Ep 279: Nausea and Vomiting In Pregnancy – What To Do To Help

Dr. Nicole (00:00): Nausea and vomiting during pregnancy can be the worst, but I'm going to help you get through it with the information in today's episode. Welcome to the All about Pregnancy and birth podcast. If you're having a baby in the hospital, you are giving birth in a system that too often takes away power from women over what happens in their own bodies. I'm Dr. Nicole Calloway Rankins, a practicing board certified OB GYN, who's had the privilege of helping well over a thousand babies into this world. I've been a doctor for over 20 years and I'm here to help you take back your power, advocate for yourself, and have the beautiful pregnancy and birth that you deserve. This podcast is for educational purposes only, and it's not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com / disclaimer. Now let's get to it. Hello there. Welcome to another episode of the podcast.

(00:59): This is episode number 279. Whether it is your first time listening or you have listened before, I am so glad you're spending some time with me today. So let me start off by sharing a quick story. It was a beautiful sunny day and I was sitting at my desk at work and I was getting ready to open up the computer, get some work done. I had these awesome huge windows in my office at work, and I was looking forward to finally accomplishing some task while enjoying the beautiful sunny view. Well then it hit me. I had to throw up right now, I was about 10 weeks pregnant at the time with our second child, and thankfully there was a bathroom right across the hall from my office. So I stood up, ran, made a beeline for the bathroom, and I made it to the bathroom.

(02:01): However, unfortunately I did not make it to the toilet. As soon as I hit the bathroom door, what seemed like everything that I have ever eaten in my entire life came spewing out of my mouth. And before I knew it, vomit was on three walls. Yes, three walls of the bathroom. None of it had landed in the toilet. I felt so bad. It was one of those little single bathrooms that I had literally thrown up everywhere. The cleaning lady came and I was like, I'm so sorry, I'm so sorry. And she said, just go sit down please and just drink some water. So I hope you can't relate to this story. I would not wish that feeling on anyone, but based on how common nausea and vomiting is during pregnancy, it can affect anywhere from 50 to 80% of pregnant women. Chances are you can relate to some part of that story.

(03:10): And today what I'm going to do is help you understand what you can expect with nausea and vomiting during pregnancy and give you some options to help. So you'll learn about what causes nausea and vomiting in pregnancy. Actually, we are not entirely sure what it is, what to expect in terms of the course of nausea and vomiting during pregnancy, and then some treatment options including non-medication options and then medications, options, and then one option that's become a little more popular, but it's actually unsafe. So we'll talk about that too. Now, before we get into this episode, I want to do a listener shout out. This is From Hell Face Killer. I love that name by the way, and the title of the review says So incredibly helpful. And the review, which was left in Apple Podcast says, I just listened to the episode about cesarean birth.

(04:01): I have vaso previa and I'll be having a c-section in about eight weeks. I'm so grateful I found this podcast, which walked me through the entire procedure carefully with matter of fact language. I feel so much more prepared and no longer afraid. Thank you so much. Well, you are so welcome, and I glad you found the information helpful. Now, if you want to step by step way to get walkthrough a vaginal birth, then do check out the birth preparation course. The birth preparation course is my signature online childbirth education class that will get you calm, confident and empowered to have a beautiful birth with a focus, especially on having a beautiful hospital birth. I've had thousands of women go through the course and find it so helpful. You can check out all the details at drnicolerankins.com / enroll, and if you use the code, Dr. Nicole, you will get an additional discount.

(04:55): Okay, let's get into the conversation about nausea and vomiting in pregnancy. So the first thing I want to say to get this out of the way, because sometimes people get really worried about this, if you don't have nausea and vomiting, then that doesn't mean that anything is wrong. In fact, at least 20% of women will not have any nausea and vomiting. So if you never have nausea and vomiting does not mean that anything is wrong. However, if you had nausea and vomiting and then it suddenly abruptly stops, especially in those early weeks of pregnancy like around 5, 6, 7, 8 weeks, then that is a possible sign of miscarriage. And that is because a decrease in symptoms can happen because of a decrease in the pregnancy hormone level HCG. So if you have a sudden decrease in nausea and vomiting, it's not unreasonable to check in with your doctor.

