medication may I be given? 

The principals for treating NVP and HG is with a ladder approach, starting on the first rung and stepping up by adding in different medication as required until the symptoms are under control. Because each of the different treatments work in different ways there is evidence that suggests combining them can be more effective. 

Most effective medications for nausea and vomiting are not licensed in pregnancy because pharmaceutical companies usually exclude pregnant women from drug trials. This is not to say that the drugs mentioned below are harmful in pregnancy, it's to say that while safety has not been definitively proven, no evidence of harm has been found either. In order to assess their safety in pregnancy, other sources of information are required such as cases where women have taken them not knowing they were pregnant, or where their sickness has been so severe that they took them as the benefit outweighed the possible risk.   

First Line Treatment - ANTIHISTAMINES (H1 receptor antagonist) or XONVEA: 

The first line treatment that will be prescribed and used for women at the EPAU is Cyclizine (brand name Valoid) at the dose one 50mg tablets three times a day. A wide body of evidence suggests that Cyclizine is an effective treatment for nausea and vomiting in pregnancy and that H1 receptor antagonist antihistamines such as Cyclizine have no increased human teratogenic potential (teratogenic means harmful defects in pregnancy) or other adverse pregnancy outcomes.  

Xonvea is the brand name of a prescription medicine licensed in the UK to treat symptoms of NVP. It has the same effect as if you combined Cyclizine with Vitamin B6. It has been licensed in the UK because a large amount of data on pregnant women indicates no increased risk of birth defects. Xonvea comes in a slow release tablet form and contains two active medicinal ingredients these are: 

• Doxylamine succinate which belongs to the antihistamine group 

     and  

• Pyridoxine hydrochloride which is another name for Vitamin B6. 

Evidence has suggested that it may be effective if used as a prophylactic for women who have previously had HG and used as basic first line treatment for these women specifically. 

Second Line Treatments - PHENOTHIAZINES:  

These drugs are also prescription only medications and will only be introduced if the first line treatment medication is not helping with your symptoms. The second line treatments that the EPAU use are Prochlorperazine (Stemetil or Buccastem) and Metoclopramide (Maxolon). Again extensive research suggests that these two medications have no increased human teratogenic potential (teratogenic means harmful defects in pregnancy) or other adverse pregnancy outcomes. However there has been research to suggest that phenothiazine’s can have an increased risks of breathing difficulties for infants after birth so these drugs will most likely be stopped in the third trimester if they have been prescribed throughout a woman’s pregnancy.  

Third Line Treatment - ONDANSETRON:  

If your nausea and vomiting is so severe that the first and second-line treatments have not suppressed symptoms to an adequate level then we may prescribe you Ondansetron (known also as Zofran) at the EPAU. This medication was originally used to treat nausea and vomiting caused by chemotherapy for cancer patients but has been increasingly being used for HG. Again this is a prescription only medication and side effects include constipation and headaches. In a recent study in 2018 regarding the safety of ondansetron they looked at 88,467 pregnancies which this drug was used in the first trimester.  The results showed that there was no association with cardiac or congenital malformations but there was a very slight possible increase in the risk of babies having a cleft lip with or without cleft palate. This risk in real terms equates to an additional 3 babies per 10,000 having an oral cleft (the baseline rate in the normal population is 7-10 babies per 10,000). It is important to note that this is a possible association and not a definite cause of cleft lip/palate. 

Fourth Line Medication - CORTICOSTEROIDS: 

If you are not able to tolerate any medication and your symptoms are still persisting this is usually HG and this could be the reason that Steroids may be suggested as treatment. Steroids have been used for a number of years in pregnancy for conditions such as acute asthma and Crohns disease. There may be a small increased risk of oral clefting associated with the use of corticosteroids and many authorities say that they should not be used to treat nausea and vomiting in pregnancy in the first 12 weeks of pregnancy. However, more recent studies are questioning this and state that theoretical risks should be weighed against the risks of malnutrition and dehydration in individual cases. Corticosteroid treatment is normally started in hospital intravenously at a high dose and then tapered off over a number of weeks it is always given under medical supervision and will be monitored and assessment regularly.  

When should I seek medical help? 

If you are finding it difficult to keep food and fluid down and are persistently vomiting after eating or drinking you should seek advice. You should always contact your GP first who will assess your symptoms and may simply offer some medication as mentioned above to help. If this doesn’t work or your symptoms are severe, then a possible hospital admission is sometimes needed. However, if you are already under our care at the EPAU for NVP or Hyperemesis then you can refer yourself back to us for an assessment. If you are 20 weeks pregnant or more then please contact the Maternity Triage unit directly for further advice. Medical intervention if needed can be so important not only for your physical welfare but your mental well-being too. 

Ask for an urgent appointment if you have any of these symptoms: 

• Unable to keep any food or fluids down for more than 24 hours. 

