For pregnant women experiencing nausea and vomiting, primary care management involves offering advice on information and support sources, such as the NHS leaflet 'Vomiting and morning sickness', the RCOG leaflet 'Pregnancy sickness', and the charity Pregnancy Sickness Support NICE CKS. It is important to reassure women that mild-to-moderate symptoms are common and usually resolve by 16-20 weeks of gestation NICE CKS,NICE NG201.
Self-care measures for mild-to-moderate symptoms include:
- Resting as needed and avoiding triggers like strong odours, heat, and noise NICE CKS.
- Eating plain biscuits or crackers in the morning NICE CKS.
- Consuming small, frequent meals that are bland, protein-rich, and low in carbohydrate and fat. Cold meals may be better tolerated if nausea is smell-related NICE CKS.
- Drinking fluids little and often NICE CKS.
- Considering acupressure on the P6 point on the wrist NICE CKS.
- Avoiding medications that may exacerbate symptoms, such as iron preparations NICE CKS.
- Managing associated gastro-oesophageal reflux, oesophagitis, or gastritis symptoms NICE CKS.
Women should be advised to seek urgent medical review if they develop features suggesting a complication or an alternative cause for their symptoms NICE CKS. For subsequent pregnancies, early use of lifestyle measures and antiemetic drug treatment may be beneficial NICE CKS.
If lifestyle measures are ineffective, pharmacological treatment should be considered NICE CKS,NICE CKS. First-line antiemetic options include oral cyclizine, promethazine, prochlorperazine, chlorpromazine, or the combination doxylamine/pyridoxine (Xonvea®) NICE CKS. Reassessment should occur after 24-72 hours NICE CKS. Doxylamine/pyridoxine is the only licensed drug treatment for this indication NICE CKS.
If first-line treatment is ineffective, second-line options include oral metoclopramide or domperidone, or ondansetron NICE CKS. Metoclopramide should not be prescribed for longer than 5 days due to the risk of neurological adverse effects, domperidone for longer than 7 days due to cardiac risks, and ondansetron for longer than 5 days NICE CKS. Exposure to ondansetron in the first trimester is associated with a small increased risk of cleft lip/palate NICE CKS. Combinations of drugs may be considered for non-responders, with different classes potentially having synergistic effects NICE CKS.
For moderate-to-severe nausea and vomiting, consider intravenous fluids (ideally outpatient) and acupressure as an adjunct treatment NICE NG201. Inpatient care should be considered for severe vomiting unresponsive to primary or outpatient management, including cases of hyperemesis gravidarum NICE NG201.