Nausea and vomiting of pregnancy


  • Cases of nausea and vomiting during pregnancy are divided into physiological emesis gravidarum (morning sickness), hyperemesis gravidarum (severe nausea with persistent vomiting) and nausea or vomiting due to an underlying disease.
  • The article discusses recent systematic literature reviews to provide an overview of the efficacy and safety of drugs that are registered or are indicated for off-label use in the Netherlands for the treatment of nausea and vomiting of pregnancy.
  • Only one drug has been officially registered in the Netherlands for the treatment of nausea and vomiting of pregnancy, viz. a combination of meclozine and pyridoxine (vitamin B6). No drugs have been registered in the Netherlands specifically for the treatment of hyperemesis gravidarum.
  • The guideline on ‘Pregnancy and the Maternity Period’ published by the Dutch College of General Practitioners (NHG) states that ginger can be recommended for moderate symptoms, while meclozine is recommended as the drug of first choice for severe complaints, and metoclopramide as the second choice. This use is off-label for both drugs. 
  • There is no specific Dutch guideline for the treatment of hyperemesis gravidarum.
  • No drugs have been proved in placebo-controlled trials to offer clinically relevant efficacy in reducing nausea and vomiting of pregnancy.
  • In view of this lack of conclusive evidence, pharmaceutical therapy should currently not be recommended for the treatment of  physiological emesis gravidarum, neither in primary nor in secondary care.
  • Women with hyperemesis gravidarum will normally be referred to secondary care, as this involves greater risks for mother and child.
  • There has been no evidence from placebo-controlled studies for the efficacy of medical treatment of hyperemesis gravidarum.
  • Medical treatment of hyperemesis gravidarum in secondary care is based on the ‘maximum  available evidence.’ No Dutch guidelines for this have been published.
  • However, not providing any therapeutic intervention because no proven treatment is available would mean ignoring the serious discomfort that nausea and vomiting can present in the everyday lives of pregnant women. The best option is to try and reassure the patient (by telling them that the condition is usually self-limiting and that the risk of adverse effects is minimal) and offering them lifestyle advice with recommendations for rest and nutrition, even though there is no evidence for the efficacy of these measures either.

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The literature refers to the Dutch text

Authors

  • dr H.I.J. Wildschut, Prof. dr F.M. Helmerhorst