Evidence-Based Approaches to Managing Nausea and Vomiting in Early Pregnancy

Tekoa L. King, CNM, MPH; Patricia Aikins Murphy, CNM, DrPH

J Midwifery Womens Health. 2009;54(6):430-444.

Assessment: The Pregnancy Unique Quantification of Emesis/Nausea Score

Most clinicians attempt to manage the early symptoms of NVP in order to prevent progression to severe symptoms. Given the subjective nature of conditions such as nausea, retching, and vomiting, consistency of the assessment is critical. The Rhodes Index^[22,23] is an objective, validated measure used to grade the severity of nausea and vomiting and to follow the course of the condition. It has been revised to measure nausea, vomiting, and retching.^[22] This scoring system, originally used to assess nausea and vomiting in chemotherapy patients, quantifies physical symptoms and the resulting stress and psychological symptoms. Although the tool has been used in many research studies of NVP treatments, it is detailed, time-consuming, and cumbersome for use in assessing women in a clinical setting. A shorter assessment guide was developed by clinicians and researchers from the Motherisk NVP helpline in Canada to streamline assessment and correct some of the problems associated with use of the Rhodes Index. The Pregnancy-Unique Quantification of Emesis/Nausea (PUQE) Index (Figure 1) is based on only three questions, is highly correlated with scores on the Rhodes Index, and has been validated in clinical use.^[24,25]

(Enlarge Image)

Figure 1.

Pregnancy-Unique Quantification of Emesis/Nausea (PUQE) index. Total score is sum of replies to each of the three questions. Nausea Score: Mild NVP = ≤6; Moderate NVP = 7–12; Severe NVP = ≥13. Reprinted with permission from Koren G et al.^[24]

The original PUQE Index focused on symptoms experienced during the previous 12 hours—and was later modified to 24 hours^[26]—reflecting the appropriate time frames to judge the efficacy of therapy for hospitalized women or those provided with frequent evaluation and follow-up. The index was recently modified to address symptoms of NVP over a longer period of time (Figure 2).^[27]

(Enlarge Image)

Figure 2.

Modified Pregnancy-Unique Quantification of Emesis/Nausea (PUQE) index. Total score is sum of replies to each of the three questions. Nausea Score: Mild NVP = ≤6; Moderate NVP = 7–12; Severe NVP = ≥13. Reprinted with permission from Lacasse A et al.^[27]

The PUQE Index score can be used to determine if the NVP is mild, moderate, or severe. If the score is moderate or severe (score of ≥7), a thorough assessment includes any changes in weight, the presence or absence of dehydration, and lab indices to check for electrolyte imbalances. Finally, if the initial onset of nausea and vomiting occurs after 10 weeks' gestation, the etiology is not likely to be NVP, and other causes need to be considered.

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Cite this: Evidence-Based Approaches to Managing Nausea and Vomiting in Early Pregnancy - Medscape - Oct 30, 2009.

Abstract and Introduction
Etiology of Nausea and Vomiting in Pregnancy
Assessment: The Pregnancy Unique Quantification of Emesis/Nausea Score
Management: Safety and Efficacy
Dietary and Lifestyle Recommendations
Nonpharmacologic Treatments
Pharmacologic Therapies
Clinical Implications
Conclusion
References

Table 1. Doses of Antiemetics Used to Treat Nausea and Vomiting in Pregnancy
Drug Name (Trade Name)	Dose	Major SEs (Recommendations)	FDA Pregnancy Category
Antihistamines (H₁ antagonists)
Diphenhydramine (Benadryl)	50–100 mg q 4–6 h PO/IM/IV	May cause drowsiness (can be used to offset anxiety caused by metoclopramide or phenothiazines)	B
Dimenhydrinate (Dramamine)	50–100 mg q 4–6 h PO/PR^a; 50 mg (in 50 mL of saline over 20 min) q 4–6 h IV	May cause drowsiness (can be used to offset anxiety caused by metoclopramide or phenothiazines)	B
Doxylamine (Unisom)	12.5 mg twice a day PO or 12.5 mg in morning and 25 mg at night PO		A
Phenothiazines (central D₂ antagonists)
Prochlorperazine (Compazine)	5–10 mg q 4–6 h PO/IM/IV; 25 mg rectal suppository bid; maximum dose is 40 mg/day	Sedation, anticholinergic effects, mouth, EPS, hypotension if given IV too quickly	C
Promethazine (Phenergan)	12.5–25 mg q 4–6 h PO/IM/IV/PR	Sedation, anticholinergic effects, mouth, EPS, hypotension if given IV too quickly	C
Benzamides (central and peripheral D₂ antagonists)
Metoclopramide (Reglan)	5–10 mg PO q 8 h PO/IM; 1–2 mg/kg IV; continuous SQ dose regimens available^b	EPS, agitation, anxiety, acute dystonic reactions (give 50 mg diphenhydramine before dose to prevent EPS)	B
Serotonin antagonists
Ondansetron (Zofran)	4–8 mg PO 3–4 times per day 4–8 mg over 15 min IV q 12 h; may be given 1 mg/h continuously for 24 h	Headache	B
Butyrophenones
Droperidol^c (Inapsine)	0.625–2.5 mg IV over 15 min then 1.25 mg or 2.5 mg IM as needed; can be given IV continuously at 1–1.25 mg/h	EPS, prolonged QT syndrome (give 50 mg diphenhydramine before dose to prevent EPS; reserve for persons who have failed other regimens)	C

bid = Two times daily; EPS = extrapyramidal effects; FDA = US Food and Drug Administration; IM = intramuscular; IV = intravenous; PO = per os (orally); PR = per rectum (rectally); SE = side effect; SQ = subcutaneous.
^aMaximum dose is 200 mg/day if taken concomitantly with doxylamine, 400 mg/day if taken as a single agent.
^bContinuous dose regimens can be found in Buttino Jr et al.^[89]
^cTo be used only after medical consultation and if other medications have failed to resolve symptoms, secondary to risk for prolonged QT syndrome.

Table 2. US Food and Drug Administration Ratings for Drug Use in Pregnancy ^a
Category	Interpretation
A	Adequate, well controlled studies in pregnant women have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy.
B	Animal studies have revealed no evidence of harm to the fetus, however, there are no adequate and well controlled studies in pregnant women. OR Animal studies have shown an adverse effect, but adequate and well controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester.
C	Animal studies have shown an adverse effect and there are no adequate and well controlled studies in pregnant women. ORNo animal studies have been conducted and there are no adequate and well controlled studies in pregnant women.
D	Adequate well controlled or observational studies in pregnant women have demonstrated a risk to the fetus. However, the benefits of therapy may outweigh the potential risk. For example, the drug may be acceptable if needed in a life-threatening situation or serious disease for which safer drugs cannot be used or are ineffective.
X	Adequate well controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks. The use of the product is contraindicated in women who are or may become pregnant.

Source: US Food and Drug Administration (21 CFR §201.57).^[72]
^aNote that the US Food and Drug Administration has proposed changes to prescription drug labeling for use in pregnancy and lactation. (See www.fda.gov/Drugs/DevelopmentApprovalProcess/DevelopmentResources/Labeling/ucm093311.htm for additional information.)

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