Seminars in Perinatology
Date: December 2014
Pages: 496-502

Published by: Elsevier

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The outpatient management and special considerations of nausea and vomiting in pregnancy

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Abstract

With 50–90% of pregnant women experiencing nausea and vomiting of pregnancy (NVP), the burden of illness can become quite significant if symptoms are under-treated and/or under-diagnosed, thus allowing for progression of the disease. The majority of these women will necessitate at least one visit with a provider to specifically address NVP, and up to 10% or greater will require pharmacotherapy after failure of conservative measures to adequately control symptoms. As a result, initiation of prompt and effective treatment in the outpatient setting is ideal. Once NVP is diagnosed and treatment is started, it is crucial to track symptoms in order to assess for a decrease in or resolution of symptoms as well as an escalation in symptoms requiring additional therapy. Of note, co-existing gastroesophageal reflux disease (GERD), Helicobacter pylori infection, and psychosocial factors may have a negative impact on the management of NVP. Ultimately, every woman has her own perception of disease severity and desire for treatment. It is critical that both the provider and patient be proactive in the diagnosis and management of NVP.

Keywords

reflux
;
pregnancy
;
nausea
;
vomiting
;
outpatient management

Introduction

Although NVP is a very common medical condition in pregnancy, symptoms are often minimized by both the patient and provider due to lack of discussion of severity of symptoms, under-diagnosis and/or under-treatment. NVP occurs in 50–90% of pregnancies, with approximately 50–55% of patients having both nausea and vomiting and 25% with nausea alone.1 Symptoms typically start between 4 and 9 weeks of gestation, with maximal symptoms at 12–15 weeks, and resolution by 20 weeks gestational age.1 Conservative, non-pharmacologic measures are often successful at treating symptoms. However, some women will require a trip(s) to the ER, provider’s office or labor and delivery triage, and some will need hospitalization for treatment of more severe symptoms.
The symptoms of NVP can occur at any time of the day, last for varying periods of time, vary from day to day and can include any combination of the following: nausea, gagging, dry retching, dry heaving, vomiting, and odor and/or food aversion.1, 2, 3, 4 It is also common for women to report certain precipitating factors that trigger symptoms, i.e., movement, heartburn, and certain foods and/or odor triggers.5 If symptoms are prolonged and/or severe, dehydration is likely. In this case, evaluation of the patient is advised to ascertain if hyperemesis gravidarum (HG), the more severe form of NVP, exists and if hospitalization is necessary in order to control symptoms and to provide adequate hydration. It is important to remember that every woman has her own perception of disease severity. As a result, providers should not dismiss complaints of symptoms of NVP because their clinical assessment may not equate with what is being reported.
When a patient presents with a complaint of nausea and vomiting, it cannot be assumed that symptoms are due to NVP. It is advised to take the pregnancy-related versus non-pregnancy-related approach when determining the etiology of symptoms, even if she is presenting with symptoms in the first trimester.2 Patients who present with a complaint of nausea and vomiting for the first time before 9–10 weeks of gestation are more likely to indeed have NVP. However, a thorough history and physical exam and confirmation of pregnancy are still necessary to confirm the diagnosis. Questioning on the onset, timing, and severity of nausea and vomiting, and aggravating and alleviating factors may elucidate another etiology for symptoms. If symptoms present for the first time after 9–10 weeks of gestation, it is important to consider other causes of the nausea and vomiting.

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Section snippets

Conservative measures

The first opportunity to assess and treat the symptoms of NVP is in the outpatient setting. It is important for the provider and/or the patient to be proactive and initiate a dialog so that symptoms of NVP can be assessed. In addition, each woman has her own perception of disease severity and desire for treatment. As a result, it is crucial that the provider not dismiss complaints of nausea and vomiting, but instead thoroughly evaluate the patient to see if treatment—whether it consists of

Assessing severity of symptoms

Once NVP has been diagnosed, it is important to track symptoms in order to assess clinical improvement, to determine how long treatment is needed, and adjust medication(s) as needed. The Pregnancy—Unique Quantification of Emesis scale (PUQE), similar to the Rhodes’ Scale used for the assessment of nausea and vomiting in patients receiving chemotherapy, is a scoring system developed for such assessment of symptoms.31, 32 The 24-h PUQE scoring system was developed to account for global nausea and

Conclusion

Although NVP is very common in pregnancy, it still remains an oftentimes difficult medical condition to manage. A consistent provider–patient dialog should occur in order to successfully manage symptoms and assess response to treatment. Once treatment is initiated, compliance should be emphasized with a plan to continue treatment for at least one month. Although many pharmacotherapies exist for the treatment of NVP, there is often a trial-and-error period that occurs in order to find the

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    • The views expressed in this presentation are those of the author and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States government.
    Drs. Shannon M. Clark and Gary D.V. Hankins were investigators on the clinical trial, “Effectiveness of delayed-release doxylamine and pyridoxine for nausea and vomiting of pregnancy: a randomized placebo controlled trial.” After conclusion of the study, they became paid consultants for Duchesnay, USA.
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