Published Studies/Guidelines: On Nausea and Vomiting of Pregnancy (NVP)

Abstract
Objectives: To review the evidence-based management of nausea and vomiting of pregnancy (NVP) and hyperemesis gravidarum.
Evidence: MEDLINE and Cochrane database searches were per-formed using the medical subject headings (MeSH) of treatment, nausea, vomiting, pregnancy, and hyperemesis gravidarum. The quality of evidence reported in these guidelines has been described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.
Benefits: NVP has a profound effect on women's health and quality of life during pregnancy, as well as a financial impact on the health care system, and its early recognition and management are recommended. (III-B)
Cost: Costs, including hospitalizations, additional office visits, and time lost from work, may be reduced if NVP is treated early.

Provided as a courtesy from the SOGC.

Nausea and vomiting of pregnancy is a common condition that affects the health of both the pregnant woman and her fetus. It can diminish the woman's quality of life and also contributes significantly to health care costs and time lost from work (1). Because "morning sickness" is common in early pregnancy, the presence of nausea and vomiting of pregnancy may be minimized by health care providers and by pregnant women (1) and, thus, undertreated. One investigator found that fewer than 50% of women who called a nausea and vomiting of pregnancy hotline and who subsequently terminated their pregnancies because of severe nausea and vomiting of pregnancy had been offered any sort of antiemetic therapy (2, 3). Of those offered treatment, 90% were offered regimens that were not likely to be effective. Furthermore, some women do not seek treatment because of concerns about safety (4). Yet, once symptoms of nausea and vomiting of pregnancy progress, treatment can become more difficult; treatment in the early stages may prevent more serious complications, including hospitalization (5). Mild cases of nausea and vomiting of pregnancy may be resolved with lifestyle and dietary changes, and safe and effective treatments are available for more severe cases. The woman's perception of the severity of her symptoms plays a critical role in the decision of whether, when, and how to treat nausea and vomiting of pregnancy. In addition, nausea and vomiting of pregnancy should be distinguished from nausea and vomiting related to other causes. The purpose of this document is to review the best available evidence about the diagnosis and management of nausea and vomiting of pregnancy.

Women suffering from nausea and vomiting of pregnancy (NVP) are often given subtherapeutic doses of Diclectin. It is critical that they be treated optimally according to their body weight, severity of symptoms, and response to treatment. This will ensure the best possible outcome in controlling this common condition of pregnancy that can exert heavy physical, emotional, and economic burdens on the pregnant woman.

Provided as a courtesy from the JOGC.

Nausea and vomiting of pregnancy is the most common condition in pregnancy and affects up to 80% of all pregnant women. There are a large number of pharmacological agents that are effective for the treatment of nausea and vomiting associated with conditions such as motion sickness and gastrointestinal conditions; however, their use in pregnancy is limited by the lack of sufficient data on their potential teratogenic effects. The efficacy of the delayed-release combination of doxylamine and pyridoxine (Bendectin, Diclectin) has been shown in several randomized, controlled trials. The present review aims to refute the unsubstantiated beliefs that Diclectin is unsafe when used in the treatment of nausea and vomiting of pregnancy.

A prospective study was performed with 160 women who provided daily recordings of frequency, duration and severity of nausea and vomiting during pregnancy.

Seventy-four percent of women reported nausea lasting a mean of 34.6 days. Nausea and vomiting in the morning alone occurred in 1.8% of women, whereas 80% reported nausea lasting all day. Half of the women were relieved by the 14th week of gestation; 90% had relief by week 22. Data based on the McGill Nausea Questionnaire that examined objectively the severity and intensity of nausea, indicate that the nausea experienced by those pregnant women is similar in character and intensity to the nausea experienced by patients undergoing cancer chemotherapy.

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At the initial call, all women responded to the question posed regarding the risk of antiemetic use during their pregnancy. Two thirds of the women reported that drug use for NVP was more likely to increase their baby's risk for malformations, whereas approximately one percent attributed no-increased risk to the fetus. Over 60% of the women reported some degree of depression because of the NVP and 50% were concerned that their NVP would impact negatively on the health of their child. Moreover, 12% of patients considered terminations of their pregnancy because of the severity of their NVP. After the counselling, women were asked the same question regarding the perception of the risk and 36.8% of those at the initial call who perceived use of medication to treat NVP as higher risk have been successfully reassured. Our investigation suggests that there is still misperception by patients and health professionals alike about the fetal risks of antiemetic medication. This study suggests that counselling can decrease the perception of teratogenic risk and support women's use of safe antiemetic drugs.

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