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Pregnancy Women's health

Nausea/vomiting in pregnancy

Last revised in May 2026

The majority of women vomit or feel nauseated in early pregnancy. Symptoms usually begin between the fourth and seventh weeks of gestation

Nausea/vomiting in pregnancy: Summary

Nausea and vomiting in pregnancy is usually diagnosed in the first trimester and other causes have been excluded.
- It usually begins between 4–7th weeks, peaks between 9–16th weeks, and resolves by 16–20 weeks of pregnancy. Onset of symptoms after 11 weeks of gestation usually suggests an alternative cause of symptoms unrelated to pregnancy.
Hyperemesis gravidarum describes the most severe spectrum of symptoms — nausea and/or vomiting which is severe enough to cause an inability to eat and drink normally, and strongly limits daily activities of living. Signs of dehydration contribute to the diagnosis.
Risk factors for nausea and vomiting include increased placental mass (molar gestation, multiple pregnancy); first pregnancy; history of hyperemesis gravidarum; family history of nausea and vomiting in pregnancy or hyperemesis gravidarum; and obesity.
Possible maternal complications if there are severe symptoms include weight loss, electrolyte imbalance, acute kidney injury, nutritional and vitamin deficiencies, gastro-oesophageal reflux disease, venous thromboembolism, and impact on psychosocial functioning.
Possible fetal complications if there is hyperemesis gravidarum include preterm delivery, low birthweight, and small-for-gestational age.
Assessment of a woman with nausea and vomiting in pregnancy includes:
- Asking about the onset, duration, severity, and frequency of symptoms; impact on psychosocial functioning; additional symptoms; risk factors; medications; and co-morbidities.
- Considering use of a validated questionnaire to assess symptom severity.
- Examination to assess for dehydration, weight loss, signs of an alternative cause or complication.
- Considering additional investigations, if there are severe symptoms or a suspected underlying cause, depending on clinical judgement.
Management of nausea and vomiting in pregnancy includes:
- Advising on sources of information and support.
- Reassurance that mild-to-moderate symptoms are common and can be treated.
- Advising on self-care measures such as dietary and lifestyle modification.
- Avoiding any contributory medications, depending on clinical judgement.
- Advising on when to seek urgent medical review.
- Advising on first, second, and third-line drug treatments available, depending on symptom severity, previous treatments, and the woman's wishes.
Hospital admission or referral should be considered if the woman has moderate-to-severe symptoms and:
- There is a defined complication or suspected complication.
- A risk score above threshold.
- Persistent symptoms despite primary care management.
- Is unable to tolerate oral antiemetics or oral fluids.
- Is unable to tolerate other necessary oral medication.
- Clinical dehydration.
- Weight loss of greater than 5% of body weight.
- Co-morbidities where there is an inability to take medications.
- Concerns regarding mental health.

Have I got the right topic?

From age 13 years to 60 years (Female).

This CKS topic covers the primary care management of nausea and vomiting in pregnancy, including hyperemesis gravidarum.

This CKS topic does not cover other causes of nausea and vomiting (obstetric and non-obstetric), or dyspepsia during pregnancy.

There is a separate CKS topic on Dyspepsia - pregnancy-associated.

The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary healthcare.

How up-to-date is this topic?

Changes

May 2026 — minor update. A typographical error has been corrected.

Previous changes

November 2025 — minor update. A typographical error has been corrected.

July 2025 — minor update. Further information added regarding the duration of treatment for ondansetron and metoclopramide in people with hyperemesis gravidarum, where experience in secondary care indicates usage for over 20 weeks of treatment with these medications.

April 2025 — minor update. Detail about the absolute risk of oral clefting with ondansetron use in the first trimester has been added to the basis for recommendation of the treatment section of this topic as well as RCOG advice that its use should not be discouraged if first line antiemetics are ineffective.

February 2025 — minor update. Further alignment with the RCOG guideline 2024. Removed broken link and the recommendation on the use of ginger.

January 2025 — minor update. The definition of hyperemesis gravidarum has been updated in line with RCOG, 2024 Guideline The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No.69). Information that growth differentiation factor 15 (GDF15) is a possible cause of hyperemesis gravidarum, and that hyperemesis gravidarum is associated with a higher risk of termination of pregnancy have also been added to this topic.

February 2024 — minor update. Topic updated to include recommendations from the RCOG, 2024 Guideline The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No.69).

In detail, these changes include:

The removal of the recommendation to check for the presence of ketones in the assessment of a woman with nausea and vomiting in pregnancy, as ketonuria is not a reliable indicator of the severity of the condition.
Addition of the Hyperemesis level prediction score (HELP) to the assessment section.
Added advice about the need for many women to have a combination of antiemetic drug treatments.
Addition of a third-line treatment of oral prednisolone.
Changes to the criteria for referral to secondary care.

December 2023 — minor update. Adverse effects of domperidone updated in line with updated SPC.

December 2022 — minor update. Added information relating to phenothiazine derivatives potentiating QT interval prolongation based on an updated manufacturer’s SPC.

December 2021 — reviewed. A literature search was conducted in November 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials (RCTs) published since the last revision of the topic. The recommendations have been updated in line with the National Institute for Health and Care Excellence (NICE) guidance Antenatal care (NICE 2021) and other current evidence in the literature. The definition of hyperemesis gravidarum has been amended, as ketonuria is no longer required to make the diagnosis, in line with the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guideline The management of nausea and vomiting of pregnancy and hyperemesis gravidarum (2016). In the Management Scenario, the Drug treatments section has been amended to include chlorpromazine as an option in line with NICE 2021 and RCOG 2016 guidance, and doxylamine with pyridoxine as an option, in line with NICE 2021 guidance. The Prescribing information section has been amended accordingly.

April 2021 — minor update. Domperidone has been added as a second-line treatment option and prescribing information has been added.

November 2020 — minor update. Restless legs syndrome added as an adverse effect of promethazine in line with the updated manufacturer's Summary of Product Characteristics (SPC).

February 2020 — minor update. Prescribing information for ondansetron has been added with information that exposure to ondansetron during the first trimester of pregnancy is associated with a small increased risk of the baby having a cleft lip and/or cleft palate.

October 2018 — minor update. New product Xonvea 10 mg/10 mg (doxylamine succinate/pyridoxine hydrochloride) gastro-resistant tablets added to new product availability as now licenced for the treatment of nausea and vomiting in pregnancy.