(06:00): So what causes nausea and vomiting in pregnancy? Well, actually, we don't actually know exactly what causes nausea and vomiting in pregnancy. We think it's primarily related to the sudden rise in hormones, particularly HCG, which is human, that's the pregnancy hormone. It's unique to pregnancy, and then estrogen goes up as well. There may also be a genetic component, daughters and sisters of women who've had hyperemesis GRA arm, which is extreme nausea and vomiting in pregnancy. I'll talk about that in a minute. They are more likely to have the same problem. So there may be a genetic component. It also may be related to slow gastric motility. And what I mean by that is that progesterone, which is another hormone that's related to pregnancy, goes up and it slows down muscles. So it's a smooth muscle relaxant. So it may make it that things empty slower in your stomach and that can contribute to nausea and vomiting during pregnancy.

(07:06): There are some other risk factors like women who have twins or at an increased risk of having more severe nausea and vomiting than hyperemesis. If you are carrying a girl fetus. So if you have a female, if you're carrying a baby girl, then you are at an increased risk. We don't know why. Also, if you have a history of having motion sickness, if you have a history of migraines, if you have a history of having nausea and vomiting in a previous pregnancy, then naturally that's also going to increase your risk of having it in another pregnancy. And if you have it in another pregnancy, approximately two thirds of women who describe their vomiting as severe and one pregnancy did unfortunately have similar symptoms in the next pregnancy. And about half of women who describe their symptoms as mild in pregnancy found that the symptoms actually worsened in the next pregnancy.

(08:01): So not the best news, but I want to give you the data that we have about what the course may be like. Now, speaking of the course, we call it morning sickness. I don't call it morning sickness anymore because that is not true. It's called morning sickness because it tends to be worse in the morning. However, nausea and vomiting and pregnancy can occur anytime of the day or night that actually throws some people for a loop. Sometimes they're like, why am I throwing up in the afternoon? If this is morning sickness? Morning sickness is a misnomer. It just means that it tends to be worse in the morning, but it can really happen all day. And as far as how long it happens, the summary is that it generally starts early and it ends fairly early. So it almost always begins around five or six weeks gestation.

(08:49): So pretty early it tends to peak and get its worst about nine weeks. And for most women, it will have completely resolved by around 16 weeks. Now for about 15% of women, unfortunately, it will continue into the third trimester for about 5% of women. It will continue all the way up until birth. And I see unfortunately that sometimes doctors don't recognize that this is a possibility that people can have that continued nausea and vomiting in pregnancy. I think we're getting better, but it definitely can last into the third trimester for a small percentage of people and for a small percentage of folks can last all the way up until birth. Now, extreme nausea and vomiting is referred to as hyperemesis GraBar. There's not one accepted definition for hyperemesis, but most accept that it's really persistent vomiting. You can't keep liquids down, you can't keep solids down.

(09:58): There's usually weight loss accompanied with it, and your daily activities are affected. You can't go to work. It's hard to function, get out of bed because the nausea and vomiting is so extreme. And with hyperemesis, it may even require hospitalization for a period of time. It may require home IV fluids, so IV fluids at home or even medications. You can actually get one of the medications Zofran on a pump at home. In extreme cases and very, very extreme cases, which I haven't ever seen actually, you get IV nutrition, which is parenteral nutrition may become necessary, but that's very, very rare. And if you want to learn more specifically about hyperemesis, then check out episode two 19 of the podcast, two 19 of the podcast. I do want you to know that nausea and vomiting in pregnancy, although it is extremely annoying and actually can be quite distrustful for folks, really miserable honestly, it can even cause depression.

(11:04): It's not physically harmful to you or your baby unless it's that extreme case where malnutrition is a problem. So for the most, the vast majority of folks, there's no physical harm to you or your baby. It's just miserable to be having that nausea and vomiting. And actually, there's pretty strong evidence that women that have nausea and vomiting in pregnancy have a lower miscarriage rate. Not sure that that makes people feel better. Maybe it does, maybe it doesn't. But again, it's annoying but not physically harmful as far as the evaluation. If someone is having nausea and vomiting, we need to look for things to make sure that it's not severe. So we really do it in people who have persistent nausea and vomiting, particularly vomiting, nausea alone. We don't typically do any blood work because nausea alone doesn't cause any issues. It's really going to be persistent vomiting.

