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Further guidance on the management of nauseas and vomiting in pregnancy can be accessed from the Royal College of Obstetricians and Gynaecologists or NICE CKS. The UK teratology information service website Best Use of Medicines in Pregnancy (BUMPS) is also useful.
Women with mild to moderate nausea and vomiting in pregnancy (PUQE score 3-12 (see below) and no dehydration or ketonuria) should be managed in primary care.
Do not use diazepam, pyridoxine, herbal treatments, homeopathy, hypnotherapy, hypnosis, or psychotherapy.
Where rest and dietary advice have been unsuccessful, early use of oral anti-emetics is recommended; these may reduce the risk of developing hyperemesis gravidarum.
Promethazine hydrochloride
OR
Cyclizine
See 4.6 Drugs used in nausea and vertigo
Note: these may cause sedation and other antimuscarinic side effects.
Review after 24 hours and if response is good, continue treatment and reassess weekly thereafter. It may be possible to stop anti-emetics at 12-16 weeks, using clinical judgement.
Consider combinations of different drugs in women who do not respond to a single anti-emetic.
If 1st line anti-emetics are not effective and the woman is not dehydrated or ketonuric, consider 2nd line anti-emetics.
Metoclopramide
OR
Prochlorperazine
See 4.6 Drugs used in nausea and vertigo
Note: there is an increased risk of extrapyramidal side effects and oculogyric crises with both metoclopramide and prochlorperazine.
Review patients regularly.
Consider combinations of different drugs in women who do not respond to a single anti-emetic.
Ondansetron (unlicensed indication) (preferably not in the first trimester)
See 4.6 Drugs used in nausea and vertigo
Note: There is less safety data with ondansetron and studies are mixed. For this reason, the Royal College of Obstetricians and Gynaecologists recommends the use of ondansetron should be limited to patients who are not adequately managed on the first- and second-line anti-emetics above, and preferably used after the first trimester of pregnancy. For further information, refer to RCOG guidance, or BUMPS.
Ondansetron must not be used in patients with any history suggestive of prolonged QT; co-administration with other medicines which prolong the QT interval should be avoided.
Review patients regularly.
Consider combinations of different drugs in women who do not respond to a single anti-emetic.
If oral anti-emetics are unsuccessful, or cannot be kept down, consider referral.
Secondary care management usually takes the form of outpatient visits, rather than inpatient care, and may include daily saline infusions for dehydration.
Severity of symptoms can be quantified using the Pregnancy Unique Quantification of Emesis (PUQE) index:
Motherisk PUQE-24 Scoring System
In the last 24 hours, for how long have
you felt nauseated or sick to your stomach? |
Not at all
(1) |
1 hour or
less (2) |
2-3 hours
(3) |
4-6 hours
(4) |
More than 6
hours (5) |
In the last 24 hours have you vomited or
thrown up? |
7 or more
times (5) |
5-6 times
(4) |
3-4 times
(3) |
1-2 times
(2) |
I did not
throw up (1) |
In the last 24 hours how many times have
you had retching or dry heaves without bringing anything up? |
No time
(1) |
1-2 times
(2) |
3-4 times
(3) |
5-6 times
(4) |
7 or more
times (5) |
PUQE-24 score: Mild ≤ 6, Moderate = 7-12, Severe = 13-15
Home > Formulary > Chapters > 7. Obstetrics, gynaecology, and urinary-tract disorders > Nausea and vomiting in pregnancy and hyperemesis gravidarum