May to June 2017 — reviewed. A literature search was conducted in April 2017 to identify evidence-based guidelines, UK policy, systematic reviews, key randomized controlled trials (RCTs), and observational studies published since the last revision of the topic. New recommendations include considering use of a validated questionnaire to assess the severity of nausea and vomiting of pregnancy; considering avoiding iron-containing preparations if they are exacerbating symptoms; and offering support in the form of self-help and support groups. There have been minor changes to the sections on when to admit or seek specialist advice; offering advice; and choice of antiemetic (the order of preference of antiemetic use). More detailed prescribing information has also been included.

September 2013 — minor update to the text to reflect current European Medicines Agency (EMA) recommendations regarding metoclopramide.

January to June 2013 — reviewed. A literature search was conducted in December 2012 to identify evidence-based guidelines, UK policy, systematic reviews, key RCTs, and observational studies published since the last revision of the topic. There is one change to the recommendations as ondansetron is now recommended as a second-line anti-emetic.

August 2012 — minor update. Minor typographical error corrected.

March 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

December 2008 — update to text regarding the use of ginger and acupressure during pregnancy. These are now recommended by the National Institute for Health and Clinical Excellence (NICE).

August 2008 — minor update to text regarding the safety of promethazine in pregnancy.

February to May 2008 — converted from CKS guidance to CKS topic structure. The evidence base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. There are no major changes to the recommendations.

November 2005 — minor technical update.

March 2005 — reviewed. Validated in June 2005 and issued in July 2005.

December 2001 — reviewed. Validated in March 2002 and issued in April 2002.

January 1999 — written, replacing the guidance on Hyperemesis of pregnancy. Validated in March 1999 and issued in August 1999.

Update

New evidence

Evidence-based guidelines

RCOG, 2024 The Management of Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum [Free full-text]

HTAs (Health Technology Assessments)

No new HTAs since 1 December 2021.

Economic appraisals

No new economic appraisals relevant to England since 1 December 2021.

Systematic reviews and meta-analyses

No new systematic review and meta-analyses since 1 December 2021.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 December 2021.

New policies

No new policies since 1 December 2021.

New safety alerts

No new safety alerts since 1 December 2021.

Changes in product availability

No changes in product availability since 1 December 2021.

Goals and outcome measures

Goals

To support primary healthcare professionals to:

Reassure the woman that mild-to-moderate nausea and vomiting is common in pregnancy, but treatments are available.
Provide advice on self-help symptom relief measures for nausea and vomiting.
Offer antiemetic drug treatment in primary care if symptoms are severe or not responding to self-help measures.
Arrange urgent hospital admission or seek specialist advice if symptoms are severe, refractory to treatment in primary care, or a serious complication is suspected.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

Background information

What is it?

Nausea and vomiting in pregnancy can be diagnosed when onset is in the first trimester and other causes of symptoms have been excluded [Nelson-Piercy, 2024a].
- It usually begins between 4–7th weeks, peaks between 9–16th weeks, and resolves by 16–20 weeks of pregnancy [NICE, 2021; Nelson-Piercy, 2024a]
- Note: onset of symptoms after 11 weeks of gestation usually suggests an alternative cause of symptoms unrelated to pregnancy [Nelson-Piercy, 2024a].
- It is commonly referred to as 'morning sickness', but symptoms can occur at any time during the day [Jarvis and Nelson-Piercy, 2011].
Hyperemesis gravidarum describes the most severe spectrum of symptoms — nausea and/or vomiting which is severe enough to cause an inability to eat and drink normally, and strongly limits daily activities of living. Signs of dehydration contribute to the diagnosis [Nelson-Piercy, 2024a].

How common is it?

The reported prevalence of nausea and vomiting in pregnancy varies due to different diagnostic criteria used and populations studied in the literature.

A meta-analysis of global data from 79 studies of nausea and vomiting in pregnancy (n = 93,753) and hyperemesis gravidarum (n = 6,155,578) found [Einarson, 2013]:
- Reported rates of nausea and vomiting in pregnancy ranged from 35–91% (average rate 69.4%). Of these, 32.7% had nausea without vomiting, and 23.5% had symptoms continuing into the third trimester.
- Symptoms were rated as mild in 40%, moderate in 46%, and severe in 14% of women.
- The prevalence of hyperemesis gravidarum ranged from 0.3–3.6%, with an average rate of 1.1%.
A UK population-based pregnancy cohort study (1998–2014) using the Clinical Practice Research Datalink primary care database (n = 417,028 pregnancies) found [Fiaschi, 2019]:
- The overall prevalence of clinically recorded nausea and vomiting in pregnancy and hyperemesis gravidarum was 9.1%.
- 2.1% of participants were admitted to hospital.
- Hospital admissions and antiemetic prescribing rates increased during the study period.
A UK prospective study of nausea and vomiting during pregnancy found that of the 266 pregnant women studied [Gadsby, 1993]:
- Around half had both nausea and vomiting.
- Around 28% had nausea without vomiting.

What causes it?

The exact cause of nausea and vomiting in pregnancy is uncertain, but it is likely to be multifactorial [Bustos et al, 2017]. Possible causative mechanisms include:

Growth differentiation factor 15 (GDF15) [Nelson-Piercy, 2024a]
- Both human chorionic gonadotropin (hCG) and GDF15 are made when genes in the placenta are activated and circulating levels have a peak in the first half of pregnancy, but no genetic variants in hCG have been identified (even in very large studies) to be associated with hyperemesis gravidarum.
- Higher circulating levels of GDF15, but not hCG were found in hospitalised hyperemesis gravidarum patients, patients taking medication for nausea and vomiting in pregnancy, and patients with 2nd trimester vomiting; hCG is therefore unlikely to be causative.
- Genetic variants associated with expression of GDF15 in families with hyperemesis gravidarum have been identified as the greatest genetic risk factor for hyperemesis gravidarum and are associated with recurrence in subsequent pregnancies.
Oestrogen [ACOG, 2018]
- Nausea and vomiting in pregnancy are more common when estradiol levels are increased. When levels are decreased, nausea and vomiting are less common.
Evolutionary adaptation [ACOG, 2018]
- It has been suggested that nausea and vomiting are a mechanism to prevent the woman eating potentially harmful foods.
Gastric dysfunction [Bustos et al, 2017]
- In pregnant women, oesophageal, gastric, and small bowel motility are impaired because of smooth muscle relaxation due to increased levels of progesterone. Delayed gastric emptying in pregnancy may also contribute to nausea and vomiting.