(12:03): So we're going to check your urine to see if you have ketones. Ketones are a substance that are produced in your urine when you get dehydrated. So if you have ketones in your urine, that's evidence of being dehydrated. We check your electrolytes like potassium and sodium when you're vomiting a lot, those can get low and they may need to be replaced. We also check your liver function. We also check your kidney function because being very dehydrated can affect those as well. And we'll also check your thyroid because sometimes abnormalities in your thyroid can actually cause extreme vomiting. If you haven't already had an ultrasound, then we definitely need to do an ultrasound to assess for multiples like twins or more, and also something called gestational trophoblastic disease. Gestational trophoblastic disease or GTD is an abnormal condition of pregnancy. Usually it results from a sperm fertilizing and empty egg or to sperm fertilizing a normal egg.

(13:13): Both conditions can cause very high HCG levels. By both conditions, I mean if you have multiples or if you have gestational trophoblastic disease, both of those can cause high levels of HCG, and that may be why you have that nausea and vomiting in pregnancy. GTD is not very common. I've talked about it on the podcast and a listener q and a episode on molar pregnancy, you have to search for it because those episodes don't get numbers. The listener q and a episodes. So if you search for molar pregnancy in your podcast app, then you can learn a bit more about gestational trophoblastic disease. And as an aside, if you have a question that you want me to answer on a short episode of the podcast, then let me know. Shoot it to me on Instagram or shoot it to me on my website. Alright, let's talk about treatment for nausea and vomiting in pregnancy.

(14:03): The goal of treatment is to really help you feel better, help improve your quality of life and help reduce those symptoms so you can feel better. And if it's severe, then we want to correct anything like making sure you're not dehydrated. Make sure that your potassium, your sodium, your electrolytes are okay if those are issues. And we want to prevent it from getting to those severe states where you have lots of vomiting that can cause weight loss or vitamin deficiencies or things like that. Okay, so it's really about feeling better, helping you feel better and helping prevent any of those dehydration or electrolyte things. So let's start with things that don't require what's called medication. One thing that is helpful is if you are taking a multivitamin at the time of getting pregnant, at least a couple studies have found that you are less likely to need treatment for vomiting.

(15:04): So taking a prenatal vitamin for at least a month before pregnancy may help prevent nausea and vomiting from developing. So everybody of reproductive age who's thinking about getting pregnant, you really should be taking your prenatal vitamins ideally before you start getting pregnant. The folic acid can also help with neural tube defects. But here's another reason why taking prenatal vitamins before pregnancy is important. If you're in the situation where you're already pregnant, there's still plenty of things that you can do. You can start with dietary changes. And to be honest, there's not a ton of scientific evidence necessarily about how dietary changes can affect nausea and vomiting in pregnancy, but in experience and in practice, they help. So it's one of those things where it hasn't been studied, but we know just from experience that it helps. So one, you want to eat before or as soon as you start to feel hungry, so you can avoid having an empty stomach.

(16:05): Having an empty stomach can aggravate nausea instead of big meals. You want to eat smaller meals every few hours and also eat slowly. This helps prevent your stomach from feeling both extremes, feeling either empty or getting too full at any given time because both of those, either feeling empty or feeling too full can aggravate nausea. You also don't want to skip meals for that reason as well about not feeling that empty sensation. You should avoid spicy foods, you should avoid fatty foods. A small study has shown that eating protein is better at reducing nausea and vomiting in pregnancy. So stick with protein rich foods like almonds, boiled eggs, Greek yogurt, lean chicken, lean Turkey. You also want to eliminate things like coffee, things that again, are really spicy or have a lot of odor or smell because sometimes that can trigger things. You don't want to eat things that are very acidic, don't want to eat very sweet foods and just again, work on those protein dominant foods and things that are just bland, low fat, dry and actually salty can help.

(17:28): So things like nuts, pretzels, crackers, cereal, toast, rice. Yes, that is an incredibly boring diet. However, if it helps you feel better and remember it's most likely going to be for a short term, you're not going to have to eat like that for your entire pregnancy, but that bland diet can help you feel better. Also, rinsing your mouth out with water or brushing your teeth or sucking on peppermint candies may reduce nausea after eating. So right after you eat, you rinse your mouth with water or brush your teeth or do a peppermint, that might help. And then there's going to be some trial and error in figuring out what foods work for you. You really just have to, and this is going to sound obvious, but determine the things that you can eat and just stick to eating that. Alright? It may be that foods you previously ate without any problems may now bother you, which can be frustrating.

