Episode 4: Pregnancy nausea and vomiting
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Episode 4 Content and Overview
In episode 4 of the Pregnancy and Childbirth podcast, Dr Greg discusses pregnancy related nausea and vomiting.
Nausea and vomiting are common symptoms that affect many pregnant women, particularly during the first trimester. This condition is often referred to as morning sickness, although this is misleading as symptoms can occur at any time. Join Dr Greg as he discusses how to manage pregnancy nausea and vomiting so that they have a minimum impact on your day-to-day function and on your general well-being.
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Transcription
0:01
Hi, I'm Greg Jenkins and welcome to this edition of my pregnancy podcast. Today, we're going to be talking about nausea and vomiting in pregnancy. This is a really common symptom. It affects a large proportion of women and predominantly is confined to the first trimester or the first 12 weeks of pregnancy. It's also commonly referred to as morning sickness, although typically for a lot of women, the symptoms are not confined to the morning and can occur at any time during the day.
0:34
In most women, the symptoms are bothersome, but not a major concern to their health. However, for a small group of women, they develop a more severe version of nausea and vomiting in early pregnancy, and this is called hyperemesis gravidarum, or often referred to as HG. In the symptoms are severe enough to cause significant weight loss and or dehydration. In these women, periods of hospitalisation may be required for administration of intravenous medications and intravenous fluids. And at the more severe end of the spectrum, this can have a significant impact on health and well being.
1:19
For most women however, their symptoms are more mild than this and can be managed without the need for admission to hospital. And there are usually measures involving lifestyle and dietary modification and simple medications, which will keep the symptoms reasonably well controlled.
1:40
So what causes nausea and vomiting in early pregnancy? Well, it's undoubtedly related to pregnancy hormones. And the higher the pregnancy hormone levels, for example, in multiple pregnancies, women tend to have more severe symptoms than in women with single pregnancies. It's not clear, however, why some women develop quite severe symptoms, and other women very mild symptoms, and some women no symptoms at all. The trajectory of symptoms does, however, follow reasonably well, the rise and fall in the pregnancy hormone level through the first trimester of pregnancy. So it's reasonably predictable, that symptoms of nausea and vomiting and pregnancy reached their worst by about 9 to 10 weeks. And after this time, in the vast majority of women, they gradually improve over the next few weeks. There are, however, a small group of women who experienced persistent nausea and vomiting for much longer than the first trimester, and very occasionally, throughout the entire duration of pregnancy.
2:47
So how do we manage nausea and vomiting and pregnancy? Well, unfortunately, the bad news is, there isn't anything we can do that's going to make it go away. So the key is to find a way to manage the symptoms, so they have a minimal impact on your day to day function, and on your general well-being. Now the majority of women find that the longer they go without having anything to eat or drink, the worse they tend to feel. So it's a little bit paradoxical. In order to not feel sick, you need to eat or drink something. Most women this is reasonably predictable. Now it doesn't really matter what you eat or drink. However, most women find that foods that are fairly bland, are carbohydrate rich, and easily digestible, are the things that work best. Similarly, with fluid, it doesn't especially matter what you drink. Some women find water to be not particularly palatable in the early trimester of pregnancy, and things like dilute fruit juice, even soft drinks, sports drinks, Hydralyte, any of those sorts of things can help to manage the symptoms and also provide carbohydrates that provide fuel and energy for your body. In terms of foods, small bland snacks, so crackers, sugary lollies, sometimes, dry toast, all of those things can be helpful, and it's a matter of experimenting with a few things and see what works best for you. You might even find that carrying snacks around. Some women find that having a snack by their bedside. So as soon as they wake up in the morning, they can have something to eat before they get out of bed that can help with the feelings of nausea and vomiting first thing in the morning.
4:33
You need not be too worried about your nutritional status during the first trimester of pregnancy unless you're experiencing severe vomiting with significant weight loss. Generally by the strategy of small frequent snacks and keeping up your fluids. You will maintain adequate nutritional status. And don't be concerned about the nutritional status of your baby. Your baby will require all it needs through the first trimester provided you're not on the brink of starvation, which happens in very, very few women in the early part of pregnancy. The other aspect is, of course, you'll be wanting to try and keep down your pregnancy vitamins, particularly in the first trimester, when you should be taking a folic acid supplement or perhaps a pregnancy multivitamin. You could try experimenting with a couple of different multivitamins if you are taking a multivitamin, as they contain different amounts of vitamins and minerals. And sometimes that can impact on your nausea vomiting in early pregnancy as well. So you might experiment with some different brands and different combinations to see whether that's more palatable for you. And obviously, there might be times of the day where you're more likely to be able to keep your pregnancy multivitamin or your folic acid tablet down, and you can tailor the timing of your tablet to the time when you're less likely to be vomiting.
