Morning Sickness

Aka: Morning Sickness, Nausea in Pregnancy, Vomiting in Pregnancy

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II. Pathophysiology

  1. Hormonally related changes in early pregnancy
    1. High bHCG levels (e.g. Twin Gestation)
    2. High Estrogen levels
  2. Gastrointestinal function changes in early pregnancy
    1. Gastrointestinal motility decreased
    2. Lower esophageal sphincter relaxed
  3. Other factors
    1. Helicobacter Pylori may be causal factor in some cases
    2. Family History in patients with the most severe of hyperemesis (e.g. requiring TPN)

III. Symptoms

  1. Gastrointestinal upset
    1. Nausea
    2. Vomiting
  2. Timing
    1. Often in morning hours (but not limited to this time)
    2. Onset at 4-7 weeks gestation
    3. Usually resolves by 13 weeks gestation
    4. Resolves by 20 weeks gestation in 90% of women

IV. Differential Diagnosis

  1. See Hyperemesis Gravidarum

V. Management: Dietary recommendations

  1. Bedrest 15 minutes after awakening
  2. Crackers before arising from bed
  3. Clear liquids and advance as tolerated
  4. Small, frequent meals (6 meals/day)
  5. Suck on Hard Candy
  6. Avoid greasy or spicy foods, or those with intense flavors or smells
  7. Minimize fluid with meals (maximize fluid other times)
  8. Avoid foods that slow gastric emptying
    1. Avoid high Protein foods
    2. Avoid fatty foods
  9. Better tolerated foods
    1. Carbohydrate (breads, crackers, cereals) and fiber rich meals (fruits, vegetables)
    2. Eat low-fat, bland foods
    3. Salty foods (e.g. potato chips)
    4. Sour liquids (e.g. lemonade)
    5. Consider salty and tart foods together
      1. Example: potato chips with Lemonade

VI. Management: Other options

  1. See Hyperemesis Gravidarum for evaluation, managment and medications for more severe cases
  2. Pyridoxine (Vitamin B6) 25 mg every 8 hours
    1. May also be used in combination with Doxylamine (Unisom) and considered safe in first trimester
      1. McKeigue (1994) Teratology 50(1): 27-37 [PubMed]
  3. Ginger extract
    1. Dosing: 125-250 mg every 6-8 hours (e.g. 250 mg three times daily)
    2. Effective and safe at standard doses in first trimester (but safety unclear at higher dose)
      1. Limit to no more than 1500 mg/day
      2. Ding (2013) Women Birth 26(1):e26-30 [PubMed]
    3. Avoid after first trimester
      1. Risk of Vaginal Bleeding, premature birth, decreased Fetal Head Circumference
      2. Munoz (2019) Obstet Gynecol 133(5): 920-32 [PubMed]
  4. Acupressure, Acupuncture or Acustimulation
    1. Acupressure applied at Pericardium 6 (P6, Neiguan point)
    2. Located 3 finger breadths proximal to the wrist crease at midline volar Forearm
    3. Examples
      1. Sea-Band elastic band worn on wrists
      2. Electrical nerve stimulation (Acustimulation)
    4. Efficacy
      1. Variable with some studies demonstrating no improvement better than Placebo for acupressure or Acupuncture
      2. Rosen (2003) 102:129-35 [PubMed]
  5. References
    1. Fugh-Bergman (1999) Altern Ther Womens Health, 1:9
    2. Larimore (2000) Prim Care 27(1): 35-53 [PubMed]

VII. Prevention: Dental Erosion from recurrent Stomache acid exposure

  1. Rinse mouth with a teaspoon of Baking Soda in one cup of water after Vomiting
  2. Use a soft Tooth Brush only
    1. Avoid toothbrusing immediately after Vomiting
  3. Use fluoride rinse (e.g. ACT) nightly
  4. Silk (2008) Am Fam Physician 77:1139-44 [PubMed]

VIII. References

  1. Broussard (1998) Gastroenterol Clin North Am 27(1):123 [PubMed]
  2. Herrell (2014) Am Fam Physician 89(12): 965-70 [PubMed]
  3. Kuscu (2002) Postgrad Med 78(916):76-9 [PubMed]
  4. Larimore (2000) Prim Care 27(1): 35-53 [PubMed]

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