What are the risk factors?

Possible factors associated with the development of nausea and vomiting in pregnancy include:

Increased placental mass (for example advanced molar gestation, multiple pregnancy) [ACOG, 2018; Nelson-Piercy, 2024a].
First pregnancy [Abramowitz, 2017].
History of hyperemesis gravidarum in a previous pregnancy [Bustos et al, 2017; ACOG, 2018; Nelson-Piercy, 2024a].
History of motion sickness [ACOG, 2018].
History of migraines [ACOG, 2018].
Family history (first-degree relative with nausea and vomiting in pregnancy) [Bustos et al, 2017; ACOG, 2018].
History of nausea with oestrogen-containing oral contraceptives [ACOG, 2018].
Obesity [Abramowitz, 2017].
Chronic Helicobacter pylori infection (may be associated with an increased risk and severity of hyperemesis gravidarum, based on mixed, conflicted evidence) [ACOG, 2018; Fejzo, 2019; Nelson-Piercy, 2024a].

What are the complications?

Maternal and fetal complications are more likely to occur in women with severe vomiting or hyperemesis gravidarum [ACOG, 2018]. Hyperemesis gravidarum can last for the entire pregnancy, is extremely debilitating and can result in life-threatening physical complications.

Maternal complications
- Metabolic [Abramowitz, 2017] [ACOG, 2018] [Austin, 2019] [Nelson-Piercy, 2024a]
  - Weight loss.
  - Dehydration.
  - Electrolyte imbalance — such as hyponatraemia, hypokalaemia, or metabolic hypochloraemic alkalosis (if severe, metabolic acidaemia can occur).
  - Acute kidney injury. See the CKS topic on Acute kidney injury for more information.
  - Abnormal liver function tests — may be secondary to hypovolaemia, malnutrition, and lactic acidosis.
  - Nutritional and vitamin deficiencies — vitamin B₆ and vitamin B₁₂ deficiency may cause peripheral neuropathy; vitamin B₁ (thiamine) deficiency may cause potentially life-threatening Wernicke's encephalopathy (may present with blurred vision, unsteadiness, confusion, drowsiness, and cause permanent neurological deficit).
- Mechanical [ACOG, 2018] [Austin, 2019] [Nelson-Piercy, 2024a]
  - Gastro-oesophageal reflux disease, oesophagitis, or gastritis. See the CKS topic on Dyspepsia - pregnancy associated for more information.
  - Retinal haemorrhage.
  - Splenic avulsion.
  - Mallory-Weiss tears or oesophageal rupture.
  - Pneumothorax or pneumomediastinum.
- Other [ACOG, 2018] [Dean, 2018] [Austin, 2019] [Fejzo, 2019] [Nelson-Piercy, 2024a]
  - Venous thromboembolism — women with hyperemesis gravidarum in combination with associated immobility and dehydration are at increased risk. One third of first trimester deaths have been attributed to hyperemesis gravidarum. See the CKS topics on Deep vein thrombosis and Pulmonary embolism for more information.
  - Fatigue. See the CKS topic on Tiredness/fatigue in adults for more information.
  - Psychosocial — affected women are more at risk of depression, anxiety, emotional distress, post-traumatic stress disorder, and reduced quality of life. 5% of women with hyperemesis gravidarum opt for a termination of pregnancy of an otherwise wanted pregnancy, and 7% suffer suicidal ideation, as symptoms are so distressing. See the CKS topics on Depression - antenatal and postnatal, Generalized anxiety disorder, and Post-traumatic stress disorder for more information.
- Maternal death (very rare) [ACOG, 2018].
Fetal complications
- Women with mild-to-moderate symptoms are unlikely to have any negative impact on the fetus, and it may be a marker of healthy trophoblast development and successful pregnancy outcome [Bustos et al, 2017; ACOG, 2018; Dean, 2018].
- Women with hyperemesis gravidarum and low pregnancy weight gain are at increased risk of preterm delivery, low birthweight, and small-for-gestational age babies [Dean, 2018; Nelson-Piercy, 2024a]. There is no significant association of hyperemesis gravidarum with the development of congenital abnormalities [ACOG, 2018].
- The American College of Obstetricians and Gynecologists (ACOG) cites evidence from retrospective cohort studies that found no association between hyperemesis gravidarum and perinatal or neonatal mortality [ACOG, 2018].
Termination of pregnancy
- Hyperemesis gravidarum is associated with a higher risk of termination of pregnancy. 5% of women with hyperemesis gravidarum undergo termination of pregnancy due to the severity of symptoms, who would not otherwise have chosen to [Nelson-Piercy, 2024b].

What is the prognosis?

Mild to moderate nausea and vomiting in pregnancy usually resolves by 16–20 weeks of gestation [NICE, 2021].
- Up to 10% of women have symptoms which may persist throughout the entire pregnancy [Bustos et al, 2017].
There is a risk of recurrence in future pregnancies for women with a history of hyperemesis gravidarum [Nelson-Piercy, 2024a].
- A systematic review of five studies (one longitudinal and four population-based cohort studies) reported recurrence rates of 15–81%, but the authors noted variations in the study definitions of hyperemesis gravidarum, data collection methods, and follow-up duration, leading to clinical and statistical heterogeneity, which affected the reliability of results [Dean, 2019].

Diagnosis of nausea/vomiting in pregnancy

How should I assess a woman with symptoms?

If a woman has a suspected diagnosis of nausea and vomiting in pregnancy:

