Symptoms and Complications
Nausea and Vomiting of Pregnancy (NVP) is more encompassing than nausea and vomiting. These two symptoms can lead to additional symptoms and complications such as extreme fatigue, dehydration, acid reflux, headaches, dental issues, trouble sleeping, weight loss, malnutrition, electrolyte imbalances, and hospitalization, as well as anxiety and depression.
NVP also occurs simultaneously with other uncomfortable early pregnancy symptoms and management of NVP needs to consider all these symptoms. This is why unmanaged NVP can sometimes spiral quickly, leaving women feeling that no matter what they do, nothing works.
Due to a lack of a single most optimal management method for all women, the most important aspect of managing NVP is avoiding complications. Once complications start to occur, they can progress quickly. Women need to get help/assistance from their health care provider (HCP) as soon as they start to feel symptoms so they can come up with a plan (read more).
Background
While NVP is mostly defined by the presence of nausea and vomiting, when left unmanaged, these two symptoms can lead to many more. Further, depending on severity, NVP can cause certain complications that may require immediate medical care. These complications can also worsen nausea and vomiting, stranding women in an endless cycle of feeling sick.
The main goal of managing NVP is to prevent complications. Women need to talk to their HCP about their NVP, any problems the condition is causing, and any other symptoms they may be experiencing. NVP can progress quickly, and women need to feel comfortable managing their symptoms well before NVP peaks.
The main symptom of NVP is nausea, which can range in severity from mild to utterly debilitating. It can completely drain women – physically and mentally – especially if they get very little reprieve.
Although officially labeled as “self-limiting”, nausea can affect every aspect of a woman’s life during early pregnancy. Most individuals report that nausea is more common, more disabling, feels worse, and lasts longer than vomiting. Additionally, nausea is much more difficult to treat than vomiting.
Nausea during NVP can be constant, as well as sudden, triggered by smells, sights, textures, temperatures, and movement. During early pregnancy, stimuli that initiate the nausea and vomiting processes are incredibly sensitive, and it does not take much to suddenly feel or become ill without warning.
Physical: Mild-to-Moderate
Other than nausea and vomiting, women can experience mild-to-moderate constipation, acid reflux, headache, and weight loss as a result of NVP in early pregnancy.
Women with constant nausea tend to eat higher-carbohydrate foods and have a harder time staying adequately hydrated, both of which can lead to constipation – which already has an increased prevalence during pregnancy.
Constipation can also worsen nausea, bloating, and overall discomfort, which can be an endless cycle. While there are dietary changes that can help, as well as stool softeners as recommended by an HCP, fibrous foods can be hard to eat and stool softeners can be difficult to swallow with NVP, leaving women with less than ideal options.
Acid reflux can be both a cause and symptom of NVP, as reflux can cause nausea and vomiting, and NVP can cause acid reflux.
At least one study has shown that women with both NVP and heartburn and/or acid reflux had more severe nausea and vomiting than women without heartburn or acid reflux.
Additional studies have shown that some women experience significant relief while taking antacids in early pregnancy because their NVP appears to be aggravated by, or even completely caused by, acid reflux.
Fortunately, there are several safe and tolerable options during pregnancy to manage acid reflux, to include in the first trimester (read Heartburn/Acid Reflux), therefore women should discuss these options with their HCP.
Headache in the first trimester in respect to NVP is assessed to be triggered by vomiting, dehydration, fatigue, stress, tension, and/or a lack of food.
Adequate rest, hydration, nutrition, and sleep are critical for preventing headaches in early pregnancy and improving daily function. Women should aim to stay hydrated as much as possible when fighting NVP. This first step can help improve fatigue, headache, and dehydration which can all exacerbate nausea. Further, focusing on dehydration alone may help women feel better enough to eat more (read Drinking).
NVP can also lead to weight loss for some women. Weight loss can be mild, moderate, or severe. While weight loss with NVP is normal and expected in some cases, severe NVP can lead to weight loss significant enough to potentially lead to hospitalization or a diagnosis of HG (more below).
Women may consider monitoring their weight at least weekly, possibly daily if recommended by an HCP. This may allow for earlier recognition and management.
Physical: Moderate
Although severities of these symptoms can overlap, moderate symptoms from NVP can include vomiting, fatigue, lack of sleep, and an increased risk of urinary tract infections.
Vomiting is a very well known symptom of early pregnancy, although not all women with NVP will vomit. For those who do experience this symptom, it can be mild, moderate, or severe, and the more severe, the higher the risk for complications.
