Management of nausea/vomiting in pregnancy in primary care/

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 ¹. It is important to reassure women that mild-to-moderate symptoms are common and usually resolve by 16-20 weeks of gestation ¹,⁴.

Self-care measures for mild-to-moderate symptoms include:

• Resting as needed and avoiding triggers like strong odours, heat, and noise ¹.
• Eating plain biscuits or crackers in the morning ¹.
• 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 ¹.
• Drinking fluids little and often ¹.
• Considering acupressure on the P6 point on the wrist ¹.
• Avoiding medications that may exacerbate symptoms, such as iron preparations ¹.
• Managing associated gastro-oesophageal reflux, oesophagitis, or gastritis symptoms ¹.

Women should be advised to seek urgent medical review if they develop features suggesting a complication or an alternative cause for their symptoms ¹. For subsequent pregnancies, early use of lifestyle measures and antiemetic drug treatment may be beneficial ¹.

If lifestyle measures are ineffective, pharmacological treatment should be considered ²,³. First-line antiemetic options include oral cyclizine, promethazine, prochlorperazine, chlorpromazine, or the combination doxylamine/pyridoxine (Xonvea®) ¹. Reassessment should occur after 24-72 hours ¹. Doxylamine/pyridoxine is the only licensed drug treatment for this indication ¹.

If first-line treatment is ineffective, second-line options include oral metoclopramide or domperidone, or ondansetron ¹. 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 ¹. Exposure to ondansetron in the first trimester is associated with a small increased risk of cleft lip/palate ¹. Combinations of drugs may be considered for non-responders, with different classes potentially having synergistic effects ¹.

For moderate-to-severe nausea and vomiting, consider intravenous fluids (ideally outpatient) and acupressure as an adjunct treatment ⁴. Inpatient care should be considered for severe vomiting unresponsive to primary or outpatient management, including cases of hyperemesis gravidarum ⁴.