Management Introduction
Management of Nausea and Vomiting of Pregnancy (NVP) is complex. Since researchers currently do not know what causes it, or even how to best manage NVP's associated symptoms (NVP causes many other symptoms than just nausea and vomiting), there is no single best management method for all women.
Despite this, women can still have adequate control over their symptoms in most cases. Updated and correct knowledge of NVP – its duration, severity, causes and contributing factors, risk factors, possible complications, latest management methods, and resulting preparation – can help women, their partners, and their family members manage not only their expectations, but the woman’s physical, mental, social, and emotional health as well (and the family's overall adjustment).
Women can take full control of their symptoms if they first learn all about the condition, engage their HCP early, determine the most optimal management plan suited to their NVP experience and overall health, prepare and plan ahead, and use a combination of various management strategies.
Of most importance, women need to find an HCP who fully understands NVP, empathizes with women who are experiencing it, and takes the time to manage all aspects of the woman's health.
Background
Although there is no single best management method for all women, women have the freedom and control to determine the best strategies for themselves, based on their own preferences and medical input from their HCP.
Categories of Management methods include:
Dietary changes (changing the way in someone eats)
Lifestyle modifications (morning/nighttime routine, work hours, mealtimes)
Non-pharmacological options (acupressure, massage, aromatherapy, distraction, counseling)
Pharmacological options (medications)
Additional major points:
NVP is considered a condition of management, not treatment, as there is no cure
HCPs should be involved early in the process.
Management is highly individualized.
Preparation for NVP leads to more options and therefore better success.
Early lifestyle/dietary changes are likely mandatory, but may be the only necessary steps for some women.
A combination of different types of management strategies aiming for small goals may be most effective.
Women have safe pharmacological (medication) options available to them when symptoms become too difficult to manage on their own.
Physical, mental, social, and emotional health need to be managed at the same time.
Managed, Not Treated
Treatment of a disease generally includes the relief, removal, or cure of a condition. Management refers to strategies that help keep a condition and its symptoms under control.
There is currently no treatment for NVP; only various methods to keep symptoms manageable and tolerable until they begin to fade on their own – usually with time.
Despite the fact research has shown women can have adequate control over their symptoms if they plan for it, at least one study found that almost half of women in early pregnancy did nothing at all or “non-evidence based” actions to manage their NVP.
The goal is to find temporary relief as many times as possible, for as long as possible – specifically to eat, drink, rest, and sleep (and in many cases – work and parent as well) utilizing many different management strategies. A large tool box will help women avoid a stall or decrease in relief as symptoms progress.
Even just several minutes of relief at a time can provide a much needed respite. Several of these types of short breaks every hour or so throughout the day (when symptoms are most severe) can potentially give women enough physical and mental rest to keep going. Women should not expect that a small well-balanced snack in the morning or ginger gum will give them all-day relief (although for some women, it could).
Additionally, NVP is not something women should “wing” or deal with as it comes. A little bit of reading and planning could put them way ahead of the condition and its debilitating symptoms. Further, just because NVP is considered normal and expected does not mean its women must suffer through it without help.
NVP may be more severe and last longer than some women and their families were prepared for; this can lead to significant frustration, impatience, and can hinder a woman’s ability to manage her symptoms.
Further, managing NVP, and determining which methods work best can be very hard for some women and takes time. While certain women may find instant relief with ginger gum or potato chips, other women may to have to work a lot harder at finding techniques that work.
If women/partners understand that managing NVP may take a little bit of work (changing schedules and routines, preparing foods ahead of time, changing family dynamic and responsibilities), then – as a family – they can more effectively combat NVP, its symptoms and potential complications, and get the woman feeling as normal again as soon as possible (and able to enjoy her pregnancy sooner).
Start Management/Get HCPs Involved EARLY
Several published studies have indicated that early recognition and management of all grades of NVP can prevent a delay in diagnosis of severe NVP and Hyperemesis Gravidarum (HG) and reduce the likelihood of an emergency department visit or hospital admission.
Again, despite this, many women do not seek any type of medical care for their NVP.
NVP progresses (gets worse) over time; it may begin anytime around 4 to 5 weeks of pregnancy and usually lasts until about 16 to 22 weeks (but may go away sooner/last longer in some women). Peak severity may occur around 9 to 10 weeks of pregnancy.