Vomiting can increase the risk of dehydration, weight loss, electrolyte imbalance, fatigue, acid reflux, dental issues, and many other complications, to include a significant detriment to mental health.
It is very important that women see their HCP as soon as they start vomiting, especially in case this symptom gets worse. Research indicates that early management can prevent more serious complications.
Fatigue is a very common early pregnancy symptom and can be more extreme in women suffering with NVP at the same time. Further, fatigue has been shown to dramatically worsen nausea, and severe nausea worsens fatigue, which significantly affects a woman’s ability to manage either symptom (also leading to an endless cycle).
It is critical for pregnant women to try their best to obtain adequate hydration/fluids to avoid a cumulative effect of nausea, vomiting, dehydration, and fatigue; women can feel so much worse if these symptoms are allowed to compound.
At least one study showed that when left unmanaged, NVP and fatigue together may be associated with depressive symptoms.
NVP can also lead to trouble sleeping, especially in women experiencing evening/overnight nausea and vomiting. Further, a lack of sleep causes complications by itself, and can make daytime functioning impossible – which weakens a woman’s ability to manage/control her nausea during the day.
Women need to talk to their HCP if they are losing a significant of sleep in the first trimester. HCPs can help women manage all symptoms that could be preventing them from getting adequate sleep (read Sleep and Rest/NVP).
Women may also experience a urinary tract infection (UTI) early in pregnancy. A UTI is an infection of the urinary tract (bladder, kidneys) due to the presence of bacteria in the urine. UTIs can be common during the first trimester/NVP as a result of dehydration.
UTIs are often asymptomatic during pregnancy, so HCPs generally screen for them with a urine test in the first trimester. UTIs can lead to very serious complications during pregnancy if they are not treated (read more).
Dental issues can also occur due to NVP. Acid reflux and frequent vomiting can lead to tooth erosion, mostly affecting the upper incisors and canines.
Further, since most women with NVP turn to carbohydrates or simple sugars for energy/nutrition, this can further decay teeth if proper dental hygiene is not performed. This can be difficult for some women, however, as even a toothbrush can trigger nausea/vomiting.
It is recommended women see a dentist for regular cleanings during pregnancy, to include the first trimester – especially in women with NVP. If women inform their dentist they are pregnant and suffering from nausea, the dentist can be extremely sensitive to the woman's gag reflex, sense of smell, and overall comfort.
Physical: Severe
If nausea and vomiting are severe, the first major risk is dehydration. Dehydration can be caused by either nausea or vomiting if women do not replace fluids quickly or adequately enough.
Severe dehydration during pregnancy is a medical emergency and requires immediate medical attention. Women should call their HCP if they experience any signs of dehydration or are unable to keep any fluids down.
Potassium: Symptoms of low potassium (hypokalemia) include fatigue, abdominal pain, cramps, constipation, and muscle weakness. Severe hypokalemia is life threatening; it can cause increased urination, decreased brain function, high blood sugar levels, muscle paralysis, difficulty breathing, and irregular heartbeat that can be fatal.
Sugar (glucose): If the body does not have enough glucose through food, the body switches to burning fat, which raises the level of ketones in the blood. High levels of ketones can be very serious during pregnancy and is most often seen in women with Hyperemesis Gravidarum.
Thiamin: Persistent vomiting can lead to thiamin deficiency (as well as other nutrients) in a matter of weeks, causing Wernicke’s Encephalopathy (WE) and other serious health problems (reversed with thiamin supplementation).
Severe NVP and the presence of the above signs and symptoms can lead to a diagnosis of Hyperemesis Gravidarum. While there is no consistent definition, it is most indicated in women with three episodes of vomiting per day accompanied by ketones in the urine, weight loss of more than 5% of body weight, muscle wasting, hypokalemia, malnutrition, unrelenting vomiting, and dehydration.
In the United States, more than 36,000 women are admitted to the hospital each year due to HG. Women with severe NVP but no “official” HG diagnosis may also require medical care.
HG is very difficult to manage and leads to numerous complications such as those described above, and generally requires medical care in a hospital, sometimes leading to several emergency department visits. Women may be treated with intravenous fluids, electrolytes, and antiemetics. Serious cases may require enteral (nasal gastric tube) or total parenteral nutrition.
Read Hyperemesis Gravidarum for more detailed information regarding complications specific to HG.
Lack of Recognition
A lack of recognition of the condition by friends/family and even HCPs is an unnecessary complication of NVP. A lack of recognition generally means a lack of support, which worsens women's' physical, mental, and emotional symptoms.
