How should I approach the management of nausea and vomiting in pregnant patients?

Approach to managing nausea and vomiting in pregnancy:

• Reassure women that mild-to-moderate nausea and vomiting are common and usually resolve by 16–20 weeks gestation.
• Advise self-care measures including resting as needed, avoiding triggers (odours, heat, noise), eating small frequent protein-rich meals low in carbohydrate and fat, trying cold meals if smell-related nausea, drinking fluids little and often, and using acupressure (e.g., P6 wrist point).
• Advise avoiding medications that may worsen symptoms, such as iron supplements, depending on clinical judgement.
• Offer information and support resources such as NHS leaflets, RCOG guidance, and pregnancy sickness support charities.
• If symptoms persist despite self-care, discuss drug treatment options considering the woman’s preferences, symptom severity, and previous treatment responses.
• First-line antiemetics include oral cyclizine or promethazine (antihistamines), prochlorperazine or chlorpromazine (phenothiazines), or doxylamine/pyridoxine (Xonvea®), the only licensed drug for this indication; reassess after 24–72 hours.
• If first-line treatment is ineffective, consider second-line antiemetics such as oral metoclopramide, domperidone, or ondansetron, with caution regarding duration and potential adverse effects; reassess after 24 hours.
• For women not responding to single agents, consider combination therapy as different drug classes may have synergistic effects.
• If second-line treatments fail, oral corticosteroids (prednisolone 40–50 mg daily) may be used as third-line treatment, with gradual tapering and monitoring for side effects.
• Refer to specialist care if third-line treatment is ineffective or if severe symptoms, complications, or inability to tolerate oral treatment occur.
• Women with severe symptoms or hyperemesis gravidarum may require inpatient care with IV fluids, electrolyte replacement, thiamine, and multidisciplinary team input.
• Advise on the need for urgent medical review if complications or alternative causes are suspected.
• For subsequent pregnancies, early use of lifestyle measures and antiemetics before or at symptom onset may reduce severity and duration.

Additional supportive measures include managing associated gastro-oesophageal reflux symptoms, thiamine supplementation if dietary intake is severely reduced, laxatives for constipation, and venous thromboembolism risk assessment.

Regular review and gradual tapering of medication is advised as symptoms improve, typically around 12–16 weeks gestation.

Safety-netting advice and patient education are essential throughout management.

References: ¹,²