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

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. Limit to more than 1500 mg/day
    3. Effective and safe at standard doses in first trimester (but safety unclear at higher dose)
    4. Ding (2013) Women Birth 26(1):e26-30 [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]

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Related Studies

Ontology: Morning Sickness (C0312416)

Definition (NCI) The nausea and vomiting that accompanies early pregnancy.
Definition (MSH) Symptoms of NAUSEA and VOMITING in pregnant women that usually occur in the morning during the first 2 to 3 months of PREGNANCY. Severe persistent vomiting during pregnancy is called HYPEREMESIS GRAVIDARUM.
Concepts Sign or Symptom (T184)
MSH D048968
SnomedCT 199020006, 156113005, 267308007, 51885006
Dutch ochtendmisselijkheid, Misselijkheid, ochtend-, Ochtendmisselijkheid
French Nausées matinales de la grossesse, Nausée matinale de la grossesse, État nauséeux de la grossesse
German Uebelkeit am Morgen, Morgendliche Übelkeit der Schwangeren, Nausea gravidarum
Portuguese Mal-estar matinal, Náuseas e Vômitos Matinais Durante a Gravidez, Náuseas e Vômitos da Gravidez, Enjoo do Começo da Gravidez, Náuseas e Vômitos Matinais da Gravidez, Êmese Gravídica
Spanish Indisposición matutina, náuseas del embarazo (hallazgo), náuseas del embarazo, pituitas matutinas, náuseas matutinas (hallazgo), náuseas matutinas, Náuseas Matinales
Japanese つわり, ツワリ
Swedish Morgonsjuka
Czech ranní nevolnost, Ranní zvracení, časná gestóza
Finnish Raskauspahoinvointi
Croatian Not Translated[Morning Sickness]
English Morning Sickness [Disease/Finding], mornings sickness, morning sickness, Morning sickness, Morning sickness (finding), Morning Sickness, Sickness, Morning
Italian Nausea mattutina (delle gravide), Nausea mattitina
Polish Nudności poranne
Hungarian Reggeli betegség
Norwegian Morgenkvalme, Svangerskapskvalme