Nausea and Vomiting: Treatment Options
There is a close association between the level of nausea and vomiting that you will experience and your level of tiredness. You should endeavour to rest as much as is practicable, although this may be quite difficult if you are working or have young children. Nevertheless, your symptoms will generally improve with increasing rest.
A well balanced and healthy diet, particularly avoiding fatty foods, will help. The mainstay of dietary modification is switching from the traditional pattern of eating three meals per day to eating multiple small meals. You should generally not go more than three to four hours without having something to eat.
This “grazing” may involve continuously nibbling away at fresh fruit, dried fruit or dried biscuits or alternatively having five to six meals a day with a three to four hour interval. Over the years I have heard a multitude of different dietary suggestions and you should feel free to try any of them. Suggestions include abolishing either or both dairy and wheat products from your diet and replacing them with rice and soya based products.
The “wet and dry” diet is popular. This involves alternating wet and dry foods. For example, toast for breakfast, a milkshake for morning tea, a sandwich for lunch, soup for afternoon tea, a normal dinner and then another milkshake before bed. Feel free to try anything that works for you.
Vitamin B6 (Pyriodoxine) has been the mainstay of treatment of nausea in early pregnancy for decades. It is extremely safe but has been improved recently with the introduction of Blackmore’s Morning Sickness Formula. This combines Vitamin B6 with a ginger extract.
The combination works better than either Vitamin B6 or ginger alone. If you cannot tolerate swallowing the tablets then they are equally effective if you suck them. Please note that these are quite a different preparation to Blackmore’s Pregnancy and Breastfeeding Formula.
Acupuncture is wonderful for nausea and vomiting in pregnancy. Provided you have no contraindications to having acupuncture (this would include having hepatitis B or C, taking drugs to thin your blood or having a bleeding disorder) then acupuncture is to be strongly recommended.
I can put you in contact with several excellent acupuncturists or alternatively you may locate an acupuncturist locally. Your General Practitioner may practise acupuncture. There is a range of other complementary therapies including aromatherapy, acupressure and Chinese herbal medicine, which you may find helpful.
If the alternatives above have not been of assistance then I may recommend that you take conventional medication. It is important to understand how drugs are classified according to their safety in pregnancy. In Australia drugs are categorised as A, B, C, D or X according to their safety in pregnancy.
Category A drugs have been taken by a large number of pregnant women for many years with no evidence of any adverse effects on the fetus ever having been reported.
Category B drugs, likewise, have never been shown to have any adverse effects but have only been taken by a limited number of pregnant women.
Category C drugs have been known to have effects on the fetus but these are not necessarily effects that may be harmful nor particularly relevant during the first trimester. For instance, it is best to avoid sleeping tablets late in the third trimester but they have no effects in the first trimester and therefore are safe to take.
Category D and Category X drugs are known to cause fetal malformations and must never be taken in pregnancy.
You can be assured that if I ever prescribe a drug for the treatment of any condition in pregnancy that I am perfectly comfortable with it’s safety. I will never prescribe a category D or X medication; almost always I will prescribe Category A and sometimes Category B drugs. If I ever prescribe a Category C drug I will explain why it is safe for you to use at that time but not safe to use later in pregnancy.
Nevertheless, I understand that there is a great reluctance for any women to take any medication in pregnancy and this is completely understandable. However, there are times when the benefits of taking medication outweighs any potential risk but it is always up to you.
METOCLOPRAMIDE (CATEGORY A)
This is frequently prescribed under the trade names of Maxolon and Pramin. This is a medication that needs to be taken three to four times a day and is best taken 30 minutes before you plan to eat.
It is not uncommon to feel drowsy with Metoclopramide. You should stop using it immediately if you feel agitated or unusual while you are taking it.
ANTIHISTAMINES (CATEGORY A, B, C)
A variety of antihistamines have been recommended including Promethazine, Chlorpheniramine, Cyclizine, Cyproheptadine, Doxylamine and others. They have long been used very safely in pregnancy and are generally all either category A or B medication.
Promethazine is a category C medication only because of its potential sedative effects on the infant so it should be avoided in the third trimester.
Antihistamines are widely used but are generally very sedating and will make it difficult for you to function normally.
The most effective antihistamine is Restavit (Doxylamine). This is a category A medication that is particularly sedating. It is ideally taken at bedtime to allow a good night’s sleep.
PREDNISOLONE (CATEGORY A)
Recent evidence has suggested that the use of high dose steroid therapy is effective for women who have intractable nausea and vomiting in pregnancy. This is reserved for the most severe forms of vomiting in pregnancy that would otherwise require long term hospitalisation.
Prednisolone is a steroid (not the type that causes your voice to deepen and build muscle bulk) that will make you more prone to easy bruising, contracting infections, weight gain, increased appetite, bloating and insomnia. These are significant side effects that must not be disregarded. It is also not possible to simply discontinue treatment immeditately if it is ineffective.
Treatment needs to be weaned over many weeks and so commencing Prednisolone is a long term commitment. However, it is remarkably effective at stopping the intractable vomiting that sometimes occurs and, if I do prescribe it, you can be assured that it is the most appropriate form of therapy for you in your circumstances.
PROCHLOROPERAZINE (CATEGORY C)
This is generally provided under the trade name of Stemetil. It can be given as tablets or suppositories. It is generally taken three to four times a day in tablet form or once or twice a day in suppository form. It tends to be more sedative than Metoclopramide and again you should stop it immediately if you feel agitated while taking it.
Prochloroperazine is given a category C medication only in relation to its use during the third trimester when it can cause irritability to your baby after delivery. It has no adverse effects during the first or second trimester and can be used very safely.
ONDANSETRON (CATEGORY B)
This is often provided under the trade name of Zofran. It is available in tablet or wafer form. Ondansetron is very expensive and there is no rebate available from the government to reduce the expense.
I generally suggest the best form to buy it in is in the 8mg wafer form as these can be broken in half and sometimes half again to provide effective relief at a fraction of the cost. The wafers also have the advantage that they can be used even if you are vomiting because they can be placed under the tongue and absorbed effectively that way, eliminating worries about whether or not you have vomited the tablet.
Ondansetron should be reserved for severe vomiting that is resistant to all other forms of therapy. This is because of its cost and the more limited experience in relation to Maxolon or Stemetil. However, if I recommend it to you, you can be certain I am comfortable with its safety and that your symptoms are so severe that treatment with Odansetron is needed in order to reduce the risks of miscarrying your pregnancy.
HOSPITALISATION AND INTRAVENOUS FLUID THERAPY
If treatment with tablets and wafers is ineffective then it is usual for me to admit you to our Pregnancy Day Care Centre for intravenous rehydration. You will be surprised how much fluid is required to rehydrate you when you have had significant vomiting.
Some women need to attend Day Care on an almost daily basis for some period of time before the symptoms are brought under control. If intravenous fluid therapy is required then many of the medications listed above can be given through the drip initially and then given orally or in wafer form after discharge. Some women find that daily visits to the Day Care Centre are too disruptive and prefer long term hospitalisation.
This is very rare and you may find that after a few visits to Day Care the frequency of visits can be reduced and a visit once a month or twice a week for a “top up” is all that is necessary.