(18:24): So you're going to again, have some trial and error. Error. For me, that was the case with Cheerios with my second daughter. I used to eat Cheerios for breakfast on a regular basis before pregnancy and during pregnancy with her. I ate Cheerios and I would throw up every single time. Finally, I was like, stop eating the stupid cheerios because you throw up every time you eat them. So there's going to be some trial and error, but just determine what you can eat and then eat that. Also, you may want to wait a bit after eating to drink. That's going to again minimize that feeling of fullness that can aggravate nausea. And then even cold drinks or frozen things like popsicles may work better to hydrate you. Sour drinks might also help. Sports drinks like Gatorade can help as well. And using a straw so that you're drinking slowly can help too.

(19:20): And then avoid any triggers that may cause you to have nausea and vomiting. You might find that certain smells or motions might just send you over the edge. We don't know exactly why some things can trigger it, and some things that may trigger it are a stuffy room. Certain smells like perfumes, chemicals, smoke certain foods. Cooking may trigger that nausea and vomiting, sometimes heat, humidity, even visual or physical motion like flickering lights may trigger it. Just do your best to avoid those triggers. Another dietary change is adding ginger into your diet. Ginger has been shown to improve nausea. It hasn't been shown so much to improve vomiting, but it has been shown to improve nausea. So you can use ginger lollipops, ginger chews, ginger tea. You can get ginger capsules over the counter. Ginger ale is fine either with or without bubbles. For some people, the carbonation helps.

(20:24): For some people, the carbonation hurts, so you can either drink straight ginger ale or if the bubbles bother you just open it and let it go a little flat before you drink it. And then finally, in terms of things that aren't medication is acupuncture or ac, acute pressure acupressure wristbands worn on the wrist at the P six point may help with nausea and vomiting in pregnancy. Results of research studies are conflicting, but it's really low risk, so it's reasonable to give it a try. And the P six acupressure point is located on the inner forearm. You can locate it by placing three fingers of your opposite hand, so like your index middle finger, your ring finger, so those three fingers just below the crease of your wrist on the inner side of your forearm. And the P six point is located in between the two tendons you feel in the center of your wrist.

(21:28): And you can apply gentle pressure with your thumb and forefinger in that spot for one to two minutes using a circular motion or steady pressure. Or you can just get a acupressure wrist band off of Amazon. Those are called C bands, motion Sickness bands. They might not be called acu Google Motion Sickness Bands. They are cheap, easily available, and they're designed to target that P six point. They provide constant gentle pressure to help alleviate nausea. All right, let's move into medication options. It is fairly common that those dietary changes and the ginger and the acupressure aren't enough and people do need medications to help. The first line of medication treatment is, and this is kind of like sort of medication because we typically combine it with another thing, but it's vitamin B six, which is perine, and it can be taken alone or it can be taken in combination with an antihistamine called domine.

(22:33): Dous and bone gesta are the prescription medication version versions that are a combination of vitamin B six and domine. However, you can get vitamin B six and domine over the counter. Vitamin B six is just vitamin B six, and Unisom is domine. The sleep aid. Do check with your doctor for directions on how to take it. Generally we start with a bedtime dose and then add it in during the day if needed. Now, if symptoms persist beyond the vitamin B six and dala amine, then we like to add medications or replace medications. Generally, we're going to add on top of things, and the way we make that decision is if something is helping some then keep taking it. So even if the nausea and vomiting isn't completely gone, but that medicine is helping some, then continue it and add something else. However, if it's not working at all, then just stop the medication altogether and you want to try new medications for at least a week to see if it helps.