5:57
Now there are some over the counter medications, which have been shown to be beneficial in helping to manage the symptoms of nausea and vomiting in pregnancy. The first line tends to be bigger vitamin so there's a vitamin called pyridoxine or vitamin B6. And there's quite a lot of evidence that pyridoxine can help to reduce nausea in early pregnancy, it probably doesn't have a huge effect on vomiting. But for a lot of women, it can result in a significant improvement in nausea.
6:30
Now ginger is a natural antiemetic. And there's a number of combination, early pregnancy multivitamins out there specifically for the purposes of managing nausea and vomiting in early pregnancy, which contain a combination of pyridoxine and ginger. And those will be available from your local chemist. For a lot of women, these combination supplements can be very beneficial in helping to manage their symptoms.
7:03
The next step beyond there is a medication called Doxylamine, the commonist over the counter version of this in Australia is a medication called Restavit. Now, it's a very safe medication to take in pregnancy, it can cause some drowsiness, and a lot of women who will help to reduce the nausea and the vomiting in early pregnancy. So it's a very simple first line approach and something that you can buy over the counter at the chemist.
7:34
Most commonly prescribed medication that I see for the treatment of nausea and vomiting in pregnancy is a medication called Metoclopramide, which the most common trade name is Maxolon. Now it's quite popular, because it's a category A medication for pregnancy, meaning there's very clear evidence that is completely safe, and is not likely to have any harmful effects whatsoever on the baby or the pregnancy. It can however, cause some sedation. And there's a bit of evidence to suggest that it doesn't work particularly well for nausea and vomiting in pregnancy. So it might be something that you try but don't be surprised if it's not especially helpful. I have seen some women where it helps. But I would say that the majority of women that I see are Maxolon it hasn't helped them particularly much. And there is of course the problem with Maxolon that it comes as a tablet, meaning that you have to swallow the tablet and keep the tablet down in your stomach for a period of time in order for it to be absorbed and in order to obtain the benefit from the medication.
8:51
The medication that I prescribe most often for women that need medication to manage the nausea, vomiting and pregnancy is a medication called Ondansetron. And the commonest trade name for this is Zofran. Zofran is unique amongst the medications for nausea and vomiting in pregnancy, in that it comes not only as a tablet, but it also comes in a form called a wafer, which is a very tiny lozenge which you dissolve in your mouth. So you don't have to rely on swallowing the medication and waiting for it to absorb in your stomach before it works. So you can just suck on it. It absorbs through the lining of your cheek, goes straight into your bloodstream and is effective very quickly. So that's one benefit to Ondansetron. The second benefit is it's an extremely effective nausea and vomiting medication and tends to work better than anything else. Now in terms of its safety in pregnancy is generally considered to be extremely safe in pregnancy. There's no evidence that it causes harmful effects on the pregnancy or on the baby and its classification is Category B1. And we'll use lots of Category B1 medications at various stages in pregnancy. Those women who don't like the taste of the wafer or the lozenge, it does come as a tablet. But as I said, one of the limitations of a tablet is that you have to retain it in your stomach long enough for it to be absorbed in order to get the benefit of the medication. The other good thing about Ondansetron is that you can just take it as you require it, it's not something that you need to take every day and you can adjust the dose depending on whether you're having a good day or a bad day, you can adjust the timing and you can dose it multiple times per day, if you're having a particularly challenging day. However, if you're one of those women that has really bothersome symptoms that occur on the vast majority of days, it's very safe to continue it for extended periods of time. In terms of side effects, it's generally very well tolerated. The most troublesome side effect, which occurs with Ondansetron is constipation. And most women who are taking Ondansetron for any extended period of time, will have some issues with constipation. So it's worth thinking about how you'll manage that, if that particular symptom occurs.
11:25
Now, there are other medications available. But in my experience, the vast majority of women can be fairly effectively managed using a combination of dietary advice, careful management of oral fluid, and the supplements and medications which we've just discussed.
11:45
So what if you're one of those women that has really quite severe symptoms, where you're at risk of becoming dehydrated and you're experiencing significant weight reduction. So it's important to have a plan in place so that you know, when the trigger points are reached, for your need to present to hospital for intravenous fluids, possibly intravenous medication as well. And you should discuss these things with your pregnancy care provider, whether that be your GP in early pregnancy, or whether it be the obstetrician or midwife that's involved in your pregnancy care. And you should have a plan as to how you will access the hospital whether that be through the emergency department, or whether special arrangements can be made for your presentation to the Birthing Unit, or for direct admission to the ward. Most women do not require extended periods of hospitalization. And in fact, women who require extended hospitalisation, on the whole tend to do a bit worse than women who are managed predominantly as an outpatient. So the principle that we try to stick to is we try really hard to keep women out of hospital to keep their symptoms well managed. And when it gets to the point where they're becoming dehydrated, or they're becoming more unwell, then a brief admission to hospital to rehydrate with intravenous fluids, to top up with intravenous medications, get them feeling as well as possible and get them back home again.