Therefore, if women start managing symptoms as soon as they begin to feel nauseous (and even before), they can potentially get in front of their symptoms and maintain a better sense of control throughout the entirety of the condition.
The first step is for women to get their HCP involved early in the management process; women should understand this does not always mean medication.
If women have at least one or more risk factors that indicate they could be more susceptible to severe NVP symptoms, they can talk to their HCP before they get pregnant about a possible management plan. Otherwise, women should call as soon as they either start to feel symptoms, or during the first appointment between 6 and 8 weeks of pregnancy.
HCPs can assess a woman’s physical condition, medical and family history, obstetric history (including birth control), susceptibility to motion sickness and hormones, and underlying health conditions (acid reflux).
HCPs also need to question women about their symptoms, when they experience symptoms, symptom severity, determine possible risk factors and contributing causes, and assess for mental and emotional concerns. HCPs also need to ask women about their lifestyles, employment, children, responsibilities, and assess each woman’s ability to mentally and emotionally cope with her symptoms.
All of these aspects can change how a woman should manage her NVP, to include which medication she should be prescribed in the event it is deemed necessary.
For example:
If a woman suffers from a borderline thyroid disorder or acid reflux that needed no treatment prior to pregnancy, treating either condition during early pregnancy could avoid worsened nausea/vomiting.
If a woman suffered severe nausea on hormonal birth control, her HCP may decide to put her on supplemental vitamin B6 at the start of her pregnancy, or even before (women should never take over-the-counter medications or supplements without talk to their HCP first).
If a woman regularly suffers from constipation regardless of pregnancy status, an HCP may need to put the woman on stool softeners or change her diet, as constipation is a major contributing factor to NVP.
A woman with moderate symptoms, but two children, full-time employment, and many other household and family responsibilities may require medication to handle her symptoms, where a woman with a first pregnancy and less responsibility may be able to handle severe symptoms without medication (individualized with more than physical symptoms taken into consideration).
Of most importance: if these conditions/scenarios are treated after NVP becomes too severe, it is possible it could be too late, and the woman may experience no relief despite these methods.
However, there is currently very little formal guidance for HCPs to individually assess women’s risk factors and symptoms, despite recommendations by researchers.
Therefore, some HCPs may manage all women exactly the same when they experience NVP symptoms. An HCP may provide the same anti-nausea medication or other management methods to every single woman who complains of severe NVP, regardless of her individualized medical/obstetric history.
If a woman’s medical history is not assessed prior to recommending NVP management methods, this can make some women feel even worse:
Some HCPs recommend ginger for all women (which is a current formal first step). However, if a woman has acid reflux, ginger can make it significantly worse; additionally, if a woman is vomiting, ginger can be incredibly painful to throw up.
Ondansetron is a very effective antiemetic medication and is prescribed to millions of pregnant women all over the world. However, it can cause horrible constipation. If a woman is already experiencing constipation as a normal early sign of pregnancy, prescribing ondansetron without taking into account her need for a change in diet or stool softener, her constipation – and therefore her nausea, could get worse.
Women need to find an HCP who fully understands NVP, empathizes with women who are experiencing it, and takes the time to manage women fully (including her mental and emotional health as well).
Individualized Plan
The development of NVP is currently assessed to be multifactorial, and different women will experience different combinations of these factors, which is why symptom severity and management effectiveness is so variable among women.
Additionally, women and HCPs tend to only consider managing two symptoms with NVP – nausea and vomiting. Many symptoms of pregnancy can make NVP worse, and NVP can make common pregnancy-related symptoms worse. The effective management of one or more may provide significant relief of others; these normal, early pregnancy symptoms are also highly variable among women.
Further, the assessed potential causes, contributing factors, symptoms, and complications of NVP are similar and overlap because what causes NVP vs. what does NVP cause has not been clearly determined or defined.
As stated above, categories of management methods include:
Dietary changes (changing the way in which women eat)
Lifestyle modifications (morning/nighttime routine, work hours, mealtimes)
Non-pharmacological options (acupressure, massage, aromatherapy, distraction, counseling)
Pharmacological options (medications)
Even the best management strategies may include a lot of trial-and-error, as it is also not always possible to determine what may be causing or contributing to a woman's NVP until after certain techniques have been tried (i.e. an empty stomach, acid reflux, lack of fiber).