(23:44): You have to give it some to see if it is effective. So you have to try the medication for at least a week to see if it helps. Now you start with the B six and the paradox scene. The next thing to add is an antihistamine. You can either do diphenhydramine is the active ingredient in Benadryl. So you can try Benadryl again, you can add it at night. You do have to be careful with doing Benadryl and Unisom at the same time because it's going to make you extra sleepy. So you can add Benadryl if the vitamin B six wasn't helping. You can also try Dramamine, which is another antihistamine. Dramamine is the brand name. The generic name is Diamond Hiate. It's a lot of tongue twisters in this episode, so you can try Dramamine as well. Also, be careful with taking Unisom and Dramamine to make sure that you're not taking too much so you don't get overly sleepy.

(24:47): All right, so you can try those antihistamines next after that, in kind of a stepwise fashion is Phenergan or Promethazine. Promethazine is considered safe for you and your baby. It's been used for decades and decades to treat nausea and vomiting in pregnancy, but it too can also have some fairly significant sedation. So you have to be careful with GaN and letting your body get used to it or timing it so that you take it more at night. And the benefit of Phenergan is that it can be given orally or rectally. If you can't keep medication down, you can also Tri Compazine.

(25:29): Prochlorperazine is the generic for that. And these are prescriptions I should say. So after Phenergan starting with these medicines, these are all prescriptions. So you can try may have mild side effects like drowsiness, dizziness, or headaches as well. And then reglan, which is a motility agent, it helps things move faster. Reglan is a prescription. The generic is Mela prma. It can have some maternal side effects with long-term use. In rare cases, it can cause movement disorders in women who take it, but it doesn't appear to increase risk for your baby. So that's not one we use commonly or for a long time. That's not something you can take for the duration of your pregnancy. You can only do it for a short period of time. And then there is Zofran. Zofran is on Dron, and the benefit of Zofran is that it doesn't cause sedation, so that's good.

(26:29): However, it does have some side effects like headache, fatigue, drowsiness, and particularly just drowsiness. Not really, really sleepy, just feeling a little bit sleepy. But sometimes the constipation can be terrible with Zofran. So you may need to take a stool softener to help if you have constipation while taking Zofran. And then the other risk of Zofran is that there is a small increased risk of congenital anomalies, anomalies including cleft lip and palate and heart malformations. That risk is most pronounced in the first trimester. And just to give you an idea, it's just a small increased risk. So if you're taking Zofran, there are about 10 cases per 100,000 births of cleft lip and palate with, I'm sorry, if you're not taking Zofran, there are 10 cases per 10,000 births. If you are taking Zofran, that goes up to 12 to 13 cases per 10,000 births.

(27:32): So a tiny increased risk of cleft lip in palate. And similar risk for heart malformations, about 10 cases per a thousand births, or 12 to 13 cases per 1000 births with Zofran. All right, so a tiny bit of an increased risk. That risk, again, is most pronounced in the first trimester. So the recommendation from acog, the American College of Obstetricians and Gynecologists is to avoid Zofran at less than 10 weeks. If nothing else is working and someone needs Zofran under 10 weeks, then just have a discussion about the risk and benefits. But it is certainly not a first line medication for nausea and vomiting in pregnancy. Now, in addition to those medicines, the bics, the Unisom, the Phenergan, Compazine, the Zofran, you may also need an acid reducing medication because if you're having acid reflux, that can make nausea and vomiting even worse. So you may also need to add Toms or Pepcid may be helpful as well to reduce the amount of acid.

(28:42): Now, one thing that's really important to remember is when you're taking these medications, you really want to take them on a regular scheduled basis. At a minimum you want to take them as soon as you experience a hint of symptoms. Do not wait until it gets really bad. Don't try to hold off and not take it and wait until it gets really bad because then it's really hard to try and catch up. So you want to try and get ahead and stay ahead of the nausea and vomiting by staying on the medication on a regular basis. Now, that brings up the question, well, how do I know when to stop the medications? So what you do is you just kind of slowly back down, go longer and longer between taking the medications, just kind of space it out until you figure out that, Hey, I don't need to take the medications anymore.

(29:34): But don't wait until it gets so bad that you're trying to play catch up. That's not in a good spot to be in. Now, last thing I want to say is about when to go to the hospital if you have severe nausea and vomiting in pregnancy. So when you need to go to the hospital is when you cannot keep anything down. No food, no liquids for more than 12 hours. At that point, you're at an increased risk of having dehydration. You're probably going to need some IV fluids. So if you're more than 12 hours, and also if you're starting not to feel well, if you're dizzy, you stand up and you feel dizzy. If you're heart is really, really racing, if you're not using the bathroom as much, those are also reasons to go to the hospital and get checked out hopefully. And what we often can do is give you some IV fluids, give you some IV anti-nausea, anti vomiting medicine, and then kind get you tuned up and you can go home on oral medication, kind of gets you fixed up and then go home.

