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.

  1. O'Donnell A, McParlin C, Robson SC, Beyer F, Moloney E, Bryant A, et al. Treatments for hyperemesis gravidarum and nausea and vomiting in pregnancy: a systematic review and economic assessment. Health Technol Assess. 2016 Oct;20(74):1-268.
  2. Grooten IJ, Roseboom TJ, Painter RC. Barriers and Challenges in Hyperemesis Gravidarum Research. Nutr Metab Insights. 2015;8(Suppl 1):33-9.
  3. Royal College of Obstetricians and Gynaecologists. The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No. 69).  2016 [14-03-2018];
  4. Veenendaal MV, van Abeelen AF, Painter RC, van der Post JA, Roseboom TJ. Consequences of hyperemesis gravidarum for offspring: a systematic review and meta-analysis. BJOG. 2011 Oct;118(11):1302-13.
  5. Niebyl JR. Clinical practice. Nausea and vomiting in pregnancy. N Engl J Med. 2010 Oct 14;363(16):1544-50.
  6. Jarvis S, Nelson-Piercy C. Management of nausea and vomiting in pregnancy. BMJ. 2011 Jun 17;342:d3606.
  7. Niemeijer MN, Grooten IJ, Vos N, Bais JM, van der Post JA, Mol BW, et al. Diagnostic markers for hyperemesis gravidarum: a systematic review and metaanalysis. Am J Obstet Gynecol. 2014 Aug;211(2):150 e1-15.
  8. Informatorium Medicamentorum, via KNMP Kennisbank. KNMP, april 2018.
  9. Koren G, Boskovic R, Hard M, Maltepe C, Navioz Y, Einarson A. Motherisk-PUQE (pregnancy-unique quantification of emesis and nausea) scoring system for nausea and vomiting of pregnancy. Am J Obstet Gynecol. 2002 May;186(5 Suppl Understanding):S228-31.
  10. Matthews A, Haas DM, O'Mathuna DP, Dowswell T. Interventions for nausea and vomiting in early pregnancy. Cochrane Database Syst Rev. 2015 Sep 8(9):CD007575.
  11. Beentjes M, Weersma R, Koch W, Offringa A, Verduijn M, Mensink P, et al. NHG-Standaard ‘Zwangerschap en kraamperiode’. Huisarts Wet 2012;55(3):112-25.
  12. Basirat Z, Moghadamnia A, Kashifard M, Sarifi-Razavi A. The effect of ginger biscuit on nausea and vomiting in early pregnancy. Acta Medica Iranica.  2009;47:51-6.
  13. Keating A, Chez RA. Ginger syrup as an antiemetic in early pregnancy. Altern Ther Health Med. 2002 Sep-Oct;8(5):89-91.
  14. Modares M, Besharat S, Rahimi Kian F, Besharat S, Mahmoudi M, Salehi Sourmaghi H. Effect of ginger and chamomile capsules on nausea and vomiting in pregnancy. J Gorgan Univ Med Sci. 2012;14:46–51.
  15. Mohammadbeigi R, Shahgeibi S, Soufizadeh N, Rezaiie M, Farhadifar F. Comparing the effects of ginger and metoclopramide on the treatment of pregnancy nausea. Pak J Biol Sci. 2011 Aug 15;14(16):817-20.
  16. Ozgoli G, Goli M, Simbar M. Effects of ginger capsules on pregnancy, nausea, and vomiting. J Altern Complement Med. 2009 Mar;15(3):243-6.
  17. Saberi F, Sadat Z, Abedzadeh-Kalahroudi M, Taebi M. Effect of ginger on relieving nausea and vomiting in pregnancy: a randomized, placebo-controlled trial. Nurs Midwifery Stud. 2014 Apr;3(1):e11841.
  18. Vutyavanich T, Kraisarin T, Ruangsri R. Ginger for nausea and vomiting in pregnancy: randomized, double-masked, placebo-controlled trial. Obstet Gynecol. 2001 Apr;97(4):577-82.
  19. Lareb. Teratologie Informatie Service Bijwerkingencentrum Lareb.  2018; Available from:
  20. Erez S, Schifrin BS, Dirim O. Double-blind evaluation of hydroxyzine as an antiemetic in pregancy. J Reprod Med. 1971 Jul;7(1):35-7.
  21. McParlin C, O'Donnell A, Robson SC, Beyer F, Moloney E, Bryant A, et al. Treatments for Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy: A Systematic Review. JAMA. 2016 Oct 4;316(13):1392-401.
  22. Boelig RC, Barton SJ, Saccone G, Kelly AJ, Edwards SJ, Berghella V. Interventions for treating hyperemesis gravidarum. Cochrane Database Syst Rev. 2016 May 11(5):CD010607.
  23. Diggory PL, Tomkinson JS. Nausea and vomiting in pregnancy. A trial of meclozine dihydrochloride with and without pyridoxine. Lancet. 1962 Aug 25;2(7252):370-2.
  24. Productinformatie metoclopramide (Primperan®). Via:
  25. Matok I, Gorodischer R, Koren G, Sheiner E, Wiznitzer A, Levy A. The safety of metoclopramide use in the first trimester of pregnancy. N Engl J Med. 2009 Jun 11;360(24):2528-35.
  26. Sahakian V, Rouse D, Sipes S, Rose N, Niebyl J. Vitamin B6 is effective therapy for nausea and vomiting of pregnancy: a randomized, double-blind placebo-controlled study. Obstet Gynecol. 1991 Jul;78(1):33-6.
  27. Vutyavanich T, Wongtra-ngan S, Ruangsri R. Pyridoxine for nausea and vomiting of pregnancy: a randomized, double-blind, placebo-controlled trial. Am J Obstet Gynecol. 1995 Sep;173(3 Pt 1):881-4.
  28. Chittumma P, Kaewkiattikun K, Wiriyasiriwach B. Comparison of the effectiveness of ginger and vitamin B6 for treatment of nausea and vomiting in early pregnancy: a randomized double-blind controlled trial. J Med Assoc Thai. 2007 Jan;90(1):15-20.
  29. Ensiyeh J, Sakineh MA. Comparing ginger and vitamin B6 for the treatment of nausea and vomiting in pregnancy: a randomised controlled trial. Midwifery. 2009 Dec;25(6):649-53.
  30. Smith C, Crowther C, Willson K, Hotham N, McMillian V. A randomized controlled trial of ginger to treat nausea and vomiting in pregnancy. Obstet Gynecol. 2004 Apr;103(4):639-45.
  31. Sripramote M, Lekhyananda N. A randomized comparison of ginger and vitamin B6 in the treatment of nausea and vomiting of pregnancy. J Med Assoc Thai. 2003 Sep;86(9):846-53.
  32. Grooten IJ, Vinke ME, Roseboom TJ, Painter RC. A systematic review and meta-analysis of the utility of corticosteroids in the treatment of hyperemesis gravidarum. Nutr Metab Insights. 2016 Feb 4;8 (Suppl 1):23-32.
  33. Kashifard M, Basirat Z, Golsorkhtabar-Amiri M, Moghaddamnia A. Ondansetrone or metoclopromide? Which is more effective in severe nausea and vomiting of pregnancy? A randomized trial double-blind study. Clin Exp Obstet Gynecol. 2013;40(1):127-30.

The literature refers to the Dutch text


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