Nausea and Vomiting of Pregnancy

Question 1

When does nausea and vomiting in pregnancy start?

Answer 1

Nausea and vomiting in pregnancy starts in the first trimester, peaking around 8 – 12 weeks gestation.

Question 2

Briefly describe the course of nausea and vomiting in pregnancy

Answer 2

Nausea and vomiting are normal during early pregnancy. Symptoms usually start from 4-7 weeks, are worst around 10-12 weeks and resolve by 16-20 weeks. Symptoms can persist throughout pregnancy.

Question 3

What is the name to the severe form of nausea and vomiting in pregnancy?

Answer 3

The severe form of nausea and vomiting in pregnancy is called hyperemesis gravidarum. Hyper- refers to lots, -emesis refers to vomiting and gravida- relates to pregnancy.

Question 4

Why does nausea and vomiting occur in pregnancy?

Answer 4

The placenta produces human chorionic gonadotropin (hCG) during pregnancy. This hormone is thought to be responsible for nausea and vomiting. Theoretically, higher levels of hCG result in worse symptoms.

Question 5

What factors can make nausea and vomting worse in pregnancy?

Answer 5

Nausea and vomiting are more severe in molar pregnancies and multiple pregnancies due to the higher hCG levels. It also tends to be worse in the first pregnancy and overweight or obese women.

Question 6

How is nausea and vomiting diagnosed in pregnancy?

Answer 6

Nausea and vomiting of pregnancy can be diagnosed based on a typical history. Nausea and vomiting needs to start in the first trimester, and other causes need to be excluded before making a diagnosis.

Question 7

Briefly describe the diagnosis of hyperemesis gravidarum

Answer 7

Hyperemesis gravidarum is the severe form of nausea and vomiting in pregnancy. The RCOG guideline (2016) criteria for diagnosing hyperemesis gravidarum are “protracted” NVP plus:

• More than 5 % weight loss compared with before pregnancy
• Dehydration
• Electrolyte imbalance

Question 8

What scoring system is used to assess nausea and vomiting in pregnancy?

Answer 8

Pregnancy-Unique Quantification of Emesis (PUQE) score.

Question 9

Briefly describe the Pregnancy-Unique Quantification of Emesis (PUQE) score

Answer 9

This gives a score out of 15:

• <7: mild
• 7-12: moderate
• >12: severe

Question 10

What antiemetics can be used to treat nausea and vomiting?

Answer 10

Antiemetics are used to suppress nausea. Vaguely in order of preference and known safety, the choices are:

• Prochlorperazine (stemetil)
• Cyclizine
• Ondansetron
• Metoclopramide

Question 11

What medications can be used for acid reflux in pregnant women?

Answer 11

Ranitidine or omeprazole can be used if acid reflux is a problem.

Question 12

Other than antiemetics, what other treatments can be used for nausea and vomiting in pregnancy?

Answer 12

The RCOG also suggest complementary therapies that may be considered by the woman:

• Ginger
• Acupressure on the wrist at the PC6 point (inner wrist) may improve symptoms

Question 13

When should admission into hospital be considered for nausea and vomiting in pregnancy?

Answer 13

Mild cases can be managed with oral antiemetics at home. Admission should be considered when:

• Unable to tolerate oral antiemetics or keep down any fluids
• More than 5 % weight loss compared with pre-pregnancy
• Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant)
• Other medical conditions need treating that required admission

Question 14

Briefly describe the treatment of moderate-severe nausea and vomiting in pregnancy

Answer 14

Moderate-severe cases may require ambulatory care (e.g. early pregnancy assessment unit) or admission for:

• IV or IM antiemetics
• IV fluids (normal saline with added potassium chloride)
• Daily monitoring of U&Es while having IV therapy
• Thiamine supplementation to prevent deficiency (prevents Wernicke-Korsakoff syndrome)
• Thromboprophylaxis (TED stocking and low molecular weight heparin) during admission