Ask about:
- The onset, duration, frequency, and severity of symptoms, including impact on oral intake.
  - Onset of symptoms after 11 weeks of gestation usually suggests an alternative or underlying cause for symptoms, unrelated to pregnancy.
  - Dehydration may be suggested by reduced or concentrated urine output.
- Sleep pattern in a 24-hour period.
- The impact on her mood and emotional wellbeing, how she is coping, support available, and impact on her daily functioning and quality of life including work, home, caring for others, and social activities.
  - See the CKS topics on Depression - antenatal and postnatal and Generalized anxiety disorder for more information.
- Additional symptoms such as weight loss, fever, urinary symptoms, headache, neurological symptoms, or abdominal pain, which may indicate an alternative cause for symptoms.
- Any predisposing or risk factors for symptoms, such as previous history, relevant surgical history (such as gastric bypass, band or sleeve) or family history.
- Any medications prescribed or taken over-the-counter, which may be causing symptoms, such as oral iron or opioids.
- Any co-morbidities such as diabetes mellitus or chronic kidney disease (CKD), where symptoms may increase the risk of complications such as diabetic ketoacidosis or acute kidney injury (AKI) respectively. See the CKS topics on Diabetes - type 1, Diabetes - type 2, Chronic kidney disease, and Acute kidney injury for more information.
Consider using a validated questionnaire to assess the severity of symptoms, such as the Pregnancy-Unique Quantification of Emesis (PUQE) or Hyperemesis level prediction (HELP) scores.
- See the section on Severity scoring for more information.
Examine the woman if symptoms are severe and/or affecting oral intake:
- Check temperature (fever may indicate an alternative cause for symptoms).
- Check blood pressure, pulse, and assess for dehydration (suggested by dry mucous membranes, tachycardia, postural hypotension).
- Check oxygen saturation and respiratory rate, for example if a complication is suspected.
- Check weight to assess for weight loss and muscle wasting.
- Perform an abdominal examination to assess for pain or tenderness (may indicate an alternative cause for symptoms).
- Check for any neurological signs such as confusion, nystagmus or ataxia which could indicate Wernicke's encephalopathy.
Assess for clinical features suggesting an alternative or underlying cause for symptoms, unrelated to pregnancy, and manage as appropriate.
- See the section on Differential diagnosis for more information.
Arrange investigations, depending on clinical judgement. Additional investigations are not needed to confirm the diagnosis if there are mild and uncomplicated symptoms.
- Arrange a mid-stream urine (MSU) sample if an underlying cause, such as urinary tract infection, (UTI) is suspected. Dipstick testing may indicate signs of a UTI. See the CKS topic on Urinary tract infection (lower) - women for more information.
- Consider arranging a pelvic ultrasound scan to identify predisposing factors (for example multiple or molar pregnancy), depending on clinical judgement and local service provision. Seek specialist advice if needed.
- Consider blood tests including: full blood count, urea and electrolytes, and blood glucose.
Reassess at 24-72 hours.

Severity scoring

Table 1 shows the Pregnancy-Unique Quantification of Emesis (PUQE) score, a validated scoring system that may be used to assess the severity of symptoms of nausea and vomiting in pregnancy.

PUQE-24 scoring system
In the last 24 hours, for how long have you felt nauseated or sick to your stomach?	Not at all (1)	1 hour or less (2)	2–3 hours (3)	4–6 hours (4)	More than 6 hours (5)
In the last 24 hours have you vomited or thrown up?	I did not throw up (1)	1-2 times (2)	3–4 times (3)	5-6 times (4)	7 or more times (5)
In the last 24 hours how many times have you had retching or dry heaves without bringing anything up?	No time (1)	1–2 times (2)	3–4 times (3)	5–6 times (4)	7 or more times (5)
Total score indicating severity of symptoms is the sum of replies to each of the three questions: mild <= 6; moderate 7–12; severe 13–15. Source: [Nelson-Piercy, 2024a]

A score of 13 or greater has been used as a criterion for admission to hospital in women with severe nausea in pregnancy.

Table 2 shows the Hyperemesis level prediction (HELP) score, which has also been validated to assess the severity of nausea and vomiting in pregnancy.


HELP scoring system
Nausea level most of the time	0	1 (Mild)	2	3 (Moderate)	4	5 (Severe)
I average _ vomiting episodes/day	0	1-2	3-5	6-8	9-12	13 or more
I retch/dry heave _ episodes daily	0	1-2	3-5	6-8	9-12	13 or more
I am urinating/voiding	Same	More often due to IV fluids or light colour	Slightly less often and normal colour	Once every 8 hours or slightly dark yellow	Less than every 8 hours or darker	Rarely, dark or bloody or foul smell
Nausea/vomiting severity 1 hour after meds or after food/drink if no meds	0 or no meds	1 (Mild)	2	3 (Moderate)	4	5 (Severe)
Average number of hours I am unable to work adequately at my job or at home due to being sick	0	1-2	3-4	5-7	8-10 (cannot care for family)	11+ (cannot care for myself)
I have been coping with the nausea, vomiting and retching	Normally	Tired but mood is ok	Slightly less than normal	It's tolerable but difficult	Struggling, moody, emotional	Poorly, irritable, depressed
Total amount I have been able to eat/drink and keep it down	Same, no weight loss	Total of about 3 meals and 6+ cups of fluid	Total of about 2 meals and some fluid	1 meal and few cups of fluid or only fluid or only food	Very little less than 1 meal/minimal fluids or frequently IV	Nothing goes or stays down, or daily IV/TPN/NG*
My antinausea meds stay down or are tolerated	No meds	Always	Nearly always	Sometimes	Rarely	Never/IV/SC pump§
My symptoms compared to last week	Great	Better	About same	Worse	Much worse	So much worse
Weight loss over last 7 days _%	0	1	2	3	4	5
Number of days treatment for nausea/vomiting	0	1	2	3	4	5+
Points (pts)	0 pts	1 pt/answer	2 pts per answer	3 pts/answer	4 pts/answer	5 pts/answer
Total each column = (#answers in column) x (#points for each answer)	0
Total for all columns	0
Source [Nelson-Piercy, 2024a] * IV = intravenous, TPN = total parental nutrition, NG = nasogastric tube § SC= subcutaneous pump

None/mild ≤19, moderate 20-32, severe 33-60.

Weight loss % = (Amount lost ÷ Pre-pregnancy weight) x 100

The HELP score has been used to inform progress with treatment in women with severe nausea in pregnancy and hyperemesis gravidarum.

Basis for recommendation

The recommendations on assessment are based on the National Institute for Health and Care Excellence (NICE) guideline Antenatal care [NICE, 2021], the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guideline The management of nausea and vomiting of pregnancy and hyperemesis gravidarum [Nelson-Piercy, 2024a], the American College of Obstetricians and Gynecologists (ACOG) practice bulletin Nausea and vomiting of pregnancy [ACOG, 2018], and expert opinion in review articles on severe nausea and vomiting in pregnancy and hyperemesis gravidarum [Dean, 2018; Austin, 2019; Fejzo, 2019].

Clinical features on history-taking

These recommendations are based on the NICE clinical guideline [NICE, 2021], the RCOG guideline [Nelson-Piercy, 2024a], the ACOG practice bulletin [ACOG, 2018], and expert opinion in a review article [Dean, 2018].
- A woman's perception of symptom severity affects decisions on whether, when, and how to treat symptoms [ACOG, 2018].