Women need to keep track of methods they are using, when they are using them, and if they are effective. However, even before this, women need to try to determine a pattern to their symptoms, which could help them identify any possible contributing factors to their symptoms (prenatal vitamins, large meals, acid reflux, constipation, empty stomach, sudden movement, malodors, fatigue).
Preparation
NVP symptoms are estimated to last an average of five to eight weeks (35 to 56 days). However, some pregnant women may experience NVP for only just a few days, while others won’t experience it at all.
However, for those who experience it for weeks to several months, preparation is necessary. Some women can easily handle nausea for a few days, but once days stretch to a week or more, its impact can be difficult to tolerate without making some type of lifestyle or dietary changes.
Current evidence-based information indicates the better a woman understands the condition, learns management techniques ahead of time, and prepares various aspects of her life – even minimally – the better her chances for success.
Women can prepare themselves, their family members, and employers, as well as their physical and mental health, homes, vehicles, and workplaces. Preparation can range in scale and is tailored to women's preferences and degree of symptom severity, from mild to severe.
Preparation does not have to take a lot of work, but it may take creativity; women need to remember the goal of preparation is to minimize stress, anxiety, fear, and guilt, as well as the severity of symptoms by having a variety of options nearby and always available.
Read more information on how to Be Ill Prepared for/during NVP.
Diet and Lifestyle
Dietary changes and lifestyle modifications are the front-line recommended first management steps before using medications or other more invasive, less studied options.
Examples of lifestyle modifications include changes to a woman's (or family's) morning and evening routines, work flexibility or a change in hours, a shift in family dynamic and household responsibility, less social activity, and a change in hygiene habits.
Non-pharmacological options are also a type of lifestyle modification. These can include adoption of new practices such as controlled breathing, acupressure, acustimulation, yoga, meditation, massage, hypnosis, aromatherapy, exploring creativity with various distraction techniques, both for the mind and the body, and learning new methods to rest and fall asleep.
In general, all the methods above can help teach women how to live with their NVP (as well as work, parent, socialize, and enjoy holidays and special events).
Although some of these methods are small, and may only provide a few minutes of temporary relief, this is the actual goal. For those with constant nausea, temporary relief means their strategies are working. Small breaks add up. These can include:
A supportive phone call from a friend
A 30-minute massage
A 5-minute shower
A brief nap
Women should not try to manage a full day at one time; they need to consider only every hour, or even every few minutes – especially when symptoms are severe. Otherwise, management gets overwhelming. It is also critical that when women do get a few minutes of relief, they try to relax and enjoy those few minutes (i.e. recharge) as much as possible.
Medications
Women have numerous pharmacological options available to help them manage their NVP symptoms if diet and lifestyle modifications do not work. Suffering is no longer necessary, and women should call their HCP to discuss their options if NVP becomes too severe.
These options include:
Antacids/proton pump inhibitors (Pepcid®)
Vitamin supplementation (B6) (with or without doxylamine)
Antihistamines (Unisom®, Dramamine®, Phenergen®, Tigan®)
Phenothiazines/Dopamine antagonists (Reglan®, Phenergen®, Compazine®, Thorazine®)
Serotonin 5-HT3 antagonists (Zofran®)
Doxylamine/vitamin B6, dimenhydrinate, metoclopramide, promethazine, prochlorperazine, chlorpromazine, ondansetron, meclizine, and droperidol-diphenhydramine are commonly used medications to treat and manage NVP (read Medications – Detailed).
Current anti-nausea medications generally fall into two categories: agents directed at suppressing nausea and preventing vomiting (antiemetics) which typically act on the brain and central nervous system, and agents directed at regulating the digestive tract (prokinetics). Some medications have properties of both categories.
Women need to have a risks and benefits discussion of these various medications with their HCP. These discussions are important, as well as an overall assessment of the woman’s physical symptoms, her perception of her symptoms, and how her symptoms are affecting her quality of life. Medication regimens are therefore also individualized to each woman.
Read Medication Introduction for more information.
Mental Health
NVP can significantly affect a woman’s mental health and overall quality of life. Women tolerate nausea differently; some women can handle six weeks of nausea without much consequence, while others may break down after a week or even a day. Every woman is different, and every woman requires adequate support from her family, friends, employer, and HCP.
