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Nausea and Vomiting in Pregnancy
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14. ACOG Resources
Nausea and Vomiting of Pregnancy
ACOG Practice Bulletin #52 April 2004
Summary of Recommendations
The following recommendations are based on good and consistent scientific evidence (Level A):
- Taking a multivitamin at the time of conception may decrease the severity of nausea and vomiting of pregnancy.
- Treatment of nausea and vomiting of pregnancy with vitamin B6 or vitamin B6 plus doxylamine is safe and effective and should be considered first-line pharmacotherapy.
- In patients with hyperemesis gravidarum who also have suppressed thyroid-stimulating hormone levels, treatment of hyperthyroidism should not be undertaken without evidence of intrinsic thyroid disease (including goiter and/or thyroid autoantibodies).
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Treatment of nausea and vomiting of pregnancy with ginger has shown beneficial effects and can be considered as a nonpharmacologic option.
- In refractory cases of nausea and vomiting of pregnancy, the following medications have been shown to be safe and efficacious in pregnancy: antihistamine H1 receptor blockers, phenothiazines, and benzamides.
- Early treatment of nausea and vomiting of pregnancy is recommended to prevent progression to hyperemesis gravidarum.
- Treatment of severe nausea and vomiting of pregnancy or hyperemesis gravidarum with methylprednisolone may be efficacious in refractory cases; however, the risk profile of methylprednisolone suggests it should be a treatment of last resort.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Intravenous hydration should be used for the patient who cannot tolerate oral liquids for a prolonged period or if clinical signs of dehydration are present. Correction of ketosis and vitamin deficiency should be strongly considered. Dextrose and vitamins, especially thiamine, should be included in the therapy when prolonged vomiting is present.
- Enteral or parenteral nutrition should be initiated for any patient who cannot maintain her weight because of vomiting.
Nausea and vomiting of pregnancy. ACOG Practice Bulletin No. 52. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;103:803–15
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* ACOG Evidence grading system
The MEDLINE database, the Cochrane Library, and ACOG's own internal resources
and documents were used to conduct a literature search to locate relevant articles
published between January 1985 and October 2000. The search was restricted to
articles published in the English language. Priority was given to articles reporting
results of original research, although review articles and commentaries also
were consulted. Abstracts of research presented at symposia and scientific conferences
were not considered adequate for inclusion in this document.
Guidelines published by organizations or institutions such as the National Institutes
of Health and the American College of Obstetricians and Gynecologists were reviewed,
and additional studies were located by reviewing bibliographies of identified
articles. When reliable research was not available, expert opinions from obstetrician–gynecologists
were used. Studies were reviewed and evaluated for quality according to the method
outlined by the U.S. Preventive Services Task Force:
- I Evidence: obtained from at least one properly designed randomized controlled trial.
- II -1 Evidence obtained from well-designed controlled trials without randomization.
- II -2 Evidence obtained from well-designed cohort or case–control analytic studies, preferably from more than one center or research group.
- I I-3 Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
- III Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:
- Level A—Recommendations are based on good and consistent scientific evidence.
- Level B—Recommendations are based on limited or inconsistent scientific evidence.
- Level C—Recommendations are based primarily on consensus and expert opinion.