Everyone knows what nausea and vomiting feels like, but not many understand these symptoms when they last for weeks or begin to interrupt the daily lives of others for longer than expected. Women can then feel alone, left to figure out management by themselves, trying not to be a burden to anyone else.
It can feel impossible trying to explain to loved ones what it feels like to be nauseated all the time. Family members with no experience with this condition can lose patience and expect women to feel completely better by the 12-week mark.
Women can also feel the same way regarding their HCP possibly trivializing their concerns and/or the severity of their symptoms. The American College of Obstetricians and Gynecologists stated as much in their 2015 NVP guidelines, stating that HCPs should not underestimate nausea and vomiting simply because it is common during pregnancy.
Even mild cases need recognition from family and HCPs; women with mild NVP have reported experiencing the same psychosocial problems as women with severe symptoms. HCPs should also recognize that although there is clinical severity (weight loss, dehydration), a woman’s perception of the severity should also be considered when management options are discussed. Very minimal weight loss or a lack of other clinical signs does not mean she is coping well.
Partners and family members of women with NVP need to understand NVP is a verifiable, real illness associated with pregnancy that has real symptoms and real effects on their lives. Prior thought and publications that minimized NVP were a detriment to the mainstream recognition of this condition, forcing many women to manage their symptoms alone, even still today.
Mental Health
Mental health concerns occur as a direct result of NVP; they are not the cause of NVP.
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 of even a day.
The effect of NVP on a woman’s quality of life depends on her support system, her employer, whether she takes care of other family members, her day-to-day responsibilities, as well as the severity of her symptoms and many other factors.
Fighting nausea weeks on end is physically draining, mentally challenging, and utterly stressful when relationships become strained during the process. Even when there is whole and complete understanding among family and friends, frustration can occur when no one knows what to do or how to help.
Additionally, overall, NVP can be traumatic, leading some women to experience posttraumatic stress symptoms, as well as signs of anxiety and depression, sometimes years later. Some studies have reached this conclusion even with mild and moderate cases. A lack of recognition can compound these issues.
Current/Future Pregnancies
NVP is often indicated as a “self-limiting” condition, a condition that is essentially limited only by the action of the individual; it will eventually go away on its own, with no lasting ill-effects. However, this definition cannot apply when NVP effects are felt years later (as stated above), when NVP ends a current pregnancy, or when NVP prevents a pregnancy in the future.
Numerous studies and reviews have indicated women with NVP considered termination or have terminated a wanted pregnancy due to the extreme severity of their symptoms. Further, women have also decided against a future pregnancy for the same reason. These consequences are life-changing and life-lasting, and illustrate the important of sincere recognition and aggressive management by family, friends, and HCPs.
Action
The most important aspect of managing NVP is avoiding complications. Once complications start to occur, they can progress quickly. Women need to get help/assistance from their HCP as soon as they start to feel symptoms (read more) to get in front of any potential complications that could get too difficult to manage later on.
In addition, women should call their HCP immediately or seek emergency care if they:
Experience severe nausea, vomiting, abdominal pain, and/or weight loss
See blood in vomit, which could be red or black
Cannot keep fluids down; experience symptoms of dehydration (above)
Pass only a small amount of urine or urine is a dark color
Have a fever
Have a rapid heart rate
Experience dizziness, faintness, tiredness, or confusion
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.
This can be a very difficult few weeks/months for women. Reading experiences of other women can help them better mentally cope and manage their symptoms and teach them to be a better advocate for themselves at home, at work, and at their HCP's office.
Partners/Support
Partners/support of pregnant women should understand that although nausea and vomiting are the most commonly recognized symptoms of NVP, other symptoms can also manifest as complications of those symptoms, such as dehydration, fatigue, headaches, loss of sleep, dizziness, faintness, and lethargy. Further, though nausea is "invisible" in comparison to vomiting, in many cases it can be much worse on the woman.
Partners can play a major role in the prevention of these additional symptoms and possible complications by offering positive emotional and psychological support, as well as lessening any daily burden she has, so she can focus on coping and managing her current symptoms – and preventing them from getting worse.
Partners should also learn to recognize the signs of complications described above, as some of them require immediate medical care; it is completely possible that partners will recognize these signs well before pregnant women.
Partners should also read:
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)
Problems of the Digestive System (American College of Obstetricians and Gynecologists)
Screening for Perinatal Depression: Committee Opinion 757 (American College of Obstetricians and Gynecologists)