Nausea and vomiting of pregnancy (NVP) is a common event that affects 70-85% of pregnant
women. Approximately 35% of pregnant women consider their symptoms severe enough to limit their
activities of daily living which extends to loss of time at work. While a single etiology of NVP has not
been identified, elevated levels of estrogen and human chorionic gonadotropin (hCG) have been shown
to be associated with it in a dose-dependent fashion. Risk factors include an increased
placental mass as seen with molar gestation or multiple gestations, a personal or family history of
hyperemesis gravidarum (HG), a history of motion sickness or migraines. NVP is often associated with
biochemical hyperthyroidism due to the action of human chorionic gonadotropin (HCG) on the thyroid-
stimulating hormone (TSH) receptor. NVP does not cause true hyperthyroidism and routine thyroid
function tests are not indicated. TSH is often suppressed to undetectable levels but as long as the
patient does not have overt signs of hyperthyroidism with elevated Free T4 after volume repletion,
antithyroid medications should not be started.
Hyperemesis gravidarum (HG) represents the extreme spectrum of NVP; it occurs in
approximately 0.5-2% of pregnancies, and includes symptoms such as persistent vomiting, dehydration,
acid-base disturbance, weight loss of at least 5% of prepregnancy weight, ketonuria, and electrolyte
disturbances. HG is the most common reason for admission to the hospital during the first half of
Clinical Course
The mean gestational age at onset is 5-6 weeks from the last menstrual period. Severity and
frequency peak at ~9 weeks and then begin to subside. Symptoms persist beyond 16 weeks in only 10 to
15% of women. When NVP persists in the second and third trimesters, the intensity usually remains
Diagnostic Approach
NVP is a diagnosis of exclusion. Physical exam findings not characteristic of NVP include:
Abdominal pain (other than musculoskeletal due to retching)
Abdominal tenderness other than mild epigastric discomfort
Abnormal neurologic exam (suggestive of a primary neurological disorder)
Goiter (suggestive of primary thyroid disease)
Alabama Perinatal Excellence Col aborative
This document should not be construed as dictating an exclusive course of treatment or procedure to be fol owed.
The presence of these findings should lead to consideration of other serious medical conditions such as
pyelonephritis and appendicitis. An ultrasound should be performed (if not already done) to rule out
predisposing factors such as multiple gestation or molar pregnancy.
Classification
After a thorough evaluation, patients with NVP can be classified according to the following criteria:
Category Symptoms Impact on daily activities and/or employment Moderate
Nausea and vomiting up to twice Moderate in a day
Significant: requires hospitalization for IV
episodes of vomiting and retching per day.
Management
If symptoms of NVP are impacting the patient’s activities of daily living, some form of management
should be initiated to prevent the progression to HG. Medications should be administered on a
scheduled basis with doses titrated to individual patient needs. Patients with severe NVP or HG require
urgent medical care due to dehydration and malnutrition. Enteral tube feeding has been found to be
well tolerated during pregnancy and can be used in severe forms of HG. All other therapies should be
considered and tried before initiating enteral tube feeding. Total Parental Nutrition (TPN) is not
Common recommendations to alleviate symptoms:
• Bland, dry diet high in protein; decrease fat and spicy foods
• Crackers in the morning before arising
• Ginger capsules, 250 mg 4 times per day
• Pressure (acupressure technique) or electrical stimulation at the Neiguan point on the inside of
Alabama Perinatal Excellence Col aborative
This document should not be construed as dictating an exclusive course of treatment or procedure to be fol owed.
Pharmacologic therapies hydrochloride (Vitamin B6) is available for the treatment of
Vitamin B6, 25-50mg 3 or 4 times per day
lower than non-fixed regimens, it may be more convenient for
Doxylamine (Unisom), 12.6mg, 3 to 4 times per day
Promethazine (Phenergan), 12.5-25mg every 4 hours, orally or rectally
Dimenhydrinate (Dramamine), 50-100mg every 4-6 hours, orally or rectally (not to exceed 400mg per day; not to exceed 200mg per day if patient is also taking doxylamine)
Me toclopramide (Reglan), 5-10mg every 8 hours, IM or
Promethazine (Phenergan), 12.5-25mg every 4 hours
Dimenhydrinate (Dramamine), 50mg in 50 ml saline
Trimethobenzamide (Tebamide or Tigan), 200mg every
Metoclopramide (Reglan), 5-10mg IV every 8 hrs
Promethazine (Phenergan), 12.5-25mg IV every 4 hrs
Ondansetron (Zofran), 8mg, IV over 15 minutes, every 12 hrs.
If still no improvement consult with MFM and consider transfer
Alabama Perinatal Excellence Col aborative
This document should not be construed as dictating an exclusive course of treatment or procedure to be fol owed.
ACOG. (2011). Practice Bulletin No. 52 Nausea and Vomiting of Pregnancy. [Practice Bulletin]. American Col ege of Obstetrics and Gynecologisits.
Olson, G. (2010). Nausea and Vomiting. In J. C. H. John T. Queenan, Catherine Y. Spong (Eds). (Ed.),
Protocols for High-Risk Pregnancies (Fifth ed., pp. 383-390). West Sussex, UK: Wiley-Blackwell.
Tan, P. C., Norazilah, M.J., Omar, S.Z. (2013). Dextrose saline compared with normal saline rehydration
of hyperemesis gravidarum [RCT]. Obstetrics & Gynecology, 121(2), 291-298.
Alabama Perinatal Excellence Col aborative
This document should not be construed as dictating an exclusive course of treatment or procedure to be fol owed.
2010 - 2011 SEMINAR SERIES 10:00am - 11:00am -- H363 Title of presentation Goal directed therapy in postoperative cardiac surgery - which targets ?Critical Care Medicine, SMBD - Jewish General Hospital and Montreal Chest Institute, Respiratory Epidemiology and Clinical Research Unit, McGill UniversityTuesday, October 12, 2010 Ilan Matok, MScPharm PhDThe BeMORE Collaboration - Using Co
Osteoporosis Canada statement on esophageal cancer and bisphosphonate use We are aware of a recent publication that reports on the association between oral bisphosphonate use and esophageal cancer1. We recognize that you might find these reports concerning. Osteoporosis Canada takes your concerns seriously and we will continue to be vigilant in order to inform you about the latest rese
Nausea and vomiting of pregnancy (NVP) is a common event that affects 70-85% of pregnant
women. Approximately 35% of pregnant women consider their symptoms severe enough to limit their
activities of daily living which extends to loss of time at work. While a single etiology of NVP has not
been identified, elevated levels of estrogen and human chorionic gonadotropin (hCG) have been shown
to be associated with it in a dose-dependent fashion. Risk factors include an increased
placental mass as seen with molar gestation or multiple gestations, a personal or family history of
hyperemesis gravidarum (HG), a history of motion sickness or migraines. NVP is often associated with
biochemical hyperthyroidism due to the action of human chorionic gonadotropin (HCG) on the thyroid-
stimulating hormone (TSH) receptor. NVP does not cause true hyperthyroidism and routine thyroid
function tests are not indicated. TSH is often suppressed to undetectable levels but as long as the
patient does not have overt signs of hyperthyroidism with elevated Free T4 after volume repletion,
antithyroid medications should not be started.
Hyperemesis gravidarum (HG) represents the extreme spectrum of NVP; it occurs in
approximately 0.5-2% of pregnancies, and includes symptoms such as persistent vomiting, dehydration,
acid-base disturbance, weight loss of at least 5% of prepregnancy weight, ketonuria, and electrolyte
disturbances. HG is the most common reason for admission to the hospital during the first half of
Clinical Course