Using a validated questionnaire for symptom severity

The recommendations on using an objective and validated questionnaire are based on the RCOG guideline [Nelson-Piercy, 2024a]and the ACOG practice bulletin [ACOG, 2018].
- Using a tool such as the PUQE or HELP scores can help classify the severity of symptoms and monitor response to treatment. The RCOG recognizes that symptom severity also includes impact on quality of life as well as frequency of symptoms [Nelson-Piercy, 2024a].

Clinical features on examination

These recommendations are based on the RCOG guideline , the ACOG practice bulletin [ACOG, 2018], and expert opinion in a review article [Dean, 2018].

Assessing for an alternative or underlying cause

This recommendation is based on the RCOG guideline [Nelson-Piercy, 2024a] and the ACOG practice bulletin [ACOG, 2018]. It is also pragmatic, based on what CKS considers to be good clinical practice.

Arranging additional investigations

The recommendation that additional investigations are not needed if there are mild, uncomplicated symptoms is extrapolated from the ACOG practice bulletin [ACOG, 2018].
The recommendation to arrange a mid-stream urine (MSU) sample to check for a urinary tract infection if clinically suspected is based on expert opinion in a review article [Dean, 2018]. The RCOG guideline advises that this may only be indicated if dipstick testing indicates signs of UTI [Nelson-Piercy, 2024a].
The recommendation to consider arranging a pelvic ultrasound scan is extrapolated from the RCOG guideline [Nelson-Piercy, 2024a] and expert opinion in review articles [Dean, 2018; Austin, 2019].
The information that blood tests are not routinely needed in primary care is extrapolated from the ACOG practice bulletin [ACOG, 2018] and expert opinion in review articles [Dean, 2018; Austin, 2019; Fejzo, 2019].
- Additional tests such as bloods may be needed if there are severe or persistent symptoms to help assess clinical severity and/or to identify an underlying cause for symptoms [ACOG, 2018; Dean, 2018; Austin, 2019].
- The RCOG guideline describes the blood tests may be helpful for assessment to exclude acute kidney injury (urea and electrolytes) , exclude acute infection (full blood count) and blood glucose (to assess for diabetes mellitus) [Nelson-Piercy, 2024a]
- The RCOG guideline also advises that ketonuria is not an indicator of dehydration and should not be used to assess severity.

What else might it be?

Alternative causes for nausea and vomiting in pregnancy include:

Genitourinary — urinary tract infection, end-stage renal disease and uraemia, pyelonephritis, ovarian torsion, renal stones. See the CKS topics on Urinary tract infection (lower) - women, Chronic kidney disease, Pyelonephritis - acute, and Renal or ureteric colic - acute for more information.
Metabolic/endocrine — hypercalcaemia, hyperparathyroidism, thyrotoxicosis, diabetic ketoacidosis, Addison's disease. See the CKS topics on Hypercalcaemia, Hyperthyroidism, Diabetes - type 1, and Addison's disease for more information.
Gastrointestinal — gastritis, peptic ulcer, gastroenteritis, pancreatitis, cholecystitis, cholelithiasis, bowel obstruction, hepatitis, appendicitis. See the CKS topics on Dyspepsia - pregnancy-associated, Gastroenteritis, Pancreatitis - acute, Gallstones, Cholecystitis - acute, Hepatitis A, and Appendicitis for more information.
Neurological — vestibular disease, migraine, central nervous system tumours. See the CKS topics on Otitis media - acute, Benign paroxysmal positional vertigo, Migraine, and Brain and central nervous system cancers - recognition and referral for more information.
Other (pregnancy-related) — acute fatty liver of pregnancy, pre-eclampsia. See the CKS topic on Hypertension in pregnancy for more information.
Drug-induced — for example iron, antihypertensives, anticonvulsants, antibiotics, opioids.
Psychological/substance misuse — for example eating disorders, alcohol/opioid/anxiolytic withdrawal. See the CKS topics on Eating disorders, Alcohol - problem drinking, and Opioid dependence for more information.

Basis for recommendation

The information on possible alternative causes for symptoms is based on the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guideline The management of nausea and vomiting of pregnancy and hyperemesis gravidarum [Nelson-Piercy, 2024a], the American College of Obstetricians and Gynecologists (ACOG) practice bulletin Nausea and vomiting of pregnancy [ACOG, 2018], and expert opinion in review articles on hyperemesis gravidarum [Abramowitz, 2017; Austin, 2019].

Management

Scenario: Management

From age 13 years to 60 years (Female).

What information and advice should I offer?

If a woman has nausea and vomiting in pregnancy:

Offer advice on sources of information and support, such as:
- The NHS leaflet (www.nhs.uk) Vomiting and morning sickness.
- The Royal College of Obstetricians and Gynaecologists (RCOG, www.rcog.org.uk) leaflet Pregnancy sickness (nausea and vomiting of pregnancy and hyperemesis gravidarum).
- Pregnancy sickness support (www.pregnancysicknesssupport.org.uk) — a UK charity that provides peer support, a helpline, web chat, and patient information on self-help techniques and treatments available.
Reassure that mild-to-moderate symptoms are common in pregnancy and usually resolve by 16–20 weeks of gestation.
Advise on the following self-care measures for mild-to-moderate symptoms:
- Rest as needed, and try to avoid sensory stimuli that may trigger symptoms, such as odours, heat, and noise.
- Try eating plain biscuits or crackers in the morning.
- Try eating bland, small, frequent protein-rich meals which are high in carbohydrate and low in fat.
- Cold meals may be more easily tolerated if nausea is smell-related.
- Drinking little and often, rather than large amounts.
- Acupressure (such as over the P6 point on the ventral aspect of the wrist using a wrist band or finger pressure).
Advise avoiding medications that may contribute to symptoms, such as iron-containing preparations, depending on clinical judgement.
Advise on the management of associated gastro-oesophageal reflux disease, oesophagitis, or gastritis symptoms. See the CKS topic on Dyspepsia - pregnancy-associated for more information.
Advise on the need for urgent medical review if the woman develops clinical features suggesting a complication or alternative cause for symptoms.
Advise that for any subsequent pregnancy, early use of lifestyle measures and antiemetic drug treatment before or immediately at the start of symptoms may be helpful.

