Nausea and Vomiting in Pregnancy

Nausea and vomiting in pregnancy (NVP) represents a conundrum for the pregnant woman. On the positive side, NVP is correlated with better fetal outcomes than the absence of these symptoms,1 but at the other extreme, NVP can interfere with nutrition and hydration for the mother and developing fetus. Symptoms may range from occasional mild nausea to multiple episodes of daily vomiting resulting in weight loss and electrolyte abnormalities. This severe manifestation is often referred to as hyperemesis gravidarum.

Usually appearing before the ninth week of pregnancy, NVP will affect up to 85% of normal pregnancies, with symptoms generally remitting by the fourteenth week. Initial presentation of symptoms after the ninth week should prompt a workup to determine an alternative cause. NVP may be mild, but up to 20% of women find their symptoms so significant that they cannot continue to work.2 The reported incidence of hyperemesis gravidarum, the most severe end of the spectrum, varies from 0.5% to 2% of all pregnancies. This severely debilitating condition is the most common reason for hospital admission in the first trimester. Mild or moderate vomiting does not appear to have any significant effects on the fetus. Among women with severe hyperemesis, the reported incidence of low birth weight is higher, but increased reporting of birth defects has not been noted.3

The cause of NVP is unknown. Both biological and psychological factors have been proposed. Human chorionic gonadotropin (HCG) and estrogen (both are hormones) have been studied as triggers for these symptoms. Daughters and sisters of women who had hyperemesis are more likely to have NVP as well. Other risk factors include a previous pregnancy affected by hyperemesis, a female fetus, and a history of motion sickness or migraines.4

When treatment is considered, risks and benefits must be clearly explained to the pregnant woman. Minimizing the risks of any treatment is desirable, but the presence of a developing fetus makes it more urgent to decrease any unnecessary exposures. This is an ideal time to use integrative approaches because drugs generally represent more risk than other modalities.

Avoid odors, increase rest, and exercise. Low blood glucose levels seem to trigger nausea and subsequently vomiting in many women; thus small, frequent, high-protein, high-fiber meals are often recommended.8 Randomized controlled trials have shown that ginger is effective for treating NVP,5 and it is the most thoroughly studied herb for this indication. Chamomile is a flowering plant that is often used for various types of gastrointestinal upset, including travel sickness, colic, and inflammatory diseases of the bowel. It is commonly used for NVP.6 Peppermint is another herb often used in pregnancy.7 The active parts are the stems, leaves, and flowers, as well as the peppermint oil that is distilled from these plant parts. Vitamin B6 is a water-soluble vitamin that is an effective treatment for nausea in pregnancy. The benefit in reducing vomiting episodes is less clear.8 The mechanism of action of pyridoxine remains unknown.

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  1. F.D. Tierson, C.L. Olsen, E.B. Hook: Nausea and vomiting of pregnancy and association with pregnancy outcome. Am J Obstet Gynecol. 155:1017-1022 1986
  2. I.D. Vellacott, E.J. Cooke, C.E. James: Nausea and vomiting in early pregnancy. Int J Gynaecol Obstet. 27:57-62 1988
  3. L. Dodds, D.B. Fell, K.S. Joseph, et al.: Outcomes of pregnancies complicated by hyperemesis gravidarum. Obstet Gynecol. 107:285-292 2006
  4. American College of Obstetrics and Gynecology: ACOG (American College of Obstetrics and Gynecology) practice bulletin: nausea and vomiting of pregnancy.Obstet Gynecol. 103:803-814 2004
  5. Natural Medicines Comprehensive Database: Ginger. 2011 Accessed September 12, 2011
  6. J.M. Wilkinson: What do we know about herbal morning sickness treatments? A literature survey. Midwifery. 16:224-228 2000
  7. P.S. Gibson, R. Powrie, J. Star: Herbal and alternative medicine use during pregnancy: a cross-sectional survey. Obstet Gynecol. 97 (Suppl 1):S44-S45 2001
  8. T. Vutyavanich, S. Wongtra-ngan, R. Ruangsri: Pyridoxine for nausea and vomiting of pregnancy: a randomized, double-blind, placebo-controlled trial. Am J Obstet Gynecol.173:881-884 1995