• Have very dark urine or have not passes urine for more than 8 hours. 

• Dizziness or fainting. 

• Palpitations (fast heart beat). 

What happens when I come to the hospital? 

You will have: 

• A discussion about how long you have had your symptoms for and whether you:   

• Are keeping fluids and food down.   

• Have tried any medication. 

• Have lost weight.   

• Have any other symptoms.   

• Have had this in a previous pregnancy.  

• A check of your general health including your temperature, pulse, respiratory rate and blood pressure; you will have your weight measured and an assessment of whether you are dehydrated.  

• Urine tests.   

• Blood tests.   

• An Ultrasound scan (if you have not already had one). This is to check how many weeks pregnant you are. It will also check for twins and rule out a molar pregnancy. If you are over 20 weeks pregnant then an ultrasound scan may not be necessary, but your baby’s heartbeat will be monitored.  

The results of these tests will help the staff decide what sort of treatment you require. 

What are the treatment options I may receive? 

• Outpatient (Community) 

Whenever possible we will try to manage your symptoms as an outpatient to minimise disruption to your family life, and avoiding hospital admission. If you are suitable for this treatment we will prescribe some anti-sickness medication as described above, a vitamin supplement called thiamine, and a higher dose of folic acid because when you are not eating and drinking adequately you may become deficient in vitamins that are necessary for you and your baby. 

• Day-case (Ambulatory) 

Day-case treatment is useful for women who have not improved with outpatient treatment but are well enough to come to the hospital for the day. We would give the vitamins and anti-sickness medication as discussed above but we may give the medication by injection rather than a tablet. In addition we will give you a short infusion of fluid by a drip into your vein, this treatment can last for up to 4 hours and you would be able to return home to continue with the medication as an outpatient. You may need to have more than one day case admission if you have a relapse of your symptoms. 

• In-patient 

Occasionally admission to hospital is necessary for women with severe symptoms such as excessive weight loss, muscle wasting, dehydration, palpitations and abnormal blood results. We will perform daily urine tests and sometimes daily blood tests. You will be given an infusion of fluids and medication usually directly into vein.  If you do not improve with these measures we may consider steroid medication as mentioned above and will involve other specialists to contribute to your care i.e. dietician or a medical consultant. 

If you have either day-case or in-patient treatment you will also be given: 

• Special stockings (graduated elastic compression stockings) to help prevent blood clots   

• Heparin injections (to thin your blood). Pregnant women are at increased risk of developing blood clots in their legs, called deep vein thrombosis (DVT) or in their lungs (called pulmonary embolism or PE). Being dehydrated and not being mobile increases this risk further. Heparin injections reduce this risk. You will be advised to continue these at home until you have had your booking scan.  

When you are feeling better, you can start to drink and eat small amounts and slowly build up to a normal diet.  

What happens after discharge if I am admitted to hospital? 

Once you are feeling better you will be discharged home on: 

• Anti-sickness medication that you have had in hospital and also extra vitamins which is Thiamine 50mg daily for 2 weeks, and 5mg folic acid until 12 weeks. 

• Heparin injections which need to be continued at home until you have had your booking scan at 12 weeks. If your date is not known yet then these injections will be prescribed until 13 weeks. If you are over 12 weeks you will be prescribed these heparin injections until your next review in antenatal clinic. 

• If you are 20 weeks pregnant or more you will be referred for a follow up appointment in Antenatal Clinic for a review of your symptoms and to plan the rest of your pregnancy care.  

Your discharge letter will include: 

• Your booking weight. 

• Number of week’s gestation. 

• Date of antenatal clinic appointment. 

• How many weeks’ heparin injections have been supplied.  

You and your GP will receive a copy of the discharge letter so you can ask your GP for a repeat prescription before your anti-sickness medication run out. Remember prescriptions can take a few days to process so order in plenty of time.  Your symptoms may return and you may become dehydrated. If this happens, contact the EPAU (if under 20 weeks pregnant) or Maternity Triage (if 20 weeks or more pregnant)  to be assessed again. Although this can be a difficult situation for you and may affect you throughout your pregnancy, the symptoms usually resolve or improve after your baby is born. If you have any ongoing concerns, contact the EPAU unit, your midwife or GP for advice and support. 

Helpful Contact numbers: 

If you are under 20 weeks pregnant, please contact: 

• EPAU: Mon - Fri 8:30am – 5:30pm; 01282 804268 

• Gynaecology and Breast care Ward: out of hours; 01282 804014 

If you are 20 weeks pregnant or more, please contact: 

• Maternity Triage: 01282 804213 

Further information: 

Pregnancy Sickness Support: This is a charity that has tips to help women cope with NVP and HG www.pregnancysicknesssupport.org.uk 

HER Foundation: This is a non-profit organisation providing support, research, advocacy and education on hyperemesis gravidarum. www.hyperemesis.org