Basis for recommendation

The recommendations on information and advice are based on the National Institute for Health and Care Excellence (NICE) guideline Antenatal care [NICE, 2021], the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guideline The management of nausea and vomiting of pregnancy and hyperemesis gravidarum [Nelson-Piercy, 2024a], the American College of Obstetricians and Gynecologists (ACOG) practice bulletin Nausea and vomiting of pregnancy [ACOG, 2018], the UK Teratology Information Service (UKTIS) monograph Treatment of nausea and vomiting in pregnancy [UKTIS, 2019], and expert opinion in a review article on nausea and vomiting in pregnancy [Bustos et al, 2017] and on severe nausea and vomiting in pregnancy [Dean, 2018; Austin, 2019; Fejzo, 2019].

Advising on sources of information and support

This recommendation is based on the RCOG guideline [Nelson-Piercy, 2024a] and expert opinion in a review article [Dean, 2018].

Providing reassurance about mild-to-moderate symptoms

This recommendation is based on the knowledge and experience of the NICE guideline committee [NICE, 2021] and the RCOG guideline [Nelson-Piercy, 2024a].
- Mild-to-moderate symptoms are common in early pregnancy and the majority settle in the later stage of the second trimester [NICE, 2021].
- If the woman is not dehydrated, manage in the community with support, reassurance, antiemetics, oral rehydration, and dietetic advice [Nelson-Piercy, 2024a].

Advising on self-help measures

The recommendations to rest and avoid sensory stimuli are based on the ACOG practice bulletin [ACOG, 2018], and expert opinion in review articles [Dean, 2018; Fejzo, 2019].
- Fatigue can exacerbate symptoms, and rest can be helpful [Fejzo, 2019].
The recommendations on dietary modifications are based on the RCOG guideline [Nelson-Piercy, 2024a], the ACOG practice bulletin [ACOG, 2018] and UKTIS monograph [UKTIS, 2019] if there are mild symptoms, and expert opinion in review articles [Bustos et al, 2017; Dean, 2018; Austin, 2019].
- Small, frequent meals can help prevent hypoglycaemia and gastric overdistension, and protein-rich meals can improve symptoms [Austin, 2019].
The RCOG guideline advises that there are no trials of community use of ginger for severe nausea and vomiting in pregnancy and hyperemesis gravidarum. A large cross-sectional survey of 512 women with HG found that:
- Ginger foodstuffs or over the counter tablets have little or no efficacy, but caused unpleasant adverse effects and worsening of symptoms in over half (54%) of participants.
- Recommendations by a healthcare professional (HCP) to try ginger was found to cause a loss of trust in the HCP and damaged clinician-patient relationships.
The RCOG advises that because prior awareness and self-administration of ginger as a home remedy prior to seeking medical help was extremely high HCPs should not suggest it and doing so may delay access to effective treatment.
The recommendation to try acupressure is based on the NICE guideline [NICE, 2021], the ACOG practice bulletin [ACOG, 2018], and the UKTIS monograph [UKTIS, 2019].
- The NICE guideline states acupressure may be used as an adjunct treatment if there are moderate-to-severe symptoms.
- The ACOG practice bulletin notes the supporting evidence for acupressure is limited and often conflicting in the literature.

Avoiding medication that exacerbates symptoms

This recommendation is based on the RCOG guideline [Nelson-Piercy, 2024a]. It is also pragmatic, based on what CKS considers to be good clinical practice.

Managing associated gastrointestinal symptoms

This recommendation is based on the RCOG guideline [Nelson-Piercy, 2024a] and expert opinion in a review article, which notes that treatment is important, particularly if symptoms persist or recur after 20 weeks gestation [Dean, 2018].

Giving safety-netting advice

This recommendation is pragmatic, based on what CKS considers to be safe medical practice.

Offering advice for future pregnancies

This recommendation is based on the RCOG guideline [Nelson-Piercy, 2024a] and expert opinion in a review article [Dean, 2018].
- Antiemetic treatment started before the onset of symptoms may reduce the duration and severity of symptoms in subsequent pregnancies [Dean, 2018].

Which drug treatments should I offer?

If nausea and vomiting symptoms persist despite self-care information and advice, discuss the option of drug treatment(s), taking into account the woman's preferences, severity of symptoms, response to treatments in previous pregnancies (if appropriate), and advantages and disadvantages of different treatments.

Prescribe oral cyclizine or promethazine (antihistamines), prochlorperazine or chlorpromazine (phenothiazines), or the combination drug doxylamine/pyridoxine (Xonvea^®) first-line, and reassess the woman after 24-72 hours.
- Consider the use of doxylamine/pyridoxine (Xonvea^®, the only licensed drug treatment for this indication), depending on local prescribing guidelines.
- See the sections on Cyclizine, Promethazine, Prochlorperazine, Chlorpromazine, and Doxylamine with pyridoxine in the section on Prescribing information for detailed information on contraindications and cautions, adverse effects, and drug interactions.
- If symptoms respond to treatment, continue and review the woman once a week thereafter, depending on clinical judgement.
If first-line treatment is ineffective, switch to a second-line antiemetic, such as oral metoclopramide or domperidone (dopamine receptor antagonists), or ondansetron (a 5-HT3 receptor antagonist), and reassess the woman after 24 hours.
Second-line therapies should be issued in combination with partially effective first line therapies for as long as the woman requires them, if they are effective.
- Oral metoclopramide should not be prescribed for longer than 5 days due to the risk of neurological extrapyramidal adverse effects.
- Oral domperidone should not be prescribed for longer than 7 days due to the risk of cardiac adverse effects.
- Oral ondansetron should not be prescribed for longer than 5 days.
  - Advise that exposure to ondansetron during the first trimester of pregnancy is associated with a small increased risk of the baby having a cleft lip and/or palate.
- See the sections on Metoclopramide, Domperidone, and Ondansetron in the section on Prescribing information for detailed information on contraindications and cautions, adverse effects, and drug interactions.
- Consider using combinations of drugs for women who do not respond to a single anti-emetic.
- Consider adding drugs rather than replacing them with different classes of drugs as different classes of drugs may have a synergistic effect.
  - Many women will require more than one antiemetic to control their symptoms.
  - Some women will require a combination of 3 or more antiemetics to control their symptoms.
- If symptoms respond to second-line treatment, continue and review the woman once a week thereafter, depending on clinical judgement.
If second-line combinations of treatments are ineffective the third-line treatment is oral prednisolone 40-50mg daily. The steroid dose should be gradually tapered until the lowest maintenance dose which controls symptoms has been reached. See the CKS topic on Corticosteroids - oral for more information.
- Corticosteroids should be reserved for people where standard treatments have failed. The should be prescribed in addition to previously initiated antiemetics. Women on oral corticosteroids should have regular blood pressure monitoring and screening for diabetes mellitus.
If third-line treatment is ineffective, seek specialist advice.
- See the section on Referral and specialist advice for more information.
Review the need for ongoing treatment, and advise on gradually reducing and stopping medication when symptoms improve, depending on clinical judgement.
- It may be possible to stop antiemetic medication at around 12–16 weeks of pregnancy when symptoms have usually improved.
- Gradually tapering the dose may reduce the risk of symptoms recurring.
- Note: If effective medication is discontinued too early it is highly likely that the patient will relapse, possibly requiring an unplanned admission to hospital.
Consider the following for all people:
- Histamine type-2 receptor blockers or proton pump inhibitors if women develop gastro-oesophageal reflux symptoms.
- Thiamine supplementation in those with severely reduced dietary intake.
- Laxatives if required for constipation.
- Venous thromboembolism risk assessment.