There are no standardized treatments or management plans for reducing anxiety, stress, or depressive symptoms in women with NVP, and current studies assessing possible strategies fall short in evidence quality. This is despite the knowledge that a reduction in these symptoms is strongly correlated with a decrease in the physical and emotional symptoms of the condition.
Women should talk to their HCP regarding their mood, emotional well-being, how they are coping with their symptoms, and how NVP is affecting their lives. Women also need to call their HCP immediately if they are becoming increasingly anxious, overwhelmed, helpless, and/or depressed.
Read more information on Mental Health Management and NVP.
Combination of Strategies
Medical management of NVP focuses strictly on symptom control and the avoidance of dehydration and other serious complications. While this is a necessary aspect of managing NVP, women may need to find additional, complimentary management strategies to handle their additional symptoms – at the same time.
The most important thing that women can do is keep an open mind. Women should not immediately dismiss a management strategy; it can be hard to determine what may actually work unless a woman gives it a try (i.e. ASMR, coloring books, knitting).
Additionally, some women may have nausea, vomiting, and other symptoms for the long haul; methods that worked during week 6 may no longer work during week 9. Women should have the largest tool box they can, with as many options as possible, as prepared and ready as possible, and always available.
For example, different “formulas” may be:
Eating/drinking strategies + distraction techniques + sleeping changes + acupressure + counseling
Eating small meals constantly + B6 + ginger + music + 2 to 3 showers a day
Avoiding hot meals + antacids + frozen yogurt and dry cereal + journaling
Women need to find the formula that works best for them, with the understanding it may need to be adjusted or changed as symptoms either progress or subside.
Women should consider sharing their NVP experience (below), especially how they felt, how long it lasted, what may have caused or contributed to their symptoms, and anything they did that relieved symptoms, even if only temporarily.
When Nothing Works
It is entirely possible, that despite women educating themselves, identifying a plan, implementing that plan, and talking with their HCP – that no matter what they eat, drink, take, or do, symptoms are still severe.
If women have engaged their HCP from the beginning, this is where it could pay off further. The HCP already knows her history, what she has tried, what she has been prescribed, and the HCP also has a better understanding of her as an individual.
The HCP can quickly determine the additional medical assistance she may need. Lab work, weight, urine tests, and possible imaging may be required to rule out other possibilities for her severe nausea and vomiting.
HCPs will also check her vital signs and dehydration, assess her mental and emotional health, and determine a path forward. There are additional medical options available for women to control their symptoms, should benefits outweigh possible risks.
Partners/Support
Pregnant women should not have to manage their NVP alone. Based on current research as described above and on individual pages, the earlier a woman starts managing her symptoms, and the earlier her family can engage and participate in this process, the better likelihood of success. Even women with severe NVP can manage her symptoms much more effectively if she has the support of her family and friends.
Partners/family members need to learn about the condition to correct current falsehoods they may have and to better appreciate its true duration, possible severity, and just how difficult it can be to find tactics that work. NVP is not gastroenteritis (stomach bug); other than sharing nausea and vomiting as symptoms, the conditions are different and should not be treated the same.
Although some of the same methods may work in women who are vomiting (crackers, broth, water, sports drinks), partners/family members should not assume that ginger, saltines, sipping water, and eating small meals will fix the condition; it is much more complex. Further, NVP results in significantly more symptoms than just nausea and vomiting.
Partners/family members can take small actions every day that can greatly ease any burden from the pregnant woman so she can focus on her physical and mental health:
Attend prenatal appointments and learn the management plan and what the next steps are if she cannot adequately manage her symptoms and needs further help.
Learn what management strategies she prefers and which ones are most effective (learning which ones are not effective is just as important).
Help her keep track of her vitamin, supplement, or medication dosing; this can be hard for some women who are on more than one medication, falling in and out of sleep, or cannot remember if/when she took certain medications.
Help her prepare for NVP, which can occur before and during the time a woman is feeling symptoms. These are steps in which a woman can prepare her home (bathroom, bedroom, kitchen), car, physical workplace, and employer, as well as her family for what NVP could look like, and what she may require in each location to help her manage symptoms effectively.
Partners should read the management pages located in the NVP category of this site; there are sections at the bottom of each page specifically for partners/family members and friends to help promote better team support for everyone who may be affected by NVP.
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)
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)