EATRS
Based on all current evidence-based information regarding Nausea and Vomiting of Pregnancy (NVP), the best way to manage the condition is to learn about it and prepare for it, even if women only suffer from mild symptoms.
If women have correct and full knowledge of the condition prior to pregnancy and before experiencing symptoms, in tandem with discussions with their Health Care Provider (HCP), they can potentially stop it from peaking to a point where it becomes unmanageable. EATRS is simply a method to formalize this process and make it easier to remember.
This method can be utilized by non-pregnant women and pregnant women, as well as their HCPs, partners, and family members.
Get Educated on Nausea and Vomiting of Pregnancy.
Apply Learning Points Early.
Track What is Working and When.
Reapply What Tracking Shows to be Most Effective and Reassess Overall Strategy
Save Everything (for HCP and any future pregnancies)
Background
Many researchers advocate for the early recognition and management of Nausea and Vomiting of Pregnancy (NVP), which has been shown to reduce the likelihood of severe physical and mental health complications. This is especially important since there is no specific treatment or medication for NVP – so prevention plays a critical role.
NVP tends to get worse after it starts, and its symptoms can become more difficult to control. Therefore, if women recognize it, visit their HCP, determine a plan and are more prepared for it, they can potentially avoid these complications.
Based on what is currently known about the causes and contributing factors of NVP , its associated symptoms and complications, the lack of one effective management strategy for all women, and the recommendation that all women have individualized management plans, EATRS may be the best formula for applying this recommendation.
Get Educated
Get Educated on Nausea and Vomiting of Pregnancy.
If women wait until they are already feeling sick to better understand NVP, women may lose valuable time getting ahead of their symptoms, as NVP tends to spiral quickly.
Further, women may find it very difficult learning about being sick during pregnancy when they are currently sick during pregnancy.
The most important benefit of getting educated ahead of time regarding NVP is it relieves anxiety and provides women options – faster. Women do not have to be afraid of the condition or its symptoms; learning about it can make women realize they can have an active role in its management. While it is possible that some women may get to a stage where "nothing works", there are many strategies and methods to try before that point.
Further, information provides women a better understanding of why they feel the way they do, how they can help themselves feel better, when they may need further help, and who may be able to help them.
NVP takes time to learn. HCPs may not have time during the first office visit to fully explain and discuss NVP with each woman. This is also very difficult to do when the woman is already feeling symptoms.
If women understand NVP before they get sick, they will experience less anxiety, stress, frustration, disappointment, and hopelessness. They will also feel less lonely and frustrated if their partners/family members are also aware of the real facts of the condition from the beginning.
Women should also be familiar with various medication options, the risks and benefits of each, and have an overall opinion of what may work for them in the event medication is needed. If NVP becomes more than can be tolerated or handled with dietary/lifestyle modifications, they can schedule an appointment with their HCP to review medication options. Women are fully informed by then and are able to better participate in that discussion.
Management strategies include four major categories: dietary changes, lifestyle modifications, non-pharmacological options, and over-the-counter and prescription medications. Women should review all these categories so they have a full understanding of the management options available and which may potentially be most effective.
Although no formal guidance exists for HCPs regarding which medications to give to any particular woman, an “algorithm” or “flow chart” has been published that most HCPs try to follow (see Resources).
Apply
Apply Learning Points Early.
Women should implement dietary or lifestyle modifications they learn about as soon as they start to feel symptoms, and in some cases, even before. These changes can start off very small, and gradually build as a woman assesses how each technique appears to be managing or controlling her symptoms.
For example, women who previously experienced severe NVP have even been advised to start medication earlier than their prior pregnancy (see Management Introduction).
Women may also want to start eating regular, small meals the second they start to feel nauseous, or even before they feel symptoms, especially in a woman who had NVP in a prior pregnancy. If they wait until after they are moderately nauseous, small meals may have less of an effect.
NVP generally gets worse than when it first starts; therefore, this method allows women to get symptoms under control from the very beginning. Further, having discussions with an HCP at this start of this process sets up both the woman and her HCP for success. If all measures fail, the HCP is already on board and aware of the woman’s history. This allows for more targeted, individualized, and aggressive treatment if necessary.
The Be Ill Prepared and Living with NVP sections show women how to very quickly prepare the different aspects of their lives so they can best manage NVP with the least adverse effects on their family’s routine, employment, social life, finances, relationships, and their physical, mental, and emotional well-being. Further, these sections are constantly updated.
Being Ill Prepared helps women logistically prepare as much as they can ahead of time for NVP, especially for women who have experienced it in the past. Further, if a woman's NVP turns out to be very mild, the preparation was very little out of her way and she can still find utility in even small preparatory steps.
Track
Track What Dietary Changes, Lifestyle Modifications, Medications, and Other Methods are Working and When.
Due to the significant amount of different strategies, foods, drinks, distraction techniques, and other methods for relieving nausea, women may forget very quickly what worked and what did not work.
It seems plausible that women with severe nausea would never forget a strategy that helped them feel better, but waves come and go, and what may have worked during week 3 may no longer work during week 5. Sometimes women find they need to start over as symptoms progress.