Basis for recommendation

The recommendations on drug treatments are based on the National Institute for Health and Care Excellence (NICE) guideline Antenatal care [NICE, 2021], a NICE evidence summary Doxylamine/pyridoxine (Xonvea) for treating nausea and vomiting of pregnancy [NICE, 2019], the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guideline The management of nausea and vomiting of pregnancy and hyperemesis gravidarum [Nelson-Piercy, 2024a], the American College of Obstetricians and Gynecologists (ACOG) practice bulletin Nausea and vomiting of pregnancy [ACOG, 2018], the Medicines and Healthcare products Regulatory Agency (MHRA) drug safety updates Domperidone: risks of cardiac side effects [MHRA, 2014a], Metoclopramide: risk of neurological adverse effects [MHRA, 2014b], and Ondansetron: small increased risk of oral clefts following use in the first 12 weeks of pregnancy [MHRA, 2020]; and the UK Teratology Information Service (UKTIS) monograph Treatment of nausea and vomiting in pregnancy [UKTIS, 2019].

When to consider drug treatment

The recommendation on factors to take into consideration when offering drug treatments is based on the NICE guideline [NICE, 2021], the RCOG guideline [Nelson-Piercy, 2024a], and the ACOG practice bulletin [ACOG, 2018].
- The RCOG guideline recommends that women with mild nausea and vomiting in pregnancy should be managed in the community with antiemetics using a stepwise approach. It cites evidence from a Cochrane review, various systematic reviews and meta-analyses, and birth registry data on the safety and efficacy of various antiemetics for this indication, and found no increased risk of teratogenesis or other adverse pregnancy outcomes.
- The ACOG practice bulletin states that early treatment may provide better control of symptoms and reduce the risk of potentially serious complications including hyperemesis gravidarum.

First-line treatment options

The recommendations on first-line treatment options are largely based on the NICE guideline on antenatal care [NICE, 2021] and the NICE evidence summary on doxylamine/pyridoxine [NICE, 2019], the RCOG guideline [Nelson-Piercy, 2024a], and the UKTIS monograph [UKTIS, 2019].
- The NICE guideline does not rank the majority of antiemetic drug treatments as first- or second-line.
- The NICE guideline notes that cyclizine, promethazine, prochlorperazine, and chlorpromazine are not licensed for this indication, but have been used in established practice for many years, with extensive clinical experience of their use. It found, however, no evidence from randomized controlled trials to support the use of prochlorperazine or chlorpromazine. The RCOG guideline cites safety and efficacy data for first-line antiemetics such as antihistamines and phenothiazines. The UKTIS monograph also supports this prescribing approach.
- The NICE guideline on antenatal care notes that the combination drug doxylamine/pyridoxine (Xonvea^®) is the only licensed medication for this indication. It cites some low- or very low-quality evidence which showed symptom relief compared with placebo, and moderate- or low-quality evidence from a small study which found it is less likely to be effective than ondansetron.
- The NICE evidence summary on Xonvea^® states that some women may prefer this over established treatments such as antihistamines and phenothiazines, because it is specifically licensed for use in pregnant women. It is not known whether the combination drug is more effective than an antihistamine or phenothiazine alone, and some women may prefer to try a single treatment before trying a combination drug. It has a reasonably well established safety profile, but the evidence review states there are no current comparative safety and efficacy data of Xonvea^® versus antihistamines and phenothiazines. The UKTIS monograph also recommends the use of Xonvea^® as a first-line antiemetic treatment option.

Second-line treatment options

The recommendations on second-line treatment options are largely based on the NICE guideline on antenatal care [NICE, 2021], the RCOG guideline [Nelson-Piercy, 2024a], and the UKTIS monograph [UKTIS, 2019].
- The NICE guideline notes that metoclopramide is not licensed for this indication, but has been used as a second-line treatment in established practice for many years, with extensive clinical experience of its use. It found good-quality evidence for its use, with benefits on overall symptom relief, and nausea and vomiting intensity, compared with placebo.
  - The information that oral metoclopramide should not be prescribed for longer than 5 days is based on the MHRA drug safety update, which notes the risk of neurological extrapyramidal adverse effects and tardive dyskinesia [MHRA, 2014b].
  - The RCOG guideline advises to ask about any previous adverse effects with antiemetic use in previous pregnancies, as drug-induced extrapyramidal symptoms and oculogyric crises can occur with the use of phenothiazines and metoclopramide. It states that metoclopramide is effective and safe, but recommended second-line due to the risk of extrapyramidal adverse effects.
- The recommendation to consider domperidone is based on the RCOG guideline, which places this as a second-line antiemetic treatment option. CKS notes that the NICE guideline does not include the use of domperidone for this indication.
  - The information that oral domperidone should not be prescribed for longer than 7 days is based on the MHRA drug safety update, which notes the risk of serious cardiac adverse effects and potential interactions with other medications [MHRA, 2014a].
- The NICE guideline notes that ondansetron is not licensed for this indication, but has been used in established practice as a treatment for severe symptoms. It cites moderate- or low-quality evidence from a small study that ondansetron is more likely to be effective at reducing nausea than the combination drug Xenova^®.
  - The RCOG guideline states that ondansetron is safe and effective, but recommended for use second-line and ideally after the first trimester of pregnancy, due to mixed safety data. It cites limited data from small studies that ondansetron is equally effective but has fewer adverse effects compared with metoclopramide, and is more effective at reducing severe vomiting than metoclopramide. It also advises that its use should not be discouraged if first line antiemetics are ineffective and that women can be reassured regarding a very small increase in the absolute risk of orofacial clefting with ondansetron use in the first trimester, which should be balanced with the risks of poorly managed hyperemesis gravidarum. The absolute risk of orofacial clefting increases from a background risk of 11 cases per 10,000 births to 14 cases per 10,000 births with ondansetron.
  - The information that oral ondansetron should not be prescribed for longer than 5 days is based on the manufacturers' Summary of Product Characteristics [ABPI, 2019].
  - The information on the risks of cleft lip and/or palate following exposure to ondansetron in the first trimester of pregnancy is based on the MHRA drug safety update, which states that ondansetron can be tried if the combination drug Xonvea^® is not suitable or sufficient alone to control severe symptoms, after a discussion of the risks and benefits [MHRA, 2020].
- The recommendation to reassess the woman after 24-72 hours of treatment is based on the RCOG guideline and [Nelson-Piercy, 2024a]what CKS considers to be good clinical practice. It is also in line with the expert opinion of previous external reviewers of this CKS topic.
CKS notes that the RCOG guideline recommends combinations of different drugs should be used in women who do not respond to a single antiemetic, as they may have different mechanisms of action and synergistic effects [Nelson-Piercy, 2024a]. The ACOG practice bulletin advises caution when using multiple antiemetics, however, due to the risk of potentially serious adverse effects, depending on the drug classes combined [ACOG, 2018].

