Guideline sources The following summarized guidelines for the evaluation and management of nausea and vomiting of pregnancy are prepared by our editorial team based on guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG 2019) and the Society of Obstetricians and Gynaecologists of Canada (SOGC 2016). 1 2 Calculator Pregnancy Unique-Quantificatio Guidelines https://web.pathway.md/diseases/recVSmSpgWh2l1J7O 1/5 6/30/23, 1:14 AM Nausea and vomiting of pregnancy Pathway 1. Screening and diagnosis Diagnosis: diagnose NVOP only if the onset is in the first trimester of pregnancy and other causes of nausea and vomiting have been excluded. B 2. Classification and risk stratification Severity grading: consider using an objective and validated index such as the PUQE score to classify the severity of NVOP. C 3. Diagnostic investigations Initial evaluation: Elicit clinical history, perform focused examination and obtain investigations to exclude other pathological causes. B Be aware of the features in history, examination and investigation that help to diagnose, assess and monitor NVOP. B 4. Medical management Setting of care: manage patients with mild NVOP in an outpatient setting with antiemetics. B Show 3 more Antiemetics: As per RCOG 2019 guidelines, offer antiemetics such as H1RAs and phenothiazines as first-line therapy in patients with NVOP. B Show 5 more As per SOGC 2016 guidelines, consider offering H1RAs for the management of patients with acute or chronic symptoms of NVOP. B Show 3 more Pyridoxine and doxylamine: As per RCOG 2019 guidelines, do not offer pyridoxine for the management of patients with NVOP. D As per SOGC 2016 guidelines, offer pyridoxine monotherapy or doxylamine/pyridoxine combination as first-line therapy in patients with NVOP. A Corticosteroids: As per RCOG 2019 guidelines, reserve corticosteroids for cases where standard therapies have failed. A As per SOGC 2016 guidelines, avoid using corticosteroids during the first trimester of pregnancy because of possible increased risk of oral clefting. D https://web.pathway.md/diseases/recVSmSpgWh2l1J7O 2/5 6/30/23, 1:14 AM Nausea and vomiting of pregnancy Pathway Diazepam: do not use diazepam for the management of patients with NVOP. D Acid-reducing agents: consider offering H2RAs or PPIs in patients with NVOP developing GERD, esophagitis or gastritis. C Rehydration therapy: use normal saline with additional potassium chloride in each bag, with administration guided by daily monitoring of electrolytes, for IV hydration in patients with NVOP. B Show 2 more 5. Nonpharmacologic interventions Diet: As per RCOG 2019 guidelines: Consider offering enteral or parenteral treatment with a multidisciplinary approach when all other medical therapies have failed. C Advise using ginger in patients wishing to avoid antiemetic therapies for mild-to-moderate NVOP. A As per SOGC 2016 guidelines, consider advising the use of ginger to mitigate the symptoms in patients with NVOP. B Supplements: As per RCOG 2019 guidelines: Offer thiamine supplements (either PO or IV) in all patients admitted with prolonged vomiting, especially before administration of dextrose or parenteral nutrition. B Consider avoiding iron-containing preparations in patients with previous or current NVOP if these exacerbate the symptoms. D As per SOGC 2016 guidelines, consider discontinuing iron-containing prenatal vitamins during the first trimester in patients with NVOP, and substituting them with folic acid alone, or adult or children's vitamins that are low in iron. B Rest: advise patients with NVOP to rest as required to alleviate symptoms. B Psychosocial care: address the severity of symptoms in relation to the quality of life and social situation, as the quality of life can be adversely affected by NVOP. B Show 3 more Cognitive therapy: consider offering mindfulness-based cognitive therapy as an adjunct to pyridoxine therapy in patients with NVOP. B Hypnotherapy: do not offer hypnotic therapies for the management of patients with NVOP. D Acupuncture and acupressure: As per RCOG 2019 guidelines, consider reassuring patients that acustimulations are safe in pregnancy. Recognize that acupressure may improve NVOP. C https://web.pathway.md/diseases/recVSmSpgWh2l1J7O 3/5 6/30/23, 1:14 AM Nausea and vomiting of pregnancy Pathway As per SOGC 2016 guidelines, consider advising acupressure for the management of patients with NVOP. B 6. Therapeutic procedures Termination of pregnancy: attempt all therapeutic measures before offering termination of a wanted pregnancy. B 7. Specific circumstances Patients with refractory disease: evaluate for other potential causes if NVOP is refractory to initial pharmacotherapy. B 8. Patient education General counseling: counsel patients with NVOP to eat whatever pregnancy-safe food appeals to them, and encourage lifestyle changes liberally. B 9. Preventative measures Primary prevention: Advise early use of lifestyle/dietary modifications and antiemetics that were found to be useful in the index pregnancy to reduce the risk of NVOP in the current pregnancy. B Consider prescribing preemptive doxylamine/pyridoxine at the onset of pregnancy in women at high risk of NVOP. B 10. Follow-up and surveillance Follow-up: Prepare an individualized management plan for patients with NVOP when they are discharged from hospital. B Offer serial scans to monitor fetal growth in patients with severe NVOP experiencing continued symptoms into the late second or the third trimester. B Clinical findings Symptoms Past medical history Nausea Migraine Vomiting Motion sickness https://web.pathway.md/diseases/recVSmSpgWh2l1J7O 4/5 6/30/23, 1:14 AM Nausea and vomiting of pregnancy Pathway Past obstetric history Family history First trimester of pregnancy Severe NVOP in mother or sister Mild or severe nausea and vomiting in previous pregnancy Lab findings Multiple pregnancy Hypokalemia Integument exam Hypomagnesemia Dehydration Metabolic alkalosis References 1. Ioannis Tsakiridis, Apostolos Mamopoulos, Apostolos Athanasiadis et al. The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum. Obstet Gynecol Surv. 2019 Mar;74 3 161 169. Open 2. Campbell K, Rowe H, Azzam H et al. The Management of Nausea and Vomiting of Pregnancy. J Obstet Gynaecol Can. 2016 Dec;38 12 1127 1137. Open 3. Noel M Lee, Sumona Saha. Nausea and vomiting of pregnancy. Gastroenterol Clin North Am. 2011 Jun;40 2 309 34, vii. Open 4. Martha Bustos, Raman Venkataramanan, Steve Caritis. Nausea and vomiting of pregnancy What's new?. Auton Neurosci. 2017 Jan;202 62 72. Open 5. Thomas R Einarson, Charles Piwko, Gideon Koren. Prevalence of nausea and vomiting of pregnancy in the USA a meta analysis. J Popul Ther Clin Pharmacol. 2013;20 2):e163 70. Open 6. G Koren, C Piwko, E Ahn et al. Validation studies of the Pregnancy Unique-Quantification of Emesis PUQE scores. J Obstet Gynaecol. 2005 Apr;25 3 241 4. Open https://web.pathway.md/diseases/recVSmSpgWh2l1J7O 5/5