Treatment of nausea and vomiting of pregnancy

A. Patients should avoid odors or foods that seem to be aggravating the nausea. Useful dietary modifications include avoiding fatty or spicy foods, and stopping iron supplements. Frequent small meals also may improve symptoms. Recommendations include bland and dry foods, high-protein snacks, and crackers at the bedside to be taken first thing in the morning.

B. Cholecystitis, peptic ulcer disease, or hepatitis can cause nausea and vomiting and should be excluded. Gastroenteritis, appendicitis, pyelonephritis, and pancreatitis also should be excluded. Obstetric explanations for nausea and vomiting may include multiple pregnancies or a hydatidiform mole.

C. Non-pharmacologic remedies are adequate for up to 90% of patients with NVP. However, about 10% will require medication and about 1% have severe enough vomiting that they require hospitalization.

D. Vitamin therapy. Pyridoxine is effective as first-line therapy and is recommended up to 25 mg three times daily. Pyridoxine serum levels do not appear to correlate with the prevalence or degree of nausea and vomiting. Multivitamins also are effective for prevention of NVP. Premesis Rx is a prescription tablet with controlled-release vitamin b6, 75 mg, so it can be given once a day. It also contains vitamin B12 (12 mcg), folic acid (1 mg), and calcium carbonate (200 mg).

E. Over-the-Counter Therapy. If pyridoxine alone is not efficacious, an alternative is to combine over-the-counter doxylamine 25 mg (Unisom) and pyridoxine 25 mg. One could combine the 25 mg of pyridoxine three times daily with doxylamine 25 mg, 1 tablet every bedtime, and V tablet morning and afternoon. There is no evidence that doxylamine is a teratogen.

Drug Therapy for Nausea and Vomiting of Pregnancy

Generic name (trade name)

Dosage

Antihistamines

Doxylamine (Unisom)

25 mg 1/2 tab BID, 1 tab qhs

Dimenhydrinate (Dramamine)

25 to 100 mg po/im/iv every 4 to 6 hr

Diphenhydramine (Benadryl)

25 to 50 mg po/im/iv every 4 to 6 hr

Trimethobenzamide (Tigan)

250 mg po every 6 to 8 hr or

200 mg im/pr every 6 to 8 hr

Meclizine (Antivert)

12.5 to 25 mg BID/TID

Phenothiazines

Promethazine (Phenergan)

12.5 to 25 mg po/iv/pr every 4 to 6 hr

Prochlorperazine (Compazine)

25 mg pr every 6 to 8 hr

Prokinetic agents

Metoclopramide (Reglan)

10 to 20 mg po/iv every 6 hr

Serotonin (5-HT3) antagonists

Ondansetron (Zofran)

8 mg po/iv every 8 hr

Corticosteroids

Methylprednisolone (Medrol)

16 mg po TID for 3 days then 1/2 dose every 3 days for 2 wks

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