(30:43): The idea is to keep you out of the hospital if we can. However, if that doesn't work, if you don't feel better after the IV medications, and you may need to be admitted to the hospital for ongoing treatment for a few days in order to get electrolytes together in order to find a combination of medicines that work so that you can then go home with a regimen that helps you feel better. And then in rare instances, the last medicine that we may add in the case of severe hyperemesis is a short course of steroids. Generally, we're going to use steroids after 10 weeks because it can increase the risk of cleft palate. It can also increase blood sugar. So we have to be mindful of that. But a short course of steroids if you need to be hospitalized may be helpful. And also gabapentin interestingly can help in nausea and vomiting.

(31:34): So I say all that to say that we have lots of options and things that we can try to help with nausea and vomiting. It's just a matter of trying different things, adding different things, figuring out what works and really taking it seriously so that we can find something that helps you feel better. Most of the time we can find something that does help you feel better and minimize those symptoms. Now, the last thing I want to say is something that is unsafe for nausea and vomiting, and that is cannabis, marijuana or weed. The use of it has increased during pregnancy. There are a lot more pregnant folks, self-reporting using it to alleviate the symptoms of nausea and vomiting of pregnancy. And although it may work, it is not considered safe in pregnancy. There are some potential risk. And at this point, 23 states in the United States have fully legalized cannabis for recreational use, and 38 states allow it for medical use.

(32:36): And you might not get this information at a dispensary that it actually is not safe to use in pregnancy. So again, although it has been shown to work very well for folks outside of pregnancy, like for people who are getting chemotherapy treatment, for instance, it really is not considered safe in pregnancy. It's associated with a lot of potential risk, including low birth weight, premature birth, smaller head circumference. It can affect brain development. It may lead to an increased risk of behavioral problems, A DHD learning disabilities, small risk, increased risk of stillbirth or issues with the placenta. So it really is best to avoid cannabis during pregnancy even though it can be effective with nausea and vomiting. And then actually some individuals who have used it in a long-term setting may experience what's called cannabinoid hyperemesis syndrome, which is actually nausea and vomiting related to the cannabis use, and that can actually make nausea and vomiting in pregnancy worse.

(33:44): Okay. All right. So just to recap, nausea and vomiting in pregnancy we think is caused by an increase in the hormones, particularly HCG and estrogen. For most people, it's going to start early, like around five to six weeks and end early by 16 weeks before a small percentage. It will last into the third trimester or even up until delivery. As far as treatment options, you can try dietary changes, acupressure, ginger, you can do vitamin B six and ox, which is perine, sorry, you can domine, which is Unisom, and then add Ergen, Compazine, Zofran. In extreme cases, steroids or gabapentin, do not use cannabis in pregnancy to treat nausea and vomiting. It's not considered safe. And if it is persistent nausea and vomiting, you can't keep anything down for a period of 12 hours, then go ahead into the hospital to get checked. I forgot to say that if you can keep fluids down, then generally you don't need to go to the hospital.

(34:58): Babies are kind of like parasites in a way, and they're stuck all the things that they need from you in order to continue growing. So if you can keep fluids down, then you don't necessarily need to go to the hospital. You can make an appointment with your doctor to get seen and get your medications adjusted. But it's really when you can't keep any fluids down that that risk of dehydration goes up. Okay. So there you have it. Please share this podcast with a friend. Also subscribe to the podcast, an Apple podcast or wherever you're listening to me right now. And do leave me a review in Apple Podcast. I love to hear what you think about the show. And I do shout outs from those reviews from time to time. Do check out the birth preparation course, my signature online childbirth education class that will get you calm, confident, and empowered to have a beautiful birth. Use the code, Dr. Nicole will get an additional 10% off. Check it out, dr nicole rankins.com/enroll. So that is it for this episode. Do come on back next week and remember that you deserve a beautiful pregnancy and birth.