Third-line treatment

The recommendation on prescribing oral corticosteroids is based on the RCOG guideline [Nelson-Piercy, 2024a]

Advising on reducing and stopping treatment

The information that antiemetic treatment may be reduced and stopped around 12–16 weeks of pregnancy is extrapolated from the RCOG guideline [Nelson-Piercy, 2024a]. It is also pragmatic, based on what CKS considers to be good clinical practice.
The recommendation to consider gradually tapering the dose is extrapolated from the NICE evidence summary on doxylamine/pyridoxine [NICE, 2019].

When should I arrange admission or referral?

Consider arranging hospital admission if the woman has persistent moderate-to-severe nausea and vomiting and:
- Suspected hyperemesis gravidarum despite oral antiemetic treatment.
- A suspected severe or serious complication.
- Symptoms are not controlled with management in primary care.
- Is unable to tolerate oral antiemetics or oral fluids.
- Is unable to tolerate other necessary oral drug treatment, such as antibiotics for a urinary tract infection or usual medication for comorbid conditions.
- Any co-morbidity in combination with an inability to take medications.
- There is evidence of clinical dehydration.
- There is weight loss of greater than 5% of body weight.
- There are concerns regarding mental health.
- The PUQE score is 13 or greater.

Basis for recommendation

The recommendations on referral are based on the National Institute for Health and Care Excellence (NICE) guideline Antenatal care [NICE, 2021], the Royal College of Obstetricians and Gynaecologists (RCOG) Green-top guideline The management of nausea and vomiting of pregnancy and hyperemesis gravidarum [Nelson-Piercy, 2024a], and expert opinion in review articles on severe nausea and vomiting in pregnancy [Dean, 2018; Fejzo, 2019].

When to consider hospital admission

Women with moderate-to-severe symptoms may benefit from intravenous (IV) fluids for rehydration and review of antiemetic treatment, ideally on an outpatient basis. Inpatient care may be needed for severe symptoms not responding to primary or outpatient care, including women with hyperemesis gravidarum who are at risk of potentially severe or serious complications [NICE, 2021].
Women with severe symptoms or hyperemesis gravidarum who have symptoms in the late second or third trimester should be offered serial ultrasound scans to monitor fetal growth [NICE, 2021].
The RCOG guideline states that outpatient management may be possible if primary care measures are unsuccessful and the PUQE score is less than 13. Inpatient care may be needed if the woman is unable to tolerate oral antiemetics, there is prolonged vomiting, complications, or outpatient management is ineffective. This may involve IV fluids, electrolyte replacement and monitoring, antiemetics (IV, rectal, subcutaneous, or intramuscular), thiamine, anticoagulant treatment, and enteral or parenteral feeding if there are severe refractory symptoms [Nelson-Piercy, 2024a].
Women with severe symptoms of hyperemesis gravidarum may need input from a multidisciplinary team including midwives, nurses, dietitians, pharmacists, endocrinologists, gastroenterologists, and mental health specialists [Nelson-Piercy, 2024a].
The recommendation for women who are unable to tolerate other necessary oral drug treatment is based on the RCOG guideline [Nelson-Piercy, 2024a] and expert opinion in a review article [Dean, 2018].
The recommendations to admit women with co-morbidities and an inability to take medications, evidence of clinical dehydration, loss of greater than 5% of body weight, or where there are concerns about mental health are taken from the RCOG guideline [Nelson-Piercy, 2024a].

Prescribing information

Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF).

Cyclizine

Dose

Prescribe cyclizine 50 mg orally up to three times a day.

[Joint Formulary Committee, 2021; Nelson-Piercy, 2024a]

Contraindications and cautions

Prescribe cyclizine with caution to people with:
- Hepatic impairment.
- Urinary retention.
- Susceptibility to angle-closure glaucoma.
- Pyloroduodenal obstruction.
- Hepatic disease.
- Epilepsy.
- Severe heart failure.
- Porphyria.

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Nausea/vomiting in pregnancy: Summary

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Background information

What is it?

How common is it?

What causes it?

What are the risk factors?

What are the complications?

What is the prognosis?

Diagnosis of nausea/vomiting in pregnancy

How should I assess a woman with symptoms?

Severity scoring

Basis for recommendation

Clinical features on history-taking

Using a validated questionnaire for symptom severity

Clinical features on examination

Assessing for an alternative or underlying cause

Arranging additional investigations

What else might it be?

Basis for recommendation

Management

Scenario: Management

What information and advice should I offer?

Basis for recommendation

Advising on sources of information and support

Providing reassurance about mild-to-moderate symptoms

Advising on self-help measures

Avoiding medication that exacerbates symptoms

Managing associated gastrointestinal symptoms

Giving safety-netting advice

Offering advice for future pregnancies

Which drug treatments should I offer?