Women may also lose track of when they took certain vitamins or medications. This is important – taking too much of any medication can be harmful, and missing an anti-nausea medication meant to be taken around the clock could wreak havoc on a nausea/vomiting cycle.
Tracking is also crucial for determining a pattern to nausea; there may also be certain techniques that work great in the morning but do nothing towards the evening, and things necessary for work but may not be necessary at home.
Even if a woman is convinced she can remember everything, writing it down can help her family members understand what works best for her and when. This tracking is also great for an HCP to evaluate as additional options become necessary.
Women should consider tracking (when feasible):
Different types of tips they have tried
What currently works for their nausea, and what currently works for vomiting (and what worked in the past)
What does not work
Nausea-free times
Time of day nausea/vomiting is at its best/worst
Patterns to nausea waves
Vomiting cycles/triggers
Fluid intake
Food intake
Medication doses, including prenatal vitamins and supplements
This does not require a “homework-style” type of task; a post-it can also get the job done. Women may find it useful to print out various Management pages and cross off or highlight actions tried and results experienced.
Reapply and Reassess
Reapply What Tracking Shows to be Most Effective, and Reassess Overall Strategy
After women have learned about NVP , applied various management strategies, and have begun tracking, at some point they need to stop and assess how everything is working.
HCPs should check in, and their partners/support should also take the time to ask the following:
How are you feeling?
What is working? What isn’t working?
What should we change?
Do you need further help?
Do you have symptoms other than nausea/vomiting?
How are you mentally handling it?
Are you concerned about work?
Are you concerned about the kids?
Note: Partners/Support should also be aware of the signs of severe complications, especially if a woman cannot express how she is feeling due to extreme fatigue or dehydration.
Women should continue using the strategies that are working and make sure they are always available (frozen water bottles, tea, bread, filled prescriptions, etc.). If nothing seems to be working, or the options that previously worked no longer do, she needs to call her HCP and get her HCP involved again. Suffering is not necessary.
Women should not wait until rock bottom before asking for more help; the point of preparing is to avoid rock bottom.
Save
Save Everything Learned and Tracked (for the HCP and any future pregnancies)
NVP can be different for the same woman across different pregnancies; it could also be exactly the same. Saving everything that was tracked from the current pregnancy can potentially put women miles in front of NVP during a subsequent pregnancy.
Further, researchers recommend that if a woman suffered NVP in a current pregnancy, she needs to make changes much earlier for a subsequent pregnancy.
If NVP turns out to be different or even worse, women are also prepared to make quick adjustments, and their HCPs already know their history and what has worked before.
For example, a woman and her HCP may learn that instead of starting pyridoxine (B6) and doxylamine at 8 weeks, the HCP may recommend starting it much earlier in a subsequent pregnancy (5 to 6 weeks), even before symptoms start.
Women should always talk to their HCP before changing their medication regimen on their own – especially with over-the-counter medication.
Action
Based on all current evidence-based information regarding NVP , the best way to manage it is to get in front of it and be prepared for it.
If women have correct and full knowledge of the condition prior to pregnancy and before experiencing symptoms, in tandem with discussions with their HCP, they can potentially stop it from peaking to a point where it becomes unmanageable.
Non-pregnant women, pregnant women, and their partners/family members should:
Get Educated on Nausea and Vomiting of Pregnancy.
Apply learning points early.
Track what is working and when.
Reapply what tracking shows to be most effective and Reassess overall strategy.
Save everything (for HCP and any future pregnancies).
To get started, we recommend the following pages:
Women should consider sharing their experience with NVP (below) for other women to read, to include whether EATRS was a viable method for them, and if learning about the condition beforehand and preparing for possible NVP had any potential positive effect on their symptoms.
Partners/Support
Partners, family members, and other support should become better educated on NVP . Partners and family members are in a position to make this condition easier on a pregnant woman – as well as the whole family.
However, this can only be done if partners/support understand the reality of the condition, as well as current research regarding management. Better information regarding NVP can teach partners/support to:
Manage their expectations regarding duration, peak, and the unpredictable nature of NVP
Recognize that science does not yet understand what causes the condition or how to best treat it
Understand that women with NVP experience many symptoms in addition to nausea and vomiting
Help prepare the pregnant woman for her symptoms (to include the bedroom, bathroom, kitchen, and car).
Understand how quickly symptoms can change in severity
Help a woman avoid nausea/vomiting triggers and aversions
Recognize when the woman may require additional or immediate medical care
Recognize the condition requires patience from all members of the family
Resources
Nausea and Vomiting of Pregnancy (Gastroenterol Clin North Am. 2011 Jun)
Nausea and Vomiting of Pregnancy-What’s New? (Auton Neurosci. 2017 Jan)
Morning Sickness: Nausea and Vomiting of Pregnancy (American College of Obstetricians and Gynecologists)
Nausea and Vomiting of Pregnancy: Committee Opinion 189; January 2018 (American College of Obstetricians and Gynecologists)
The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum (U.K. Royal College of Obstetricians and Gynaecologists)
Algorithm for Treatment of NVP (page 18; Association of Professors of Gynecology and Obstetrics; 2011)
The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum (algorithm page 25 and 26; U.K. Royal College of Obstetricians and Gynaecologists)