13:23
Now, for women with significant weight reduction, and persisting symptoms, the involvement of a dietitian can be extremely helpful in looking after your nutritional status during the early part of pregnancy, particularly for women where their symptoms are progressing into the second trimester.
13:42
Now, I should say that most women are going to experience pretty much a complete resolution of symptoms by about 15 weeks. It'll most commonly be a slow, steady improvement in symptoms between 10 and 15 weeks. However, in some women, the symptoms disappear very quickly. There'll be a smaller group of women whose symptoms persist beyond that, most will get better between 15 and 20 weeks, and a small number will persevere between 20 and 25 weeks. The bad news, unfortunately, is if you've still got symptoms by about 25 weeks, that's going to be pretty much how it is for the remainder of your pregnancy. So it's important if you are one of those small group of women, that you have a strategy to help maintain your nutritional health, maintain the nutritional health for your baby, and also maintain your general well being through the remainder of the pregnancy because this can be both physically and mentally a very challenging situation to manage.
14:41
It's reassuring to know that in the vast majority of women who have nausea vomiting in pregnancy, even women with fairly severe symptoms and women with hyperemesis gravidarum that pregnancy outcomes are not impacted on by this condition. So you can expect that you will have a healthy pregnancy and a healthy baby at the end of this. The only exception to that is a woman who becomes severely nutritionally unwell during the pregnancy, and hence the need for involvement with a dietitian.
15:16
So what about if you've had nausea and vomiting or hyperemesis gravidarum in a previous pregnancy? What can you expect in your next pregnancy? Well, unfortunately, the symptoms tend to be fairly similar, and tend to last for a fairly similar duration. Now there can be some variation, some women's symptoms will be a bit less severe, or maybe a bit more severe. And this seems to be fairly random occurrence. There's no particular association with the gender of your baby or with any other variables that we can predict or identify. But generally speaking, if your symptoms were at the more severe end of the spectrum, they're likely to be there again. And they're likely to last for about the same duration into your pregnancy. If your symptoms were fairly mild, they will probably be fairly mild again. And if you're a woman who had no nausea or vomiting in her pregnancy, then that will probably be what happens to you in your next pregnancy as well.
16:17
If you're somebody who did experience significant symptoms in a previous pregnancy, is there anything that you can do before you get pregnant, to help to improve the symptoms? So there are a couple of things, you can make sure that you're nutritionally well before you get pregnant. That will help you to sustain yourself and sustain the well being of your pregnancy throughout the early part of the pregnancy. The second thing you can do is to start your pregnancy multivitamins two to three months before you become pregnant. There's a little bit of evidence to say that women who've been taking a pregnancy multivitamin in a couple of months prior to pregnancy, might have less severe symptoms than women who have not done so.
17:05
And the other piece of evidence out there is for women who have significant symptoms of reflux, or indigestion or heartburn prior to pregnancy. There's some evidence that for those women being on treatment, that has effectively reduced those symptoms before they become pregnant, that the nausea and vomiting through the first trimester of pregnancy may be significantly improved.
17:33
The other thing to consider is your general well-being and support during early pregnancy. So if you're a woman who has experienced quite severe nausea and vomiting in a previous pregnancy, then you want to try make sure that you have as much support around you as possible. So given that you've had a previous pregnancy, there's going to be a toddler or a small person in your life that's going to require care during the time in pregnancy where you might be feeling particularly unwell. So making sure that you have some sort of support strategies in place can help to make life a lot easier for everybody, including yourself during the early part of pregnancy at that time, when you're feeling unwell and maybe struggling to manage things on a day to day basis.
18:24
Also talking to either your GP or your pregnancy care provider to make sure that you can get access to medications early in pregnancy, when your symptoms begin. If you're somebody who feels they might need prescription medication to manage their symptoms in early pregnancy, that is a good strategy.
18:46
So I hope you found some of that information useful, helpful and informative. I do have the greatest sympathy for women who experienced significant nausea or vomiting in early pregnancy, it can be unrelenting and it can be psychologically and physically very challenging. And I think part of what we can do as healthcare providers is offer as much support as possible for you in helping you get through that challenging part of the pregnancy. And particularly for that very small group of women whose symptoms persist for the duration of pregnancy. Having a relationship with a pregnancy care provider that provides you with support at lots of different levels can help to make things a bit easier on the journey of your pregnancy.
19:31
So that's it for now. Again, if you have any feedback, you would like to leave or you have any suggestions for future topics to cover, they would be very warmly received. Bye for now.
