For women in the throes of first trimester pregnancy nausea, it often seems like the magical 14th week - when "morning sickness" should subside - will never arrive.
The middle trimester of pregnancy is usually a calmer time for women, but some experience hyperemesis gravid, a debilitating form of pregnancy-related sickness. The condition, which accounts for only 2% of pregnancy-related nausea, was thrust into the worldwide spotlight in 2012 when Catherine, Duchess of Cambridge, was briefly hospitalized for what was described as "acute morning sickness." Symptoms of hyperemesis include vomiting more than three or four times daily, loss of more than 10 pounds, dizziness and/or dehydration.
"The key factor is how the nausea is affecting these women's lives," explained Jean Ramos, CNP, WHNP-BC, who practices at Northwestern Medical Group Obstetrics & Gynecology in Chicago. "Is there any weight gain? Are they keeping any food down? When we start to see dehydration symptoms like sunken eyes, darker urine, dizziness, we're starting to go into the danger zone."
Early in pregnancy, weight loss is not usually a significant concern because the woman will catch up and gain the recommended 25 to 35 pounds (for women of average weight) during gestation.
Hyperemesis most commonly affects women who have multiple pregnancies, overweight stature or trophoblastic disease. The condition has no long-term effect on a baby. If a woman experiences hyperemesis in a pregnancy, research shows that she faces a 15% to 20% likelihood that the condition will recur in a subsequent pregnancy.
Dietary and Integrative Measures
A variety of interventions are available to manage nausea and vomiting during pregnancy. As with many health complaints, the clinicians we interviewed view lifestyle modifications as first-line treatment. The most common nonpharmacologic strategies are avoiding a full or empty stomach, consuming electrolyte-containing sports drinks or ginger tea, and keeping a record of triggers to avoid. Eliminating coffee, spicy foods, odorous foods, cigarette smoke, sweet foods and strong motion can also be helpful. Ramos advises her patients to eat protein-dominant, salty, bland foods every hour or two.
At Massachusetts General Hospital in Boston, Marie Henderson, CNM, advises patients to "follow their gut" as far as food desires and not to stress over balanced nutrition in the first trimester. "Vegetables will look good again by the second trimester," she said.
Johnetta Miner, NP, AHN-BC, BCC, owner of Lifestyle Wellness Enterprise, is a women's health nurse practitioner and holistic and integrative healing arts practitioner in New York. She said essential oils were helpful with nearly every patient she encountered during her years in women's health settings. "Ginger is commonly known to reduce nausea," she said. "You can chew ginger or apply the same theory with lemons. I told women to buy nonorganic lemons, peel the yellow rind away and just smell the lemons. That carries over into essential oils, such as orange, mandarin and grapefruit. You can put a couple of drops on a tissue, place it in a baggie and carry it around the house to sniff. Others use an atomizer of one of the four essential oils. It works for everyone."
Miner is certified to perform auricular acupuncture in pregnant women and reports excellent outcomes with auricular and full body acupuncture, even for women with hyperemesis. Other touch modalities can also be effective for pregnancy-related nausea. For example, drug-free wristbands marketed for relief of nausea are often used by pregnant women. Ramos said her practice distributes these in the office with good response.
While some pregnancy-related nausea and vomiting can be controlled with dietary and complementary therapies, many cases require medication, IV fluid replacement or even hospitalization.
After implementing nutrition changes, Ramos' first pharmacologic choice for nausea is pyridoxine, a form of vitamin B6. This can be purchased over the counter, but Ramos usually writes a prescription for it, to ensure correct dosages and to remind the patient to take it every 6 to 8 hours. Pyridoxine is often mixed with the antihistamine doxylamine. The only side effect, she said, is more fatigue.
A new formulation of doxylamine-pyridoxine, marketed as Diclegis, is a delayed-release tablet that received FDA clearance in 2013. It is dosed at bedtime so that the drug is at its peak serum concentrations in the morning, when nausea and vomiting may be worse. Diclegis is the only Pregnancy Class A medicine approved by the FDA to treat morning sickness. Diclegis is not approved for hyperemesis, but a study showed that the drug may be effective for this more severe condition when taken pre-emptively instead of reactively.
Henderson has been prescribing Diclegis with good results, but she notes that no treatment is 100% preventive. "There's absolutely nothing on the market that will eliminate nausea," she said. "I set the baseline expectations with patients that there is no cure. I offer suggestions to manage symptoms to a point where they can function in their lives."
For pregnancy-related vomiting including hyperemesis, ondansetron is commonly prescribed. Some patients vomit so severely that they can't tolerate any oral medication. In these cases, Henderson uses suppositories. She encourages patients to find the routine that works best for them.
"With regard to complementary treatments, I encourage women to try different strategies to get through the day," Henderson said. "It is a day-by-day struggle."
She added that once a patient finds her "personal best" hour, it's a good idea to schedule a walk in that time frame. "Never underestimate the power of 20 minutes outside your house, taking deep breaths," she said. "Walking increases serotonin levels in the brain and makes women feel better. This increases their coping ability."
Robin Hocevar is a staff writer. Contact firstname.lastname@example.org.